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May 2001

Researching the nature and extent of HIV/AIDS discrimination in South Africa for the Department of Health

S&T, in partnership with the AIDS LAW project of the Centre for Applied Legal Studies at Wits University, won a tender from the Department of Health to assess the extent and nature of discrimination against people with HIV and/or AIDS. The project will be run by Ross Jennings and Jowie Mulaudzi.

Discrimination

Every day people living with HIV or AIDS face one problem after another because of discrimination. People struggle to get access to proper medical treatment, school for children, shelter, work and food. It is difficult to buy a house because it is impossible to get insurance. The children and families of those with HIV or AIDS face harsh words from friends or colleagues. The current stigma attached to HIV/AIDS can compound existing levels of discrimination on the basis of race, class, sex and so on.

The Department of Health has recognised that fear of discrimination is a significant obstacle to persons coming forward for counselling, testing, support and treatment. Against this backdrop, the Department is currently involved in a series of programmes aimed at creating an environment that protects and promotes the rights of people living with HIV and AIDS. However, the Department needs primary data about the nature and extent of discrimination.

The Department has commissioned S&T to undertake research to establish baseline information on HIV/AIDS discrimination in South Africa. The research study is also required to develop a draft strategy on ways in which the dis-crimination can be countered.

A powerful team

To meet the objectives of the study, S&T has formed a partnership with the AIDS LAW Project of the Centre for Applied Legal Studies. This brings together an organisation conversant in the issues and problems surrounding HIV and AIDS and discrimination, with our strong track record in rigorous socio-economic and development research.

Our methodology is based on a bottom-up approach. While we recognise the institutional dimension of discrimination, our belief is that this form of discrimination is being tackled through various legislative initiatives. Our focus is more on the social and communal aspects of discrimination found in every day life.

The first part of the research will be sifting through the wealth of material that the AIDS Law Project has accumulated on the issue from years of helping people with HIV/AIDS to deal with the numerous problems associated with discrimination. These issues will be further explored and expanded through a series of focus groups. A survey in two different areas of the country will then be undertaken to Ďarbitrateí the findings of the qualitative phase. Finally, a draft strategy will be workshopped with key stakeholders before being put to the Department.

 

Unemployed youth in the Eastern Free State: a learner profile

S&T has won a tender to help profile youth in the Eastern Free State, writes project leader Ross Jennings.

JET is busy with the establishment of a Curriculum Team and building consensus on a Curriculum Framework. There are a number of key research activities that will underpin this process:

  • An awareness of the local economy.

  • A profile of the target market.

  • An assessment of service providers in the area.

Strategy & Tactics has been commissioned to undertake the profile of the target market.

Using a mixture of methods - which include analysing existing quantitative data and gathering primary qualitative data - the Learner Profile will address the following objectives:

  • Providing an understanding of the social context of youth development.

  • Profiling the target market in terms of skills level, work experience, qualifications and aspirations for the future.

Reflecting on the proposed curriculum on the basis of the above two objectives.

 

S&T and Development Update

S&T Senior Partner David Everatt recently guest edited a special youth edition of Development Update, which has been widely hailed as a key intervention in the youth sector.

Since then, David was asked to join the Editorial Board of Development Update, which is published by Interfund and is a joint venture between Interfund and the South African National NGO Coalition (SANGOCO).

David was also commissioned to edit the Annual Review, which has just appeared; as well as the subsequent edition, reviewing development between 1994 and now. This will include an article by Moagi, entitled "Partnership with civil society in public works".

Analysing the transition

S&T has also been commissioned by Interfund and the CS Mott Foundation to produce a book that critically analyses the transition period. The book will be edited by David Everatt, joined by Professor Deborah Posel of the Wits Institute for Social and Economic Research, and Dr Vincent Maphai, chairperson of the SABC and head of corporate affairs at SA Breweries.

The book will bring together some of South Africaís leading intellectuals to assess key aspects of transition. More detail will appear in the next edition of Phatlalatsa.

