EVALUATION REPORT OF SUPPORT GROUPS IN ZAMBIA 2009
Table of Content i
Acronyms ii
Acknowledgement iii
Foreword iv,v
Executive Summary vi
Introduction 1,2
Methodology and data collection 3, 4
General impression 4,5
Evaluation Results 6
Financial Management 7
Support group activities 8
Main Challenges 9
Suggestions 10,11
Conclusion 12
Tool used annex i
Additional suggestions annex ii
i
Acronyms
ZUNO Zambia Union of Nurses Organization
NNO Norwegian Nurses Organisation
NEC National Executive Committee
SG Support Group
Norad Norwegian agency for development cooperation
ZNA Zambia Nurses Association
HIV Human Immunodeficiency Virus
AIDS Acquired Immune Deficiency Syndrome
IGA Income Generating Activities
ii
Acknowledgements
On behalf of the National Executive Committee (NEC) and indeed on my own behalf, I wish to convey my heartfelt gratitude to all the nurses and midwives and the Zambia Union of Nurses Organization leadership for their willingness to participate in the evaluation of the Zambia Union of Nurses Organization (ZUNO) Support Group (SG) project.
My special thanks go to evaluators Anne Berit Rafoss and Astrid Grydeland Ersvik of the Norwegian Nurses Organisation (NNO) for their dedication and hard work. I also wish to acknowledge with thanks, the logistical and financial support from Norad and the NNO, without which it would have been much more difficult to successfully conduct the evaluation.
Furthermore, I would also like to thank Norad and the NNO leadership and members for the collaboration that ZUNO has enjoyed for many years by way of financial, technical, material and moral support that they have rendered through-out the life-span of the support groups.
Last, but not least, I wish to acknowledge the great contributions in form of an enabling environment and logistical support accorded to ZUNO, and the ZUNO/NNO Partnership by the Zambian Government through the Ministry of Health (MoH).
ZUNO and the Zambian Nursing community are greatly indebted to all of you.
Thom D. Yungana
ZUNO PRESIDENT
iii
Foreword
Zambia Union of Nurses Organization in collaboration with the Norwegian Nurses Organisation developed a Caring for Carers Model Project to help address issues of HIV/AIDS among nurses and midwives in Zambia. The project which was implemented for six years from 2002 to 2007 and extended for one more year to 2008 was developed out of the needs assessment conducted among nurses and midwives and other health professionals in Zambia in 2001. The assessment revealed the need for an intervention strategy to empower and support caregivers in order to prevent HIV infection both in the workplace and in their social lives including providing care and support to those already infected with the virus and otherwise affected.
The assessment gave birth to a six year ZNA/NNO HIV/AIDS Project for Nurses and Midwives in Zambia, whose implementation started in 2002. From the results of the assessment the broad objective emerged to be: “to reduce the prevalence and incidence of HIV infection among nurses and midwives and to contribute towards improved health and working abilities for infected and affected nurses”. From this objective, intervention areas were developed. The interventions included:
1. Knowledge and Skills
2. HIV and the workplace
3. Voluntary Counselling and Testing (VCT)
4. Care and support
5. HIV Prevalence and Incidence
6. Patient Care
Out of these intervention areas, one hundred (100) support groups for nurses and midwives were established at different stages during the lifespan of the project as mechanisms for providing care and support to members and orphans left by deceased nurses. Eighty-nine support groups received USD $1000 as seed money to establish Income Generating Activities (IGA). In some provinces the seed money of USD $1000 was shared between two support groups. Depending on the exchange rate at the time the support group received the money, some support groups received more money in Kwacha terms. Throughout the duration of the project, the support groups had their own operational structures at Branch level which were parallel to that of the Zambia Nurses Association.
iv
With the transformation of Zambia Nurses Association into Zambia Union of Nurses Organization, the Support groups’ activities and operational structures were integrated into the Zambia Union of Nurses Organization structures at Branch level. The integration aimed at consolidating and harmonizing the programmes and projects under the legitimate and structured leadership of ZUNO at all levels. The support group activities were intended to cover all nurses and midwives in Zambia, both in the public and private sectors and this was achieved.
