‘SAVE OUR YOUTH FROM AIDS’

DRAFT PROPOSAL

                                          February, 1998

1. Context (Problem Analysis)

1.1 General Situation

HIV/AIDS has had a major impact on the health status of Zimbabweans. Zimbabwe is among the five most affected countries in the world.

Despite various efforts over the past years to combat the epidemic, sexually transmitted diseases and HIV/AIDS remain a serious problem in Zimbabwe. It is estimated that roughly 35% of the urban and 20% of the sexually active is being infected. The epidemic has reached all subgroups of the population, including youth and children. 60% of new HIV infections in women are under 20 years of age; 20 % of the unmarried men are already infected.

The impact of the epidemic both on the macro-economic (losses within the productive age groups, especially skilled, professional and hard to replace labour, the burden of a high number of patients with HIV-related diseases on the health sector) and the household and community level (death of breadwinners and high numbers of AIDS orphans) is enormous and threatens to jeopardise the country’s chances of socio-economic development.

Ultimately, each effort to successfully fight the spreading of HIV/AIDS has to address the root of the epidemic: social and individual attitudes and behaviour regarding sex.. As transmission depends to a large extent on individuals engaging in sexual risk behaviour, protection requires the adoption of HIV-preventive behaviour. This requires providing information on reproductive health and safe sex practices as well as addressing cultural norms and values regarding partnership, family and social life in general.

Despite ongoing IEC campaigns, a large percentage of the youth still lacks sound knowledge on safe sex practices and prevention of sexually transmitted diseases and have not changed their attitudes and behaviour. Moreover, being subjected to contradictory messages from many sources (official health messages vs. traditional beliefs, religious indoctrination from churches, influence of media, etc.) and confronted with conflicting official and informal norms and negative role models, misconceptions, prejudices and myth have prevented the youth from changing their behaviour and attitudes.

In families sexual matters are still a taboo topic between parents and children and are also not a subject for open discussion between sexual partners. Traditionally key members of the extended family, aunts and uncles, rather than the parents teach children about sex. This system, however, is functioning less in a changing society with reduced extended family contact, urbanisation and modernisation. Prevalent is a restrictive attitude: parents want their children to abstain from premarital sexual relationships and do not accept that youth engage in sex. It is a widespread fear even among the educated parents that talking about sex might stimulate sexual interest of their children. Therefore children receive no sexual education from their families and become adolescents without anyone explaining what happens to them.

Not being allowed to bring their boyfriends or girlfriends to their homes and having few alternative opportunities to meet socially, young people lack the chance to develop sound relationships and social skills in general, and especially the sexual negotiation skills. This makes them prone to seduction of "sugar daddies" and they are at risk to become victims of sexual abuse. In the absence of real information and the prevailing misconceptions and myth (e.g. use of contraceptives will cause infertility) even normal sexual relationships between adolescents carry the risk of infection. The strategic study of the National Youth Reproductive Health Survey provides comprehensive data on socio-demographic characteristics and reproductive health behaviour important for the implementation of youth oriented programs.

The same underlying attitude is found in teachers who are supposed to teach reproductive health, as well as in nurses and health workers who fail to recognise and who fail to recognise and address the needs of the youth. As a result that there are no strong links between young people and health services. In a society in transition in which the changing value system are not constructively discussed and official and informal norms and values are at variance, most IEC messages for youth emphasise "don’ts" instead of "do’s" and fail to deliver the know-how and information of responsible sexual behaviour. Young people, therefore, have few good role models and no "confidants" outside their own age group in their community. Youth have only their friends to talk about sex.

Reproductive Health education is part of the curriculum in schools, but is not widely implemented and of highly varying quality depending on the commitment and skill of teachers.. As only roughly half of the 15 year olds (57% of the boys and 50% of the girls) and only one quarter to one third of the 17 year olds (35% of the boys and 25% of the girls) attend secondary school, the majority of the potentially sexual active youth is not reached by services (figures from Matabeleland North CSO). Out of school youth –most of them without employment or a perspective in life - are not reached by IEC programs in formal teaching settings.

