Alleviating the Burden of Responsibility: Report on a Study of Men as Providers of Community-Based HIV/AIDS Care and Support in Lesotho Lesotho Ministry of Health and Social Welfare in Collaboration with The Capacity Project January 2009 C. Newman N. Makoae E. Reavely L. Fogarty The views expressed in this document do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Table of Contents Abbreviations and Acronyms ............................................................................... ii Foreword ................................................................................................................ iii Executive Summary ............................................................................................... 1 Introduction ............................................................................................................ 4 Context and Justification ....................................................................................... 7 Goal, Purpose and Objectives ............................................................................. 11 Methodology and Data Analysis ......................................................................... 12 Discussion .............................................................................................................. 33 Annex A: Data Collection Tools ......................................................................... 40 Annex B: Gender Analysis Domains .................................................................. 91 Annex C: Study Sites ........................................................................................... 92 Annex D: References ........................................................................................... 93 Report on a Study of Men as Providers of Community-Based HIV/AIDS Care and Support in Lesotho i Abbreviations and Acronyms CHAL Christian Health Association of Lesotho CHBC Community Home-Based Care CHW Community Health Worker DHI District Health Inspector DHS Demographic Health Survey DMO District Medical Officer DPHN District Public Health Nurse FGD Focus Group Discussion GOL Government of Lesotho HC Health Center KII Key Informant Interview LENEPWHA Lesotho Network of People Living with HIV/AIDS MDA Miners Development Agency MOHSW Ministry of Health and Social Welfare NC Nurse Clinician NGO Nongovernmental Organization PHC Primary Health Care PLHIV People Living with HIV and AIDS TEBA The Employment Bureau of Africa VSO Voluntary Service Overseas WLSA Women and Law in Southern Africa Report on a Study of Men as Providers of Community-Based HIV/AIDS Care and Support in Lesotho ii Foreword Gender disparities need to be addressed in human resources for health (HRH) policy and planning, workforce development and performance support to assure that men and women contribute to and benefit from social and economic development on an equal basis. The desired outcomes of all gender-related actions in HRH are improved service delivery and health—for workers and for the communities they serve. As it works to strengthen HRH systems to implement quality health programs in developing countries, the Capacity Project—a USAID-funded global project that focuses on planning, developing and supporting the health workforce—is concerned with how differences and inequalities affect women’s and men’s opportunities for education, training and occupational choice. The Project promotes interventions that are deliberate in addressing gender disparities, working from the following strategic framework: • Purpose: Reduce gender barriers to women’s and men’s participation in the health workforce by addressing inequalities that affect workforce entry, safety, professional satisfaction, mobility, rights at work and retention • Strategic objectives: (1) Strengthen HRH policy and planning to promote gender equality; (2) increase gender integration in education, training and work; (3) create supportive, fair and safe work environments. Gender segregation of occupations, which typically assigns caring/nurturing jobs to women and technical/managerial jobs to men, has been recognized as a major source of inequality worldwide with implications for the development of robust health workforces. Gender segregation in HRH tends to differentially restrict access to health occupations, positions and tasks for interested men and women. Stereotypical conceptions of women and men, which sustain occupational and task segregation, may be embedded in educational or occupational recruitment strategies, educational curricula and institutional hiring policies that impact would-be health service providers from the time they enter primary school to the time they complete professional education or enter a health occupation. Gender segregation of health occupations in the era of HIV/AIDS, in combination with the problem of “brain drain,” makes for inefficiencies and missed opportunities that are highly problematic because they create barriers to workforce entry and hence, the fullest possible pool of formal and nonformal health workers. The Capacity Project assisted the Lesotho Ministry of Health and Social Welfare to strengthen its capacity to respond to the HIV/AIDS pandemic by addressing gender segregation in nonformal caregiving through the active engagement of men as providers of community and home-based HIV/AIDS care and support. Most men in Lesotho have been attracted to mining in South Africa, but as these jobs have disappeared, and as the demand for more workers to respond to community- based HIV/AIDS care and support needs has increased, there is increasing awareness of the need to move beyond traditional divisions of labor, multiply the number of hands to do the work of caregiving and “alleviate the burden of responsibility” (Government of Lesotho. Gender and Development Policy, 2003). The Capacity Project conducted a study to understand the gendered division of labor and the dynamics of caregiving in Report on a Study of Men as Providers of iii Community-Based HIV/AIDS Care and Support in Lesotho three districts of Lesotho and to identify sustainable, gender redistributive1 approaches to recruit, train, support and retain men in jobs traditionally considered the province of women. The study had an additional aim, which was to offer alternatives to male unemployment while addressing the critical shortage of health workers in Lesotho. The study’s central questions were: To what extent can men be attracted into caregiving jobs traditionally considered the province of women? What will it take to increase the numbers of male HIV caregivers and to address barriers that may keep the potential pool of male HIV caregivers low? The recommendations of this report focus on ways to reduce gender segregation in HIV/AIDS caregiving through health workforce policy and planning, development and support efforts. Constance Newman Senior Technical Advisor IntraHealth International January 2009 1 The Lesotho Gender and Development Policy defines “redistributive” approaches as “Interventions intended to transform existing stereotypes to ensure gender equity and equality by a more even redistribution of resources, responsibilities, and power between and among men and women, girls, and boys.” Report on a Study of Men as Providers of iv Community-Based HIV/AIDS Care and Support in Lesotho Executive Summary Early in 2008 researchers conducted 25 individual interviews and 31 focus groups with 264 respondents in villages, health clinics and hospitals across the three districts in Lesotho chosen to represent two ecological zones, to contain both rural and urban sites and to achieve Ministry of Health and Social Welfare and Christian Health Association of Lesotho representation. The study collected a range of perspectives about gender and HIV/AIDS care from those participating in and potentially affected by health care initiatives. The objectives of the study were as follows: 1. Determine the need to bring men into community-based HIV/AIDS care and support 2. Determine the feasibility of engaging men as providers of community-based HIV/AIDS care and support, especially the gender-related and cultural factors that need to be addressed to increase male involvement in community-based care, based on an analysis of gender relations in Lesotho 3. Identify factors that facilitate or hinder substantive and sustained male involvement in community-based HIV/AIDS care and support 4. Make recommendations for feasible gender-redistributive recruitment, training, support or retention strategies to increase the number of male community- based providers of HIV/AIDS care and support in Lesotho. Analysis of these interviews has determined that there is a need, and it is feasible, to involve men in community home-based care (CHBC) in Lesotho. The study used gender analysis techniques to learn how gender relations might influence the involvement of men in CHBC. It formulated recommendations consistent with Lesotho’s 2003 Gender and Development Policy, asking how interventions might affect gender relations and whether proposed recruitment, training, incentive and retention strategies were “gender redistributive.” The study found that: • Caregiving is a gender-segregated job. A nexus of gender stereotypes about essential “male” and “female” traits, status beliefs and perceptions of men and of caregiving kept women in voluntary HIV/AIDS caregiving and kept men out of it. In the long run, increasing and sustaining men’s participation in home-based care appears untenable as long as women’s continued volunteer labor is expected to fill the breach. • It is feasible to involve men in CHBC, since the Basotho men and women in the study sample demonstrated psychological and social flexibility in taking on the domestic and household tasks ascribed to the other gender. • Male respondents emphasized the technical aspects of caregiving, identified with more powerful male tasks and groups (first aid, miners) and represented this Report on a Study of Men as Providers of 1 Community-Based HIV/AIDS Care and Support in Lesotho work as more “masculine” by using male-identified traits, such as bravery, courage, dignity and discretion. • Training can mitigate negative stereotypes of men, assuage women’s fears about men’s potential for sexual exploitation and increase men’s skills. Training for male and female community health workers (CHWs) should involve critical reflection on gender roles and responsibilities. • Men stand to lose respect from other men and discretionary time by entering CHBC, but stand to gain economically by entering the now-remunerated CHW cadre. While men’s participation in CHBC can alleviate the disproportionate burden of HIV/AIDS care, women stand to lose the benefit of social recognition and may face competition from men in the CHW job. • Standardized working conditions, such as financial and nonfinancial incentives, supplies and equipment, income generation activities, water and food security are essential elements of a increased response to community-based HIV/AIDS care and support needs. The Government of Lesotho, nongovernmental organizations and donors have an opportunity to increase the pool of community and home-based HIV/AIDS caregivers of both sexes through resourced CHBC. CHBC policies and programs should address existing inequalities through explicitly gender “redistributive” and egalitarian policies, messages and recruiting, training and incentives practices (Government of Lesotho, Gender and Development Policy, 2003). Study recommendations targeted national policy, district and community-level interventions: 1. To reduce gender segregation in health work, national health, HIV/AIDS and CHBC and human resources policies should be gender redistributive and explicitly promote a more equal division of responsibilities between women and men, in general and in the context of HIV/AIDS care and support. The Lesotho government and other stakeholders involved in CHBC should simultaneously continue to strengthen women’s capacity to care for those affected by HIV/AIDS through gender-responsive policies, budgets and initiatives. 