May I end by calling upon the ZUNO leadership and the staff in management positions to take note of the findings of the evaluation and ensure that all the recommendations are included in the ZUNO plan of activities for 2010. The ZUNO leadership in collaboration with its partner, the Norwegian Nurses Organisation should ensure that such recommendations form part of the critical inputs for the forthcoming annual planning process.
Liseli Sitali
ZUNO GENERAL SECRETARY
December 2009
v
Executive summary
The aim of the project was to develop and implement national and local guidelines on care and support to health personnel who are infected and/or affected by AIDS related illnesses and to contribute to appropriate treatment accessible to nurses and midwives. The ultimate goal was to reduce the negative consequences on health services resulting from reduced workforce due to illness or premature death.
The evaluation revealed a number of challenges; a large number of support groups were struggling in terms of membership turnover, available funds for activities, non-availability of past records on support group activities, no regular meetings specifically to plan for support group activities and lack of organizational physical infrastructure. Based upon the findings, the support groups visited were divided into three categories; good, fair and poor. Two (18.2%) support groups emerged good, five (45.4%) were fair and four (36.4%) were poor. The categorization was based on record keeping, financial accountability and general performance of the support group.
Generally, the level of engagement and number of activities has decreased considerably over the last two years.
THOM DAUTI YUNGANA
ZUNO PRESIDENT
vi
Introduction
The global HIV/AIDS epidemic has continued to expand and cause great pain and destruction to many. The pandemic has posed and continues to pose tremendous challenges to health systems of developing countries.
Before the HIV/AIDS pandemic, the health systems of sub-Saharan Africa were steadily improving the overall health status of the population. This could be attributed to higher quality of and increased access to various health services. However, millions of Africans having been infected with HIV since the beginning of the pandemic and over 28 million still living with HIV infection, the impact on the health sector over the next decade will be greater than in the past two decades combined. HIV and AIDS have substantially increased the demand for health services. Patients seeking treatment for more traditional illnesses are being crowded out to peripheral health facilities. This has led to congestion at the secondary and tertiary levels, while weakening services at the primary level. Furthermore, there has been significant impact of the epidemic on the health workforce, which includes nurses and midwives, attrition due to illness and death, absenteeism, low morale, increased demand for provider time and skills, diversion of resources, budgetary and managerial inadequacies and other effects of managing systems under stress(Tawfik and Kinoti: 2003)
HIV/AIDS affects the performance of health systems by increasing demand for services in both quality and complexity and by reducing the supply of services by its impact on the numbers and performance of the health workforce. AIDS related illnesses and death of employees reduces the quality of services provided and increases expenditures due to replacement and training of new employees.
Great concern within the ministry of health about perceived increase in absenteeism and mortality among health personnel, led to an assessment of the impact of HIV/AIDS on human resources in the health sector. The data collected concerned mortality among female nurses at two hospitals in Zambia in 1990, the observed increase in mortality was attributed largely to HIV infection (Tawfik and Kinoti: 2003)
AIDS is the most serious threat to the development agenda in Zambia. Most of the Millennium Development Goals (MDGs) will not be achieved unless the response to HIV prevention, treatment, care and support is scaled up. According to Central Statistics Office of Zambia 2007 Demographic and Household Survey, out of the numbers tested for HIV, an average of 17.8% of women compared to 12.9% of men were found to be HIV positive.
1
Furthermore, the statistics showed that there was a reduction in the HIV/AIDS prevalence in the country from 15.6% to 14.6%. At the same time improvements occurred as the antiretroviral therapy became more accessible
Nurses are part of the community as well as the health care system. Nurses are at the forefront of the HIV/AIDS epidemic in Zambia, caring for the sick and the dying, both at the hospital and in their homes. However, there is no defined system to take care of the caregivers when they fall sick both at the hospital and at home. This realization by Zambia Union of Nurses Organization gave birth to the establishment of support groups whose objective was to give support to fellow nurses and midwives who were either infected or affected. Guidelines were developed on how to form support groups, which would provide assistance to these nurses and midwives, otherwise not cared for by the public healthcare system.
