Making services support children

Sonja Giese, of the Children's Institute at the University of Cape Town, looks at ways of maximising opportunities, within existing services, for the identification, care and support of vulnerable children in the context of HIV/AIDS¹.

Looking For Signs of Vulnerability

Characteristics of the HIV/AIDS pandemic
We are faced with a problem of massive proportions, with profound implications for the well-being of children in South Africa and for the realisation of their rights. In the year 2002 alone, 89 000 children were infected with HIV, while another 204 000 lost a mother (73% of them as a result of AIDS), bringing the estimated total number of maternal orphans in SA in 2002 to 885 000 (Dorrington, Bradshaw and Budlender 2002).

HIV/AIDS compounds vulnerabilities within households and communities, and widens inequalities. In the context of the illness, death and poverty that characterise the pandemic at household and community level, poverty, patterns of individual and household mobility, the necessity for children to work, the role of children and elders as carers, and children's domestic workloads are all increased. There are, however, few vulnerabilities that can be attributed solely to HIV/AIDS; many children living in poverty, for example, have similar experiences.

In AIDS-affected communities, where levels of mortality are increasing, the burden of exacerbated poverty and increased numbers of children in need of care is felt collectively. Increasing income dependency ratios, as a result of illness and death in broad family networks and beyond, exacerbate household poverty and increase the vulnerability of children. There is also increasing dependency on formal and informal networks of care and support (Giese, Meintjes, Croke, Chamberlain 2003).
The pandemic exposes problems within existing services and service infrastructure that have long been in existence and which, like the epidemic itself, are partly the result of economic and social fragmentation, deepening poverty, inequalities in urban and rural resource distribution, gender inequalities, cultural practices, and other material and social conditions.

Characteristics of our response thus far
A large part of the burden of delivering services is placed on CBOs and NGOs, with access to state support being limited because of bureaucratic hurdles and limited capacity. In particular, there is a trend, in both international and national policy and practice, to place the core of responsibility for supporting orphans and other vulnerable children on “communities” and “households”. As the number of adult relatives decreases and the number of children experiencing orphaning increases, this responsibility is borne more and more by volunteers, particularly poor women.

Within Government, care and support of orphans and other vulnerable children is seen largely as the responsibility of the Department of Social Development, with some role for the Departments of Health and Education. There is a need for a much broader inter-departmental approach, which would require proper coordination and collaboration, and some more imaginative thinking.

Responses to the impact of HIV/AIDS on children have tended to focus on children who have lost one or both biological parents, often ignoring the very real vulnerability of children living in the care of sick adults, children affected by HIV/AIDS in other ways and those simply living in contexts of dire poverty.

Given the scale of the problem, resource limitations, the urgency of the need, and the infrastructure that exists in South Africa, we need to think beyond the immediate and obvious functions of services and make maximum use of opportunities to identify and support vulnerable children, focusing on the functions that service providers are best placed to perform.

Examples of Missed Opportunities Within Services

Schools

“When I was in Grade 8, I was looking after my 3 sisters“There was no time for books. The teacher at my school would shout at me because I didn’t do my homework or because I fell asleep in class.” “Tiko, 14 year old girl.

This is just one of numerous examples of educators responding inappropriately, or not at all, to signs of vulnerability in children. In our research we found many instances of schools suspending children, withholding report cards, punishing, preventing children from moving to the next grade, not allowing children to write exams, and not providing transfer letters, all because of non-payment of school fees, even though legal provision is made for exemptions. Schools are often ambiguous places for children: perhaps providing some relief from the pressures of home and the benefits of a school feeding scheme but, at the same time, many children face discrimination and abuse at the hands of teachers.

We are not na–ve to the challenges that educators face but there is much potential for schools to be playing a greater role in assisting children to access care and support services.

Our research suggests that, where teachers were sensitive to the vulnerabilities of their learners, they often felt frustrated by the inadequacy of referral options to other services or lacked knowledge about who to refer children to and what services were provided by the state and the non-governmental sector (Giese, Meintjes et al. 2003).

Health facilities

“Children under the age of 16 years who arrive alone are not admitted [to the clinic] unless they require immediate treatment, such as for malaria” But the community doesn’t listen, children keep coming alone and being sent away”. “Clinic manager, Ingwavuma

Health facilities, like other services, have an important role to play in identifying children experiencing orphanhood. The early identification of vulnerable children lends itself to timeous interventions and referrals for support. This makes it imperative that opportunities for the identification of vulnerable children through health facilities are optimally used.
Many health workers, however, do not recognise the potential vulnerability of children who arrive at clinics unaccompanied, a situation likely to arise very frequently within the context of the HIV/AIDS pandemic. The opportunity to identify and refer a potentially very vulnerable child is lost when a child is sent away unaided. Further, it is likely that the child will be discouraged from seeking assistance in the future. Our research suggests that other opportunities within health service delivery to identify vulnerable children are also not optimally utilised. For example, few of the health workers we interviewed used the contact with a terminally ill adult as an opportunity to identify children who may be made vulnerable as a result of that adult’s illness or death.