In general the preventive and curative services offered by the government health services are inadequate in terms of quality and quantity. The situation is even worse for the projected target group, young people between the age of 10 and 24. For them the services are virtually not accessible at all or, if accessible, they are not youth friendly. Young people are not only not encouraged to seek consultation on sexual matters, preventive methods or sexual diseases, they are often denied both information and help. Even if health workers want to assist, they lack the knowledge and know how. Simple IEC material that is attractive for the youth is also lacking. This is especially true for the most vulnerable group, young girls and women. In a male dominated society, women have no voice in sexual matters and are subject to sexual violence and abuse both before and within marriages. But it is the girls and women who face stigma and social discrimination in cases of unwanted pregnancy, AIDS/HIV infection and even when just seeking advise. The community response to rape, for example, is not rarely marrying off the victim to the rapist.

Poverty, unemployment and lack of recreational facilities leave the youth without meaningful activities and make sex the only outlet in a life otherwise lacking perspective and meaning. To be successful links between safe sex education and informal sector /vocational training initiatives have to be introduced.

It has been universally recognised that change of behaviour can not be effected by isolated programs but only through concerted efforts. There have been efforts to implement inter-sectoral, inter-disciplinary programs. The most successful of these have involved the members of all social forces (government institutions, NGOs, churches, associations, etc.) and especially the members of the target group themselves (peer education, drama groups, youth centres and clubs). They have been only partly successful on a large scale due to lack of political commitment resulting in a lack of co-operation and co-ordination between the various ministries (MOH, MOE, Ministry of Labour, Planning and Social Affairs) and other key players. Most of the programs and services offered did not reach the district level and individual initiatives on the district level failed because of lack of co-ordination, support and resources.

1.2 Situation in Matabeleland North

Matabeleland North is the largest of the ten provinces in Zimbabwe with a surface area of 75000 square kilometres and a population of 766 000, with 49 % of the population being children below 15 years and 19% teenagers between 15 and 19. The age group of 10-24 comprises about one third of the population.

Reproductive health indicators for Matabeleland North:

Fertility: The age specific fertility rate in teenagers between 15-19 is higher is higher than the national figure (157/1000 vs. 124/1000) and 17% of all birth are in teenagers (national average 14%)

 Abortions: Figures indicate, that induced abortions are not a problem in the teenage group.

Contraceptive use in general is very low (28% vs. 42% in Zimbabwe as a whole). Contraception use in youth is negligible. The attitude of health workers does not encourage use of contraceptives by youth.. HIV prevalence and STI: HIV prevalence among pregnant women varies from sevem to more than forty percent with a provincial average of 11,6% of women presenting for a first antenatal visit have HIV infection. STI is a problem in all districts. No analysis has been done of STI attendances by age group.

Sexual abuse: Half of the reported 200 rape cases occur in girls younger than 16 years. There are reports that girls have contracted or died from AIDS after rape.

School attendance: Roughly half of the 15 year olds (57% of the boys and 50% of the girls) and only one quarter to one third of the 17 year olds (35% of the boys and 25% of the girls) attend school.

Special Youth Programs: Apart from two districts with school health clubs and some workshops on reproductive health, very few programs for the youth are going on in the province. In all districts there is a lack of recreational facilities, e.g. sport facilities, libraries, movie houses, youth centres or clubs, etc.

Three districts with quite different characteristics are suggested to participate in the project:

Binga District:

A rural district with a population of 105 000. Means of livelihood are subsisting farming, fishing and upcoming tourism. Binga has only recently opened to outside influences and traditional values are still intact. It would be a challenge to keep the HIV prevalence low in the young generation.

There are 56 primary and 9 secondary schools in the district. A multi-sectorial Binga AIDS Committee is active, but has not yet developed many youth oriented activities.

Bubi District:

Bubi District is the smallest, predominantly rural district in the province with a population of nearly 50 000. Bubi is the site of an ongoing study into reproductive health concerns of teenagers and their views on health services. The dialogue with youth and health workers should be kept up. There are 26 primary and 4 secondary schools in the district.

Victoria Falls:

Victoria Falls is an urban town in Hwange District district with a total population of 30 000, living predominantly from tourism. A considerable percentage of the youth is (self-) employed in the tourist industry. Despite the presence of an intermittently active multi-sectorial STI/AIDS committee, very much unprotected sex takes place and the HIV prevalence is high. Because of the presence of the STI committee and the serious problems related to HIV, Victoria Falls should be included in any project attempting to reduce the incidence of AIDS in Mat-North. There are 3 primary and 1 secondary schools in the district.

