1. Policy implications of the TASO/IPFRI Operations Research Robert Ochai Executive Director, TASO.

2. Background The Studies Findings and Conclusions Policy Implications Outline

3. TASO, The AIDS Support Organisation, is the leading HIV/AIDS care organisation in Uganda. It serves approximately 100,000 people living with HIV/AIDS annually. Most of the TASO clients are poor, far below the poverty line. PHAs have multiple needs; including, medical, psychological, and social support. Most TASO clients cannot afford 2 full meals a day. Background

4. The need for nutritional interventions in caring for people with HIV is now generally accepted (Gillespie et al. 2007)because; Adequate food enable the body to cope with the multiple drugs taken daily. Counteract the wasting that accompanies AIDS Cater for the children; both infants (not breast feeding) and the older ones who are vulnerable to hunger and malnutrition. PHA have been receiving vital nutritional support projects through WFP, ACDI-VOCA, etc; but most have wound up. There is need to conduct more research in the area of HIV and AIDS in order to determine the minimum requires and sustainable strategies for meeting those needs. Integrated HIV/AIDS and Lively-hood Programming (IHLP)

5. Objective: To critically examine the group approach to programming among IHLPs in Uganda, and to explore and problematize the assumptions underpinning this model. Methods: A case-study approach was adopted. Multiple in-depth interviews were conducted, along the livelihood program chain, with staff from TASO, 16 IHLP partners, and 71 HIV-infected TASO-registered client households. The “Group” in IHLP: An Opportunity or Challenge?

6. Virtually without exception the group is the focal point for material and intellectual inputs of IHLPs. three important considerations emerged: Group membership is widely held to confer benefits in the form of psycho-social and motivational support, particularly in empowering individuals to access HIV services and handle stigma. However, This is comes with the inherence challenge of stigma arising from “public declaration” of HIV-status; (a + for prevention, a - if it results in discrimination). Results

7. Membership in groups can bring economic benefits through the pooling of labor, resources, and peer support. These benefits however need to be set against the costs of membership, when members are required to make contributions in the form of money, goods or labor. In this exchange, individual choice and control are diminished and problems of ownership and use of resources held in common can arise. Emerging Consideration 2/3

8. Agric IHLPs require land, may be labour intensive, but improve food security. Non-agric IHLPs do not require land, not labour intensive, but are vulnterable to competition and market price swings; thus creating considerable risk. Thorough analysis of circumstances must be done in each case. Agric Vs Non Agric IHLPs

9. While the group model brings benefits to IHLP efficiency and by extension to food-security, and other outcomes, its application needs to be carefully scrutinized at the individual program design level, in terms of appropriateness vs potentially adverse effects. Conclusion

10. IHLP Impacts As perceived by the Beneficiaries

11. “What has changed is that before I started growing my vegetables and keeping goats and pigs, every money I could get could be spent on buying vegetables and food but now that is history. My money only goes in school fees, my sickness takes the smallest percentage of my money like eating lunch when I go to the centre for treatment and may be transport but this is not much.” (Client, Jinja) Clients very pleased to be able to produce their own food Key cultivars include: matooke, cassava, rice, soy, maize, beans Clients also involved in dairying and poultry-raising, producing milk and eggs Clients typically split their production: Houshold consumption Sale (then use proceeds for groceries, HH necessities, school fees) Reproduction to ensure continued production Clients stress the benefits for their children, in terms of ability to provide food and education Many clients express a strong sense of pride in these achievements Key Impacts in Agriculture-Oriented IHLPs

12. “Yes it has helped me a lot because when I got this sewing machine, I bought my threads and started sewing, in our village here when hunger had stricken, some could just come with eggs and say make for me this cloth and the eggs were helping me in my life. Those who have money could give me. At this time there is some one who has told me to pick the cloths and make.” (Tailor, Mbale) In non-agricultural IHLPs, profits are in cash rather than direct benefits from crops and animals Money used to buy food, household necessities and pay for school fees Some clients also refer to the relief they and reduction in stress they feel As with agricultural IHLPs, clients stress the benefits for their children, in terms of ability to provide food and education As with agricultural IHLPs, clients feel pride in these activities Key Impacts in IHLPs with Non-Agriculture Focus

13. Training: very appreciated by both agri- and non-agri IHLP clients Agri-IHLP training: agriculture, animal husbandry Non-agri training: business management, accounting, credit management, trades such as tailoring Other enabling factors (agri) Land access Family support (encouragement, labour, land or money) IHLP or TASO inputs: tools, seeds, fertilizers Capital to pay for part-time labour Other enabling factors (non-agri) Possessing an existing business Existing skills which can be refined and marketed Family support Capital for business expenses Enabling Factors in IHLP Participation

14. A minority of IHLP clients reported that they felt no impact from their participation Eight agri-IHLP clients mentioned: Problems with groups dynamics Issues of livestock fertility Slowness of animals in reaching maturity Crop failures Seven non-agri IHLP clients noted: Difficulties in meeting loan payments Technical problems with equipment Inadequate training Difficulties in finding a reliable market/customers Stigma is an obstacle to people joining IHLP groups Challenges

15. The process “black box” was also analysed Processes Processes Inputs Outputs Impacts Outcomes We examined 16 organizations, using in-depth case study approach

16. Causal pathways are, in theory, plausible Frontline IHLP personnel could not consistently articulate coherent program objectives Some program personnel lacked substantive information on key program design components Strong, but unproven assumptions that program delivery models and implementation are optimal Inadequate monitoring systems Selected OR findings

17. Conclusions Well thought through, implemented and evaluated HIV-responsive food & nutrition security interventions are lacking Despite progress, paralysis pervasive through international agencies, donors, governments and therefore not surprisingly, implementation organizations on the ground A commitment to cohesive strategies needed The need for OR to improve integrated programs and enabling their scaling up & rigorously evaluating these interventions has never been more urgent

18. With over a decade worth of knowledge on the importance and linkages between livelihood security and the AIDS epidemic, we still know unacceptably little about the nuts and bolts of how to make these interventions work. We plan programs and research in an opportunistic way while strategic interventions are required. More targeted research is necessary; especially in the “black box” where action takes place. Conclusions …

19. While the groups approach should be the standard strategy to IHLP because of their social and economic benefits; the context may demand variations. Since groups have additional psycho-social support benefits; it is necessary to train some of the group members as counsellors. Integration of clients groups into mainstream community development processes should be considered in order to fight stigma. Service providers should build more capacity among their staff and the groups in order to improve performance. More strategic and purposeful and strategic programmes designs and research is urgently needed for better IHL. Policy Implications

20. Suneetha Kadiyala Terry Roopnaraine Frances Babirye TASO staff and clients who participated. Acknowlegements