Home based care

“We don’t support children as such. We don’t care for the children, we just care for adult patients” “Home-based carer, Phutaditjhaba.

–It is not part of our institution to look for children with TB or HIV/AIDS” “Manager, home based care organisations, Tzaneen

“We never focus on children, we hope that other organisations are focusing on children “We think like that. We hope, but it doesn’t seem to work like that.” “Home based carer, Ingwavuma

Home-based care is a cornerstone of our country’s response to addressing the needs of HIV-infected individuals. Homebased care organisations are mushrooming and they deliver invaluable services to the communities they serve. Yet, once again, we found a focus on adult illness, with a failure to recognise that sick adults are often surrounded by vulnerable children. Some programmes that do provide support to children, limit their response, providing aid and support only to those orphaned by AIDS.

So, our argument is that within the contexts of poverty and HIV/AIDS, service providers, such as home-based carers, health workers and teachers, should be encouraged to view every contact with a child or a caregiver as an opportunity to identify or prevent vulnerability. In order to ensure that this does not place unrealistic additional burdens on already overworked service providers, we need to look at the functions that various service providers are best able to fulfil during the normal course of their service delivery. Let’s take schools as an example”

Why should schools be nodes of care and support for children?
Schools have a fundamental role to play because of their numbers and their nature. There are some 28 000 schools spread throughout the country, which reach 11 500 000 children (Department of Education, 2002), including those most affected and most at risk of infection. The strengths within the education system in responding to the impact of orphanhood on children include relatively high enrolment rates, the existence of collaborative structures between education, health and social development, the school feeding scheme, and a national HIV/AIDS Lifeskills programme.

Children spend a great deal of time, over a period of many years, at school, in an environment that is supposed to be centred on them and their development and well-being. As a consequence of the pandemic they need extra support to help them cope with their further responsibilities such as caring for ill caregivers. Providing such support would encourage children to attend school, and addressing the social needs of children would help to alleviate the burden on educators.

Activities in the school environment
Building school environments that are conducive to care and support can be furthered, for example, by developing peer support programmes to supplement the support provided by teachers and other professionals. NGOs can also assist with programmes that complement existing life skills education.

Schools also provide opportunities for identifying vulnerable children and their particular needs, through such means as artwork, class assignments, teacher/caregiver meetings, etc., as well as for providing information to children and caregivers on services available within communities and how to access these.

An extended school-based feeding scheme would not only increase the learning capacity and school attendance of children but would also go some way towards alleviating the effects of poverty on children.

Similar arguments could be made for health facilities, such as clinics and hospitals, and for organisations providing home based care services.

What are some of the implications of an approach that encourages imaginative thinking around the role of service providers? Among other things, such an approach would:

Demand and facilitate improved coordination and collaboration;
Require a review of performance indicators for service providers, for example, teachers” performance would no longer be measured only on the academic achievements of their learners;
Introduce new elements into the training of professionals and lay workers;
Create networks of support for service providers themselves;
Mainstream children's issues, in line with national and international obligations;
Address the impact of HIV/AIDS on children within the context of other vulnerabilities of childhood;
Facilitate early identification of vulnerable children and minimise the risk of any child falling through the service gaps.

References

Dorrington, R., D. Bradshaw, D. Budlender. (2002). HIV/AIDS Profile In The Provinces Of South Africa: Indicators For 2002. Cape Town, Centre for Actuarial Research, University of Cape Town.

Giese, S., H. Meintjes, R. Croke, R. Chamberlain. (2003). Health and Social Services to address the needs of orphans and other vulnerable children in the context of HIV/AIDS in South Africa: Research Report and Recommendations. Report submitted to HIV/AIDS directorate, National Department of Health, January 2003. Cape Town, Children's Institute, University of Cape Town.

Department of Education (2002) Draft Education for All Status Report 2002: South Africa. Pretoria: Department of Education.

Notes
1. This article is an adaptation of a Powerpoint presentation made at the South African HIV/AIDS conference in Durban 3-6 August 2003, drawing on research conducted by Giese, Meintjes, Croke and Chamberlain (2003).

This feature: ChildrenFIRST : Issue 50 (August/September 2003)