1.2 Situation in Masvingo Province

Masvingo Province is found in the southern eastern part of Zimbabwe and has a surface area of 56,560 square kilometres. The province has a population of 1,334,886 with 48% of the population being children below 15 years and 12.9% teenagers between 15 and 19. The age group of 10-24 comprises about one third of the population.

Reproductive Health Indicators for Masvingo Province

          (i) Fertility - Masvingo Province’s women have an average of 6.7 children each (1992 census).

          (ii) Abortions - no age distribution figures however 65% of women presenting for treatment of incomplete abortion is  query induced.

          (iii) Contraceptive use (modern methods) in general is low 38% vs. 42% in Zimbabwe as a whole. Contraception use in youth is negligible mainly because of the attitude/influence of parents, church and health workers.

          HIV prevalence and STI - HIV prevalence among pregnant women varies from 25% - 50% (Masvingo Town) and

          11% - 45% Gutu Mission (source HIV surveillance 1991 - 1996; Health Profile). STI is a problem in all the seven

          districts of Masvingo province. HIV prevalence among STI clients varies from 50% to 82% (Masvingo Town) and

          36% to 69% Gutu Mission Hospital).

Special Youth Programmes

Very few youth programmes are going on in the province; the programmes that are there are mainly church oriented and

institutionalised ones at schools. In all districts there is lack of recreational facilities e.g. sport facilities, libraries, youth

centres/clubs etc.

Two areas are proposed to participate in the project.

          1. Masvingo town - has an area surface of 6832 hectares and has a population of 51,743. Masvingo town is at the

          cross roads of Bulawayo/Mutare and Harare/Beitbridge roads. This means that a lot of long distance truck drivers

          make Masvingo town their resting place and very often youngsters are hired by these drivers. STDs is a number two

          health problem in the town. A study on youth sexuality (Masvingo town) reports that 51% of the school children

          already had sexual intercourse, which makes them prone to STI/HIV infections. There is an effective commercial

          sex worker peer education programme in the town BUT unfortunately youths arc not targeted. There are 7 primary

          and 4 secondary schools in Masvingo town.

   2.Gutu district has the highest rural population (215,123 - 16%) in the province. Of this 67,327 (31%) are youths aged 10-25 years. Means of livelihood are mainly subsistence farming and the fast growing Gutu Mpandawana growth point provides jobs to quite a number of people. The growth point houses about 2,000 people and it is well known for harbouring commercial sex workers some of whom are youths. It would be quite a challenge to keep the STI/HIV prevalence low in the young generation.

GUTU STI INCIDENCE

Gutu district has 53 secondary and 150 primary schools. The school enrolment is 60,904 primary pupils and 24,458 secondary pupils. These pupils arc under the hands of 1,542 primary teachers and 877 secondary teachers.

SCHOOL ENROLMENT RATIOS BY AGE AND SEX MASVINGO PROVINCE

  SCHOOL ENROLMENT RATIO

Source: 1992 census. Compiled by A P Vhoko Provincial Health Education Officer for Provincial Medical Director: Masvingo

2. Project Purpose, Target Groups and Development Policy Status

2.1 Project Purpose

The key to successful STI/AIDS prevention programs are obviously changes in awareness and behaviour of the target group. This is expressed in the Project Purpose:

"Responsible sexual behaviour is practised by the target group"

Indicators for the achievement of the project purpose are:

  abstinence (postponing the onset of first sexual activities),

     practising safe sex methods,

     no arbitrary frequent change of partners,

     reduction of incidents of sexual abuse,

     better risk assessment regarding sexual contacts

     voluntary testing for HIV.

The indicators will have to be detailed in terms of quantity and quality based on reliable baseline data at district level.

2.2 Development Policy Status

The achievement of the project purpose will have a direct effect on the reproductive health situation of the target group, expressed in the Development Goal and the Overall Goal:

          Development Goal: "Number of HIV/STI infections and teenage pregnancies reduced in the target groups of

          selected districts"

          Overall Goal: "Reproductive Health Status of Target Group in selected districts improved"

In view of the estimated death of at least a quarter of the sexually active adults in Zimbabwe in the next few years, the reduction of STI/HIV infections and the resulting improvement of the health status of the younger generation is of crucial importance and will have an impact on the socio-economic, political and cultural development of the country that cannot be overestimated.