 

Research into lump sum payments for the RAF Commission

Senior partner Ross Jennings has just completed a fascinating project for the RAF Commission.

The Road Accident Fund Commission was established by the State President to inquire into and to make recommendations regarding a "reasonable, equitable, affordable and sustainable system" for the payment of compensation or benefits to the victims of road accidents in South Africa.

As a part of their comprehensive investigative process, the Road Accident Fund (RAF) Commission approached Strategy & Tactics to undertake research into the expenditure of lump sum payments made by the Fund to the victims of road accidents in South Africa.

Ground-breaking research

World-wide, research into this issue is minimal. One of the reasons for this is the sensitive nature of the information that is sought; and the fact that claimants are not obliged to, or may not be able to, account for the expenditure of their lump sum payment.

The Road Accident Fund provided access to information from their database, and ten claimants residing in Gauteng (for ease of access) were selected from the database to pilot the questionnaire. It was initially hoped that information on claimants from 1995 onwards could be obtained. However, the database only started capturing information from the end of 1997. As a result, a decision was taken to concentrate only on claims from 1997 (a total of 112 claims). Due to the difficulty of tracing claimants, it proved necessary to extend the focus of the study and information on all claims above R250 000 paid in 1998 were added to the sample frame.

Survival or assistance?

The Road Accident Fund, a parastatal, presently determines the compensation to be paid to a road accident victim. The compensation is allocated across a number of categories according to the damage the victim has suffered.

These categories include medical expenses, loss of earnings and general damages for pain and suffering. Most frequently, the compensation is paid out by way of one lump sum to the claimant. This payment is usually made through an attorney.

Without pre-empting the release of the Commissionís report later this year, the main finding was that claimants were largely ignorant of what the lump sum payments had been targeted at. As a result, the lump sum payment was seen as a means to survive, as a way of getting over the impact of the accident or a way of securing the future for themselves or their children. Given the socio-economic status of many claimants, this financial resource appears to have gone some way to ameliorating a desperate situation.

While the uses that the lump sum payments were put to may have been financially prudent, it did question the resources used by the RAF and the various legal representatives to dedicate particular portions of the payment to particular categories.

"My enigste seun is 9 jaar oud en kruip in huis rond. Geen geld kan hiervoor vergoed."

"Theyíve taken too long to settle the claim and I am still unaware about many things regarding the claim."

"I think the lawyers and the legal games are the problem with the Fund."

"It helped me a lot to provide for the future with my husband no longer with us."

The final RAF Commission report will be released later this year.

 

Innovative logframe planning for the WK Kellogg Foundation Africa Programme

David and Matthew are currently assisting the W K Kellogg Foundation (WKKF) Africa programme develop a programme-wide monitoring and evaluation strategy.

The WKKF Africa Programme

The WKKF Africa Programme works across 8 Southern African countries: South Africa, Namibia, Botswana, Zimbabwe, Malawi, Lesotho, Mozambique and Swaziland. The Programme aims are two-fold:

  • To assist in the regionís social and economic transformation through investments that will maximise the regionís systematic social and economic change as evidenced by inclusive and growing economies, better policy environments, and more participatory institutions and effective leaders, and

  • To nurture examples of healthy and sustainable rural communities with mutual, healthy urban links and greater advancements for women and youth in economic power, civic participation and skills development.

These goals will be achieved by three initiatives, namely:

  • the Integrated Rural Development Programme (IRDP), which aims to build capacity and promote civic participation, and thereby transform rural institutions to promote rural development.

  • the Initiative for Development and Equity in African Agriculture (IDEAA), which aims to facilitate the transformation of institutions and related policies that hinder effective provision of services to small-holder farmers.

  • the Leadership Regional Network for Southern Africa (LeaRN), which aims to nurture leadership for social and economic transformation through learning opportunities, building social partnerships and facilitating critical reflection.