2. Gender redistributive HIV/AIDS and CHBC policies should be promulgated through training curricula, job descriptions and protocols. The national CHBC training curriculum should include skills training, critical reflection on masculine and feminine gender roles and gender equality in caregiving, communication, HIV/AIDS education, service ethics, gender-based violence and an introduction to male role models already engaged in CHBC. 3. Organizations should adopt a “Volunteer Charter” for CHWs and home-based caregivers to address conditions of work including standardized resources and protections with standardized working hours and remuneration; psychosocial support; response to harassment and violence; tangible protections such as pensions and child-support grants; and supplies needed to cope effectively. Report on a Study of Men as Providers of 2 Community-Based HIV/AIDS Care and Support in Lesotho 4. CHBC programs operating at district or village levels should be designed or redesigned to be “redistributive.” Explicitly promote the equal sharing of responsibilities between women and men in training and supervision and in the recruitment of men. Interventions to recruit men for CHBC should not reinforce stereotypes or expectations of masculinity that might exacerbate existing gender inequalities. We hope this study will help human resources for health practitioners in Lesotho and elsewhere to think about ways to reduce gender segregation in health occupations and tasks, to alleviate the burden of care on women and to address the shortage of nonformal health workers involved in HIV/AIDS prevention, care and support. Report on a Study of Men as Providers of 3 Community-Based HIV/AIDS Care and Support in Lesotho Introduction Lesotho is a small country with an area of 30,355 square kilometers and a population of 1.8 million, landlocked and enclaved within South Africa. The country has four distinct ecological zones: the lowlands, foothills, mountains and the Senqu valley. The country is mountainous and more than 80% of the land is 1,800 km above sea level. This topography and a climate of often severe winters present challenges to health service delivery (GOL Gender and Development Policy, 2003). Economy Lesotho is a resource-poor country with a large percentage of the population (76.2%) residing in rural areas, where poverty is most prevalent. The country depends mainly on subsistence farming, manufacturing and remittances from migrant labor in South African mines. Population Lesotho has a young population, 40% of which is under 15 years of age. The current annual population growth is estimated at 25% and in 33 years the population is expected to double, 76.2% of the population reside in the rural areas where poverty is most prevalent (Health and Demographic Survey, 2004). Health Care System Primary health care (PHC) was adopted as a strategy for health service provision in Lesotho in 1979. Eighteen health service areas were delineated on the basis of the catchment populations. The nineteenth health service area is served by the Lesotho flying doctor service, providing assistance to the most remote areas of the country. Public health care and social welfare services are administered by the Ministry of Health and Social Welfare (MOHSW). The GOL also subsidizes the provision of health services by the Christian Health Association of Lesotho (CHAL) and a limited number of other nongovernmental organizations (NGOs). CHAL provides approximately one-third of health care through a network of eight health service area hospitals and 73 health centers (HCs). CHAL facilities tend to be located in sparsely populated, remote and underserved populations. In 1997 the local government established administrative districts that were charged with overseeing the provision of health and social welfare services. The decentralization affects the delivery of health services, and there are often overlaps in service management. It is not clear how district level HIV/AIDS councils relate to MOHSW health service areas. Report on a Study of Men as Providers of 4 Community-Based HIV/AIDS Care and Support in Lesotho Disease Burden Lesotho has the third highest HIV prevalence rate in the world, at 23%. It also has the fourth highest rate of tuberculosis incidence and a growing problem of multi-drug- resistant tuberculosis. These high rates create a heavy burden and severe adverse impacts on socioeconomic indices of the population. The Demographic and Health Survey (DHS) measures of attitudes of acceptance toward those living with HIV include the following: 87% of women and 79% of men are willing to care for a family member with the AIDS virus in the respondent’s home; and 64% of women and 66% of men would not want to keep secret that a family member was infected with the AIDS virus, though women’s and men’s acceptance on five attitude measures was low (24% of women and 20% of men). UNAIDS estimated 23,000 annual deaths in Lesotho due to AIDS in 2003. The Lesotho Network of People Living with HIV/AIDS (LENEPWHA) Five-Year Strategic Plan states that “the number of people living with HIV/AIDS is high and steadily growing,” with about 55% (146,300) of cases in 2005 being females aged 15-49, of which 75% were aged 15-29. Of the 270,000 Basotho living with HIV in 2005, 14% were receiving ARVs. Life expectancy in Lesotho fell from 60 years in 1989 to just 39 years by 2005. The impact of the HIV/AIDS epidemic has resulted in an increased burden on the health care system. It directly affects the health of large numbers of people in society and reduces the overall health status and wellbeing of the nation contributing to increased morbidity and mortality and placing stress on already overstretched health care system (National AIDS Policy, 2006). The most basic level of PHC service provision is at the community/village level where an estimated 4,800 volunteer community health workers (CHWs) are the first line health providers (Human Resource Needs Assessment Survey, 2004). LENEPWHA notes that many of these women, who are primary family caregivers, will experience early mortality. Among AIDS deaths in 2005, 54% were women and 46% were men, 97,000 children were orphaned as a result of AIDS and other causes and with an increase in children-headed households. This suggests that children and adults needing care, psychosocial support and community mobilization will likewise increase. A 2004 UNAIDS report estimated that in Africa, only approximately 12% of HIV-positive people in need of home-based care actually received it. This study supports two strategic options included in the GOL’s 2006-2010 National HIV/AIDS Strategic Plan: promoting the involvement of men in home-based care; and recognizing and supporting caregiving services offered by women and girls to HIV/AIDS patients. The study was conducted on behalf of the Lesotho MOHSW’s Family Health Division and its partner, the Capacity Project, in order to find out what it would take to attract, train, support and retain men as providers of community-based, home-based HIV/AIDS care and support. Report on a Study of Men as Providers of 5 Community-Based HIV/AIDS Care and Support in Lesotho