The focus on a multi-sectoral, community based approach at district level is in line with the ongoing decentralisation efforts and the growing awareness that short- and medium-term effects can best be attained and demonstrated at local level. Ownership of programs at local level make it possible to develop appropriate methodologies and approaches.

The reduction of HIV/STI infections and unplanned/unwanted pregnancies can be measured directly. Well defined indicators for the reproductive health status exist in the health sector and can be applied. Targets in terms of quantity and quality have to be defined by each district depending on the prevailing reproductive health status in the age groups targeted by the project.

2.3 Target Group(s) of the Project

The main beneficiaries of the project are children, adolescents and young adults between 10 and 24 years of age. The age groups thus include school children, sexually active youth and young couples. Their risk awareness and conscientious and responsible sexual behaviour will be at the centre of the project activities.

The project will focus especially on girls and young women as the most vulnerable section of the target group. They run the highest risk of STI/HIV infections and are the ones who suffer most both physically and socially.

Most members of the target group belong to the rural and urban poor and neglected parts of the society. A high percentage of the out of school youth is without jobs with limited or no training opportunities and career prospects. Their access to health promotion and health services is very limited.

A secondary target group of the project are parents and members of the extended families (uncles, aunts). To enable them to practice sexual education of their children, t hey will receive information on reproductive health and education in communication skills.

Situated at district level, the project will work directly with the target groups. Teachers, social workers, staff of heath institutions, and members of religious groups and others working on district level will receive training in order to act as intermediaries.

3. Project Design

3.1 Relation to other Projects

The project is designed as a multi-sectoral approach involving the MOE, the Ministry of Higher Education, the Ministry of Public Services, Labour and Public Welfare, the Ministry of National Affairs, Employment Creation and Cooperatives and NGOs under the leadership of the MOH/CW. As such it is related to other efforts on national (National STI Program), provincial and district level of these sectors to combat STI/AIDS, provide education and services on reproductive health and support services (vocational training). Additionally, it will co-operate with projects supported by other development agencies (UNICEF, Netherland Reproductive Health Program amongst others).

  The project should exchange information on concepts and experiences with similar projects/programs in other countries, like e.g. with the global sector project "AIDS Control and Prevention in Developing Countries" and the "UNAIDS/WHO/GTZ Local Level Response Initiative".

  The following programs are of immediate relevance for the planning and implementation:

     Denmark/DANIDA: AIDS Prevention and Control (1994-97): Support of the Family Health Programme with the focus on MOH&CW and ZNFPC (1993-1997)

     USA/USAID: Support of the Family Health Programme with IEC Components (1991-1998); Support of the National AIDS Programme (1994-1998)

     UNICEF AIDS prevention program

3.2 Activities and their Results

3.2.1 Short Description of the Methodical Approach

The proposed project follows an integrated and comprehensive multi-sectoral, interdisciplinary approach. The main feature of the project is the collaboration of relevant sectors on district level to combat the risk of STI/HIV infections and unwanted pregnancies in the rural youth population (children, adolescents and young adults between the age of 10 to 24) by

  providing relevant information on reproductive health and prevention of sexually transmitted diseases,

     improving the sexual education both at home and in schools and other institutions,

     providing better access to more youth friendly health services.

     improving the access to related education, social and economic support services.

The effort to raise awareness and change behaviour cannot be successful if focusing too narrowly on reproductive health and sexuality alone. These have to be seen in context with prevailing norms and values that shape the social life of a society or culture as well as with the socio-economic conditions that affect the life of the youth and are at the root of their problems. In the long run information and education will only have lasting effects if at the same time efforts to improve the economic situation.

 In order to effectively reach and influence the youth, the project will involve members of the target groups in planning and implementation of the project as well as in material development, health message formulation and improving services to be more youth friendly. Peer group training will be an essential part of the project.

The following procedures and methods are applicable: structured counselling, the use of young peers for young people, the inclusion of satisfied users of preventive methods as role models, formal and informal education in schools, youth clubs, meeting places and work places.