Activities to be performed 11by these three initiatives include promoting better community governance structures (such as womenís and youth organisations), promoting civic participation at all levels of governance, developing a leadership academy, building a leadership network, promoting credit institutions for small-holder farmers, and developing models of integrated rural development.

Taking logframes a bit further...

To assist the WK Kellogg Foundation succeed with this ambitious programme, S&T has been assisting the initiatives in a series of workshops, working alongside a Harare-based company, Cyberplex. Our task is to develop robust planning documents that are internally coherent; provide realistic targets; assist managers and implementers; guide evaluators; enhance monitoring; and are not cluttered with too many indicators or milestones. To do so, we have had to make traditional logframes more flexible, allow space for qualitative and process indicators, and make them flexible enough to reflect initiative activities alongside six support services, across the eight countries.

Once this process is complete S&T will assist the programme identify different evaluative opportunities and methods for each initiative, and following this define programme-wide monitoring and evaluation possibilities.

 

Workflow Study

Typically, when big organisations are faced with problems similar to the DoL they tend to focus on their organisational structure and thereby change the way they are organised. In most cases this does not fundamentally change how people operate as they continue to operate in the same way, albeit in a different structure. Workflow studies on the other hand focus on the work process, prior to making any changes to the organisation. A workflow study is usually conducted in three phases:

Phase one: Analyse the System

  • Define what should be happening and who should be performing these tasks

  • Analyse the current system,

  • Identify the weaknesses in the current system

  • Compare what should be happening with what is actually happening

Phase two: System Planning

  • Decide which tasks should remain, and performed by whom

  • Define revised organisational structure to match these tasks

  • Identify what extra resources are required

  • Define the steps necessary to implement the new system

Phase three: Implementation

  • Document and promote the details of the revised system

  • Ensure required resources are in place

  • Educate everyone in the organisation

  • Train each individual in her/his revised or new responsibilities

  • Plan and schedule the introduction of the new system

Over the next 6 months Matthew and his colleagues from the DoL will be conducting their workflow study following the phases outlined above. It is hoped that by September the DoL will have successfully implemented a revised system in the three provinces in which the study is being conducted.

As part of S&Tís continued involvement in the Department of Labourís Labour Market Skills Programme (LMSDP) Matthew Smith has been assisting the programme in a workflow study across three provinces. The study flows directly out of the provincial planning exercises which Matthew helped facilitate. During these planning exercises it became clear that at the provincial level the Department of Labour (DoL) is beset with staffing, service delivery and management problems. The DoL has therefore embarked on an ambitious study to understand how work flows through the organisation.

 

Measuring Client Satisfaction

Matthew Smith and Beth Engelbrecht of the Health Systems Trust assess the state of the Client Satisfaction Tool developed by S&T, and patient rights in general.

Introduction

Care for the patient is the fund-amental aim of health services, and motivates many service providers. The public health system in South Africa has often been accused of inefficiency and the abuse of patientís basic rights. Consumers are now increasingly aware of their rights.

The assessment of client satisfaction forms an important part of the management of a health facility, especially after the adoption of the Batho Pele (People First) principles and the Patients Right Charter.

The main objective in undertaking our research project was to develop an instrument that would assess the satisfaction levels of clients, using two district hospitals in South Africa as pilots. The hospitals were the Gordonia hospital in Upington, and the East Griqualand and Usher Memorial Hospital in Kokstad.

What is a Client Satisfaction Tool?

The literature suggests that a CS tool should be a key instrument in any hospital/clinic management strategy, provided the tool has been well designed and is administered in a scientific manner. To ensure full participation from the client, the CS tool must be easily understood, and it must take cognisance of the clientís ability to complete the survey while maintaining confidentiality.

Taking the above into consideration it was decided to implement a two-phase research process. In the first phase, qualitative methods were used to determine the concerns of the clients in depth. In the second phase, quantitative methods were used to measure levels of satisfaction amongst clients at the two hospitals.