2
Methodology and data collection
The main objectives of the evaluation were:
· Evaluate the current status of a randomly selected number of support groups (SGs)
· Gather feedback from SGs about the transformation from Zambia Nurses Association (ZNA) to Zambia Union of Nurses Organization (ZUNO)
· Consider the degree of integration of the SGs into the ZUNO structures and the use of funds
In order to gather objective feedback on these issues a random selection of 12 SGs in three randomly chosen provinces were selected for visits by the Director for programmes and professional affairs from ZUNO, a Special adviser from NNO and the Chairperson for the public health nurses interest group from NNO. For each of the three provinces, 4 SGs were selected and there is a mix of general hospital SGs, district hospital SGs and health station SGs. This random selection of support groups is deemed to be representative of SGs nationwide.
The support groups were notified of the upcoming visit approximately one week ahead of the actual visit by the ZUNO secretariat in Lusaka. They were only told that a team from ZUNO/NNO would visit and evaluate the support group status and performance.
The following support group sites were chosen for site visits:
CENTRAL PROVINCE
1. Chibombo Liteta District Hospital
2. Kapiri Mposhi District Hospital
3. Kabwe Mine Hospital
4. Kabwe General Hospital
LUAPULA PROVINCE
1. Milenge District Hospital*
2. Mansa General Hospital
3. Nchelenge District Hospital
4. Mbereshi District Hospital**
*Milenge district hospital was replaced by Mwense health centre due to staff being called away for National Child Health Week duties.
**Mbereshi district hospital had to be cancelled as all nurses at the hospital were called out to assist in the National Child Health Week
3
NORTHWESTERN PROVINCE
1. Solwezi General Hospital
2. Mwinilunga District Hospital*
3. Mukinge Mission Hospital
4. Kasempa District Health Centre
*Mwinilunga district hospital was replaced with Solwezi district hospital due to the bad road and weather conditions
The interviews were conducted with members from the SGs; in some instances the chief nurse officer and hospital management were also present. The questionnaire set out to ascertain information about the following issues:
· Organizational management
· Structural development
· Financial sustainability
· Support group activities – for members
· Support group activities – for orphans
· Challenges faced since inception
· Suggestions from support group members on how to best improve their performance
General impression
The evaluation tour described here is the first of its kind since the establishment of support groups in 2003. However, another evaluation with a different approach was undertaken in 2007, for further details, see attachment: ZNA-NNO HIV/AIDS PROJECT for Nurses & Midwives - 2007 EVALUATION REPORT. The evaluation process in 2007 used questionnaires and interviews.
The SGs have had visitors from 2003 through 2007 by various international NGOs, some foreign national nursing organizations and government institutions. The recent evaluation tour chose 12 SGs at random from three provinces in order to gain an objective and representative overview of the current status of support groups.
4
As a general trend, the level of engagement and number of activities has decreased considerably over the course of the last two years. The transformation of ZNA into ZUNO emerge as one of the main contributing factors to this effect, as members of support groups have increasingly come to regard ZUNO as the contributor of funds and organizer of activities. Thus, the level of activity and engagement in the SGs to meet regularly and organize income generating activities has gone down, in some instances to the point of disintegration of some SGs and attempted revival of others.
Another potential contributing factor explaining the decrease of engagement and activities may be the relocation of staff process the Ministry of Health (MOH) has embarked on since 2007. It has been argued that this has resulted in members of the support groups having been relocated to other stations, either not leaving complete records or taking them with them. As often as not, there would not be left any written guidelines for operation of SGs, leaving it to new members to revive SGs with lacking information/documentation and often missing, little or no funds. The relocation process is scheduled to be completed in June 2010 and it is then hoped that SG structures may have a more enduring character with committee members being stable over a longer period of time. No official records of this relocation process have been provided; as such NNO must refrain from including it as part of the explanation.
The degree of preparedness and supply of records varied greatly and five of the SGs did not have the complete records at hand.
Although the missing records prevented the evaluation team of gaining full insight, it was not a major hindrance as the SG members were able to supply sufficient information on the activities and the general status of the SGs.