3.2.2 Results and Activities

At this stage of the project planning definite results cannot be formulated. This has to be done at district level with regard to local conditions, existing structures and efforts. In general, however, the following major results and pertaining activities to achieve the purpose will include:

   1.Stakeholders are effectively organized and co-ordinated

     Recruitment and employment of a youth focus co-ordinator

     Establishment of a multi-sectoral AIDS committees at provincial and district level

     Exploration of existing multi-sectoral committees to see where youth issues could be handled/supported

     Creation of a youth forum to identify needs and solutions for services

     Planning and development of the organizational structure together with the stakeholders

   2.Program for multi-sectoral approach elaborated

     More involvement of youth in youth related programs

     Introduce youth friendly services

     Strengthen reproductive health programs in schools

     Try to reach out-of-school youth through projects (recreation, skills training)

     Co-ordinate research and back-up program with research data

     Ensure that the female members of the target group are adequately reached by the programs

   3.Participating actors are trained

     Train and support peer educators/counsellors

     Facilitate parent-child communication

     Train health workers on youth friendly services

     Train teachers in communication skills regarding reproductive health

   4.IEC interventions in STI/HIV prepared and carried out

     Use existing and develop new IEC materials to cover identified youth problems

     Intensify use of media (radio/TV, newspapers, posters, neon signs etc.)

     Improve dissemination of relevant information for youth

     Elaborate innovative methods of dissemination of information

   5.Services of health institutions meet needs of the target group

     Find out attitude, needs and wishes of the target group

     Re-organise health system and services at district level to make them more youth friendly

     Make family planning services available and accessible for young people

     Train health workers in youth friendly service delivery

3.3 Schedule

A detailed schedule for the project cannot be given at this. Since the peak of the STI/HIV infections, however, is expected for the year 2000 - 2010, the project should start as soon as possible with massive interventions to have an impact.

  The schedule of the project depends to a large degree on the willingness of other sectors to follow the initiative of the MOH and their degree of involvement and commitment (including funding).

Once the project is approved, detailed finance plans and time plans have to be developed by the districts with the support from the respective provinces.

4. Legal Form, Tasks, Responsibilities

The Ministry of Health as the initiator of the project is a State authority and corresponds in its organisational form to the structures common in anglophone Africa.

Implementing agencies will be District AIDS Committees to be established after the project start. They will be funded by the MOH and other involved ministries.

4.1 Organisational Structure, Number and Qualification of Staff

The District AIDS Committee is a consultative and decision making body in charge of planning, monitoring and implementation of inter-sectoral programs (incl. budgeting) and the coordination of sector programs. District AIDS Committees exist already in some districts in some districts and have to be set up in others participating in the project. The committee will consist of the following members:

     District AIDS Coordinator

     Education Officer (MOE)

     District Social Welfare Officer (Ministry of Public Services, Labour and Social Welfare

     District Nursing Officer/Health Education Officer (MOH/CW)

     Chairman of the Health Committee of the Rural District Council

     Youth Representative

Depending on the local conditions in participating districts, there may be other members (e.g. representatives of religious groups, co-operatives etc.).

The committee will mediate between participating and other interested parties to ensure the unity of health and sexual health messages to the target group by arranging meetings, discussion forums, workshops, training etc.

The members of the committee are responsible for

     the implementation of scheduled activities within their sectors

     make contributions to the activities with other sectors

     link-up with, inform and generate support from institutions in their sector

They will interact with and get support from the National AIDS Coordination Program (NACP), the Zimbabwean AIDS Network and research institutes (collection and provision of relevant existing data and literature).

The representatives of the different sectors will have special responsibities:

MOH/CW:

     Initiation and monitoring of the project

     Initial coordination of the functions of other departments in reaching out to youth

     Mobilizing and accounting for resources

     Dissemination of information on reproductive health

     Offering of youth friendly services

MOE, Ministry of Higher Education:

     Mobilization of teachers and students

     Education in reproductive health/sexual health

     Support of youth peer groups and youth clubs

     Provision of atmosphere for reaching students

Ministry of Public Services, Labour and Social Welfare:

     Identification of special needs of youth

     Provision of support

Ministry of National Affairs:

     Skills training

     Mobilisation of out-of-school youth for the project

Past experience with existing District AIDS Committees and similar bodies have shown that they tend to become inactive in the absence of strong and competent leadership. It is therefore strongly recommended to install a full-time District Aids Co-ordinator responsible for the management and co-ordination of all activities (planning, monitoring, supervision of programs, meeting management, distribution of resources, accountable for project budget) acting additionally as a resource person and supervisor. The coordinator will have his/her office at the Rural District Council. It should be a person senior enough to have authority; a medical background would be an added advantage.