Developing the tool was undertaken in 4 distinct stages between June 1999 and July 2000. In each pilot, both the instrument (the Client Satisfaction Tool) and the data gathering process were tested. The methods used in this research study can be outlined as follows:

Stage 1

In stage one, focus group discussions were held within a framework of quality of service concerns.

Stage 2

In stage two, the pertinent issues that influence the perception of clients about the service they receive, together with internationally accepted norms and approaches, were used to develop a questionnaire around the main domains that influence client perceptions.

Stage 3

In stage three, the questionnaires were piloted. A Xhosa version of the Client Satisfaction assessment tool was piloted in Kokstad, and an Afrikaans version was piloted in Upington. In both instances training was provided to a local fieldworker, who administered the instrument.

A manual to assist hospital management to manage the client satisfaction assessment process was also developed. This phase ran parallel to stage 3 and was therefore tested as part of the third stage of developing the assessment tool.

Stage 4

In the final phase of the project we assisted hospital management teams make decisions based on the findings and thereby improve the quality assurance programmes in their hospitals.

Results

The series of pilots, outlined above, led to the development of a valid and reliable CS Tool; and the pilots produced data that could be analysed and used.

The analysis of the results gathered by the CS tool illustrates that there is a strong link between the survey results and the data gathered in the focus groups. Participants in the focus groups and in responses to the questionnaire demonstrated that while they were happiest with staff, they have reservations about most of the services offered by the two hospitals. In particular, clients were especially unhappy with access to the two hospitals.

Developing a South Africa-specific instrument

The preliminary results indicated that average scores hover between 0.5 and 1.0 (on a scale between -2.0 and 2.0), which suggests that clients are more satisfied than dissatisfied with the two hospitals. In the second phase of the analysis the questions were sorted into five SERVQUAL domains, namely tangibles, reliability, responsiveness, assurance and empathy. In addition, two new domains were created: one for access and the other for general satisfaction.

Other than for access, all the domains achieved a positive score, albeit relatively low. Empathy - the ability to care and display compassion towards clients - scored the highest out of all the domains.

Although the scores from the pilot studies are low, hospital management at both hospitals could take some satisfaction from the fact that clients are not completely dissatisfied with the levels of service provided by these hospitals, as some media reports may lead one to expect. The data suggest that there are some key areas hospital management should consider, which in turn could lead to higher levels of satisfaction amongst their clients.

CS tools are by their very nature instruments which even when used properly can only assist in the gathering of information. Moreover, quantitative studies of this nature will only measure the items on the questionnaire. Alternatively, qualitative methods provide a richer and deeper understanding of what clients are thinking, but the findings are not generalisable. Using a combination of quantitative and qualitative methodology can provide a more accurate picture of the perceptions of clients. Future studies of this nature would do well to not only constantly test the reliability and validity of the CS tool, but to also explore the thoughts of the clients through periodic focus groups or by collection of comments made by respondents during the surveys.

 

The role of traditional leaders in rural development projects (Part II)

In the December edition of Phatlalatsa, S&T Senior Partner Moagi Ntsime, and Sibongile Mthembu, EPA Developmentís Provincial Programme Manager, discussed the role of traditional leaders in development. In this edition Moagi develops answers to some of the questions raised in the first article.

In the first article, we indicated that traditional leaders play a major role in community-based development projects - but that this can be either a positive or negative role.

Community development projects are expected to generate employment opportunities, enhance economic development and activity and open possible new opportunities; enhancing social cohesion is also important. Traditional leaders are key stakeholders located between organs of government, funding sources, development agencies and local people. The challenge is ensuring that they are development partners.

Are traditional leaders gatekeepers?

There are specific examples in the country where traditional leaders have acted as gatekeepers; and there are instances where their involvement in development initiatives functioned well and benefited the local community. In other words, there is no single answer: traditional leaders can be either gate-keeper or facilitator.

