In countries where populations live scattered, separated by long distances from understaffed clinics and hospitals, the answers to the HIV epidemic — care, treatment, prevention — rested on the shoulders of community health workers from the start. As donors and governments recognized the needs HIV spelled out for comprehensive services — for food and nutrition, for maternal and infant care, for family planning, for primary health care, and for the tuberculosis screening as HIV hastened the spread of that disease, the value of those unpaid, or barely compensated frontline responders increased.
In Tanzania, one of three countries to become a focus of the U.S. President’s Emergency Plan For AIDS Relief obliquely acronymed “GBV Initiative,” community caregivers now are pivotal players in a response to a fatal cycle of inequity and violence. (The other two are Mozambique and the Democratic Republic of Congo.)
GBV, of course, is short for “gender-based violence,” which, in turn is short for physical, sexual, and psychological abuse directed at people because of their gender, or gender identification. That includes girls, boys, men, women, people who are gay, transgender, or other sexual minorities, but in its most frequent usage, it means violence against women. It is both a risk factor for, and a consequence of getting HIV, and in Tanzania, as many countries, explains in part why women are disproportionately affected by the epidemic.
Pathfinder International has worked in Tanzania since 1984 on HIV, reproductive health and local civil society strengthening programs. When the organization took on its role in the GBV initiative, home-based caregivers were a natural source for the program’s “main platform,” Pathfinder Tanzania country representative Mustafa Kudrati said. The task of those workers had long shifted from palliative care, essentially “dignified care for the dying,” to long-term support, Kudrati noted. In Pathfinder programs home-based care providers have linked community members to services ranging from village savings and loan groups to family planning. “It’s really important who your source is when you talk about family planning,” Kudrati said.
Kudrati was speaking Thursday at a panel discussion hosted by the Center for Strategic and International Studies Global Health Policy Center on “Using Community-Based Platforms to Provide Integrated Services for Women: The Pathfinder Approach in Tanzania.”
The role of community-based platforms, in short, is valuable, and becoming more so, in a country where a woman faces a one-in-23 lifetime risk of dying in childbirth, where as many as 18 percent of women and girls have been victims of genital mutilation, where 44 percent of women who have ever been married have been beaten or sexually assaulted by a partner, and where an investment is now being made to end a cycle of inequity.
Through Pathfinder, caregivers have gotten training that costs about $800 per person to provide, in an array of services integral to their communities, including newborn and maternal health services,TB services, and now “GBV” services. In the process, Kudrati said, many have been trained repeatedly in something called “engaging the community,” — an inflexible Ministry of Health requirement that seems potentially linked to a need to keep a steady supply of trainers’ per diem pay coming in — every time. The last is a source of some frustration as it appears to be a waste of trainees’ time after the first time, and that is a concern, because Kudrati fears, in effect, that their time will someday run out.
That is because, with a stipend of about $12 a month, the people who link the community to the initiative are essentially volunteering time that adds up to a full work week every month to the effort. World Health Organization guidelines, Kudrati said, recommend asking no more than eight hours a month from volunteers. So far, Kudrati said, they keep coming back. But he wonders how long it will last.
“How do you continue?” Kudrati asked. “It’s really hard to motivate people to continue volunteering.”
CSIS Global Health Policy Center senior associate, who authored the report Gender-Based Violence and HIV Emerging Lessons from the PEPFAR Initiative moderated the discussion, which also included Pathfinder President Purnima Mane, and Daniela Ligiero, senior gender advisor for the Office of the Global AIDS Coordinator.