The DAC will be financed at first through donor contributions which will gradually be replaced by funds from the MOH/CW. The DAC can be assisted by a volunteer from a volunteer organisation (DED, OEDD or others).

Other major actors participating in the project as intermediaries and their respective functions are:

     Youth and Youth Groups: Peer education, participation in the implementation of the programs and in material

     development and distribution, attract other youth into the project.

     School Teachers: Implementation of AIDS education program in schools, participation in material development. The

     Education Officer is responsible for creating problem awareness, motivation, training and supervision of teachers. Technical

    input to the education programs will come from DNO/DMO and other health personnel in the district, and the Social

     Welfare Officer.

     MOH personnel (nurses, EHTs): Deliver youth friendly services, IEC, counselling, training, technical support to

     programs.

     Councillors: Political support, facilitation, mobilisation, resource person for development activities.

     Rural Development Committees/ Municipalities: Provision of recreational facilities for youth, income generating

     projects.

     Political Parties: Political commitment and support

     Churches: Youth mobilization and support, provide links between spiritual guidance and enabling better risk assessment.

     Parents: Sexual education, moral support

     NGOs: Mobilise youth especially out-of-school and unemployed youth together with MOH/CW, funding, implementation, support (human, technical, logistic etc.).

4.2 Relation to the Target Group

Operating at the district level, the implementing agency and the intermediaries are physically close to the target groups, some, e.g. teachers, have close contact to important section of the target groups. To win their trust and confidence and be accepted as confidants will, however, depend on their attitude towards youth and their needs and wishes as well as their attitude towards sexual relationships. There is a growing awareness of the importance to offer youth friendly services in the health sector, which, however, might not be initially shared by all potential intermediaries. Mediation to find consensus on norms and values and to agree on consistent messages that appeal to the youth will be an essential task of the project.

4.3 Effects on the Implementing Institutions

If the innovative youth friendly approach is adopted, integrating a number of actors from very different strata of life, it will be a shared learning experience to all actors involved. The cooperation of different sectors on district level will be a test for integrated approaches, which often have been proclaimed but rarely successfully implemented on national, provincial or district level. The ultimate success of the proposed collaboration of different sectors and actors will depend on the awareness of the urgency of the problem that calls for innovative approaches.

5. Finances

5.1 Contribution of the MOH/CW

The MOH/CW must supply a proportionate share to implementing agencies outside the Health Sector, e.g. NGOs, proportionate operating and administrative cost (e.g. T&S, office space, equipment and materials). Further the MOH/CW will second technical personnel for the implementation of project activities, in accordance with staff requirements, and second suitable MOH/CW professionals for the training measures. It must guarantee an itemised budget of its own to ensure sustained functioning and continuation of the program after completion of external assistance.

5.2 External Support

(To be elaborated at district level)

6. Risks and Assumptions

The main assumption at this stage of the project planning is the willingness of other sectors to co-operate in an integrated approach and to provide support (including funds, personnel, etc.) to activities outside their own immediate sphere of influence.

  Regarding the concept and content of the project approach, the success of the project depends on the actors agreeing on an un-dogmatic realistic approach to reproductive health education and sexual relationship. At present, given the conflicting value systems and the resulting contradictory messages to youth, this cannot be taken for granted. It is the task of the project to act as a mediator and to stimulate discussion and value negotiation between the various actors and help them to find a consensus that will benefit a troubled and endangered young generation. Even if total consensus cannot be achieved, there must be a critical mass of dedicated people working towards the same end, to have the desired effect on the sexual and social behaviour. There might be, however, outside (political, religious, cultural) influences that counteract these efforts and prove to strong to be overcome by the project.

Finally, the ultimate success of the project will depend on frame-conditions: the improvement of the economic situation of young people is essential for the decision to chose life rather than death.