For example, in one instance in Izingolweni, in the Ugu District Council, a baseline study was commissioned by the National Department of Public Works. This was to assess poverty levels and development need profiles of the surrounding communities. The baseline was important in that the Department would have accurate data upon which their poverty alleviation strategy would be based.

Prior to fieldwork, initiatives were undertaken to inform the local leadership and all stakeholders about the study and its overall objective. The fieldwork team could not access some areas without the permission of the local Inkosi. But the relationship did not prove easy, and meetings to resolve the issue were continuously postponed.

This delay posed serious challenges for the project. Firstly, the project was time bound: it had to be completed, results analysed, and presented to the Department with concrete policy recommendation within a specified timeframe. Secondly, delays had direct cost implications: fieldworkers had to be paid while waiting for access. Thirdly, the longer it took to provide data, the longer the Department had to wait to check their strategy and goals. The Department could not go ahead and implement projects that may not have been priority projects for the area.

Various strategies were used to finally break the logjam and receive permission to collect data in the area. Some important findings emerged from the study. For example, clean water was cited by respondents as a top development priority for the area. People had to travel long distances to fetch water, and these were mostly women and children. Secondly, access to health care was the second mostly identified development need by the local community. While there was a mobile clinic in the area every fortnight, this did not reach the majority of people because of the distances they had to travel and the number of people it had to cater for. Again those who suffered the most were the poor in the area, pregnant women, children and the terminally ill.

Politics must give priority to strengthening rural areas

It is important that policy-makers, Councillors in rural areas, traditional leaders and other stakeholders should listen more to the priorities and concerns of residents. Through close dialogue, which could be facilitated by the involvement of traditional leaders, local communities will be better placed to identify, prioritise and participate in processes of ensuring that their development needs are realised. As the Integrated Development Plan (IDP) takes centre stage in delivering development in South Africa, so this must become a priority.

Somehow, development needs must override political boundaries. For example, the fact that people of Squngqweni village in Tsolo could be cut off by heavy rains defined their needs - not their political affiliation, or what the local chief would like them to say or not say. The local chief can play a unifying role in activities geared towards resolving the problem.

We need to caution that this is always not easy, especially if project officials in a particular area do not perceive traditional leadership as central to sustainable development initiatives. Traditional leaders can obstruct such initiatives because they want to flex their political muscle, and signal their control over rural jurisdictions. But they can also be critical links between the project team and the local community. Through their assistance, problems of post project control, ownership and management by local communities can be addressed and sustainability considerably enhanced.

Concluding remarks

It is time for a free and frank discussion about the role of traditional leaders as development partners. We have no easy solutions to offer - but the issue needs sensitive research and a commitment from both sides to develop workable positions.

For example, where traditional leaders resist attempts to enhance opportunities for women, it is important that these leaders are engaged in a strategic process of discussion. This may ensure their involvement by demonstrating in practical terms how these projects impact positively on the lives of their people.

A broader development perspective would also equip traditional leaders to understand and explain why targeting exercises may benefit one area but not another; or why programmes give preference to particular groups or types of individual. Traditional leaders must be brought on board for rural development to meet the challenges of the 21st century.

 

Empowerment Opportunities & the role of women in the Consolidated Municipal Infrastructure Programme

S & T senior partner Moagi Ntsime looks at the role of women in labour intensive infrastructure delivery projects within the Consolidated Municipal Infrastructure Programme (CMIP), managed by the Department of Provincial and Local Government (DPLG.

In previous editions of Phatlalatsa, we have assessed critical development challenges faced by infrastructure delivery programmes that focus on the empowerment of poor communities through participation in the identification and selection of required projects. S&T partners are heavily involved in two of these, namely CMIP and the Community Based Public Works Programme (CBPWP).

Objectives of CMIP

In the past, CMIP placed more emphasis on urban than rural development. The programme has been criticised in some quarters for placing more emphasis on budget spending and construction phases than performance and impact, whether or not target groups were reached, employment opportunities, and maximising training opportunities for the poor.

For the 1999/2001implementation strategy, the programme aimed at:

  • Provision of household infrastructure and affordable services,

  • Creation of liveable, integrated cities, towns and rural areas,

  • Local economic development, and Community empowerment and redistribution.

The programme aimed to achieve empowerment of women and the poor by providing for community participation in project identification and implementation; and ensuring that projects are sustained after completion. Creating linkages between infrastructure delivery and local economic development was important in the latter instance.

Employment opportunities created - for men

The CMIP Programme Manager collates data regarding performance and progress on a monthly and quarterly basis. This includes information about the employment of women in the programme. The data we use here cover the period March 1999 to December 2000. It is immediately noticeable that employment opportunities for women have remained largely static for two years.

For example, the October - December 1999 quarterly report records a total of 2 387 623 labour days created up to December 1999 on CMIP projects across all provinces. When analysed across three categories used (women, men and youth), 1 861 990 labour days for men were created (78%), while 237,974 (10%) labour days were created for women and 287 800 (12%) labour days were created for youth.

When analysed across provinces, we find that on average three-quarters of all employment opportunities were created for men, with the remainder apportioned to youth and women. Clearly, more purposive management is needed to expand opportunities for women in all provinces.

Getting better?

However, 1999 showed a steady increase in the proportion of labour days created for women. Provinces doing better included the Northern Province (23%), Mpumalanga (20%), and the Free State (15%).

The overall programme figures (from inception to date) show that women accessed 10% of all employment opportunities created. There are wide provincial disparities in the data: Mpumalanga (21% of employment opportunities went to women), Northern Cape (28%), and Northern Province (26%) performed relatively well, while others were considerably worse.

What are the key issues?

Firstly, the DPLG should be commended for managing a functioning monitoring system that provides us with accurate, timeous data; and permitting analysis to inform programme managers. The key is to learn from the past in order to improve the situation in future, which requires strong political will and commitment from implementing agents as well as government.

It is important to note that a whole series of cultural, social and other issues come into play when seeking to maximise labour opportunities for women, and the problems should not be minimised. It may be useful to deploy fast turn-around diagnostic studies, at site level, to assess the problems in context and help build up a picture that highlights key challenges. These may differ from one local area to another.

While many government programmes share broad policy objectives of empowering the poor, and women in particular, through a range of interventions, the extent to which these objectives are met continues to be faced with various challenges on the ground. In some cases, those tasked with helping programmes meet their objectives, do not share similar values to those who designed the programme. In other words, they stress a technocratic approach - arguing that their role is ensuring the delivery of assets in time and budget - but miss the social aspects and goals of the programme.

Monitoring data influencing awareness

At the 8th Provincial Programme Managersí Quarterly workshop for CMIP, which I attended, all Provincial Programme Managers committed themselves to the objectives of the programme, especially ensuring that women access opportunities to participate in the programme. The National Department and the Provincial Programme Managers noted that the employment of women in the programme has been disappointing. This is an important step, and shows monitoring data influencing management thinking.

But there are still some worrying issues, which reflect the differing approaches to the programme. One person at the workshop said: "I donít know what government expects us to do. You tell us what are your expectations, we are told to deliver projects, and yet time and again we are told about looking for women to work on projects. Ensuring that there is service delivery remains my primary objective - the issue of women for me is secondary".

Development or charity?

This was said by a government official, not - as might have been expected - by one of the engineers implementing the programme. Empowering women is still regarded by many in and out of government as an act of charity, rather than fundamental to successful and sustainable development.

Others speakers claimed that women do not want to work on projects, and prefer to do domestic work. These archaic attitudes are in direct contrast to CMIPís policy goal, which states that "women make up at least 50% of the total labour force employed for each project, and that emphasis should be placed on female single headed households, and have dependants."

Development initiatives cannot afford to operate on the basis of "business as usual" - which means deliver a functional asset within the set time limit and ignoring the deliberate social goals of the programme. Sustainability is created through a participatory approach, in which women and men must be equal.

 

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