Universal access and attainment of health rights
Zimbabwe: Local level advocacy in health and rights
Von Joshua Mavundu
Support groups in Zimbabwe are turning into advocacy groups with People living with HIV (PLHIV) successfully utilising advocacy methods in order to achieve better medical treatment and to reduce stigma in society. Success stories in Zimbabwe show the potential of HIV and AIDS related activism, linking local level activity with national campaigns.
The concept of local level advocacy initiatives in Zimbabwe began when Batanai HIV and AIDS Service Organisation (BHASO) in Masvingo, an NGO partner of fepa, trained the first core group of 30 advocates. Two people living with HIV (PLHIV) were chosen from each local support group and were trained to be advocates. BHASO provided them with systematic advocacy training which involves technical knowledge about the disease, treatment literacy and human rights, national and international networking as well as thorough preparation of campaigns.
PLHIV as drivers of advocacy
Local level advocacy is spearheaded by PLHIV in the communities with knowledge on advocacy, human rights and law. The local advocacy committees in Masvingo involve all people in the community by holding consultation at all levels of the community. In most cases of HIV and health, consultations involve support group leaders, youth support groups, AIDS services organisations in Masvingo like Batanai, Zimbabwe AIDS Network, National AIDS Council, Red Cross, SolidarMed and many others. Local business people provide financial assistance during community meetings and are aware of the work that the advocacy committee is doing. A diverse network of community participants are consulted and involved in the work of the provincial advocacy committee. This has enabled a shared vision with the community assisting in keeping the vision alive. For example, every time there are health rights violations in the community, e.g. drug stock-outs or discrimination, ordinary people in the community would generally ask if the advocacy committee knows about it and make every effort to bring the issue to the attention of the advocacy committee for action. This happens because everyone in Masvingo is aware of the shared vision of community health based on a human rights agenda.
The structure of local level advocacy creates a network of advocates from the community level up to the national level and operates at five levels: at the ward level, cluster level, the district level, the provincial level and the national committees. Almost all the provinces now have functional advocacy committees coordinated and run by PLHIV. Outside Masvingo the structure is coordinated by Zimbabwe Lawyers for Human Rights (ZLHR) in partnership with Zimbabwe Network PLVIH (ZNNP+). In 2009, the national committee used to convene as a national roundtable, which is now the National Health and Rights Advocacy Forum.
The unique concept of advocacy committee is based on ownership by PLHIV who are supposed to drive the initiatives and function independent of anyone or any organisation. They are free to network and create partnerships in the communities as they deem fit in order to promote the shared vision of rights and health in the communities. Advocacy committees like support groups belong to the community and not to any institution or aids service organisation. Approaches have sought to dissociate the concept from the usual uneasy approach where people are owned by some person or institution. Advocacy committees therefore belong to the community and are there to hasten and behold to community needs and problems. They can operate independently because the concept is not expensive and is community driven.
Experiences in Masvingo have shown that advocacy is taking action and speaking out on a problem. Advocacy committee in Masvingo has undertaken action directed at changing the policy, practice, program, system, behaviours or environment in a manner that addressed the everyday problems faced by people in the community. Cases studies from Masvingo have shown that advocacy action involves putting a problem on the agenda and drawing a community’s attention to it and the need to solve the problem. Advocacy action herein highlighted involves a wide array of activities undertaken to achieve the desired change.
CASE 1: DRUG STOCK-OUTS
The first case happened in May 2008 and concerned drug stock-outs in the whole province. The advocacy committee received reports from concerned community members that there was a shortage of the drug in the province. The drug was said to have been withdrawn and this was causing an increase in cases of opportunistic infections among PLHIV in the province. This resulted in PLHIV experiencing increased medical costs since they were paying consultation fees and other medical fees to treat related the opportunistic infections. Just over 1 400 PLHIV were accessing the drug.
The advocacy team first engaged the District AIDS Coordinator (DAC) through a meeting where the committee highlighted the problem to the DAC, who later recommended a meeting between the advocacy committee and the Matron of Masvingo General Hospital. The meeting with the Matron did not yield much. The committee then engaged the Natpharm manager who highlighted that the Ministry of Health and Child Welfare (MoHCW) owed them a lot of money and the drugs were available but they could not be released owing to the debt.
The advocacy committee then had a meeting with the hospital pharmacist, who confirmed the information on condition of anonymity. From there the committee went to the MedicalSuperintendent and demanded a meeting. During the meeting, the Medical Superintendent said there was no fuel to collect the drugs from Harare but the committee insisted that the drugs were there at the Natpharm pharmacy and that PLHIV should access those drugs immediately. Later on the Medical Superintendent (MS) went with members of the committee to Natpharm and met with the Natpharm manager who later agreed to release ten boxes of Cotrimoxazole.
Results of advocacy: Natpharm released 10 boxes of Cotrimoxazole to Masvingo General Hospital on the day and more supplies were subsequently released.
Throughout the narrative of advocacy diaries in Masvingo, it is apparent that advocacy action should first identify an advocacy objective. The advocacy committee or team has systematically set out what they intended to achieve before embarking on advocacy action. In most instances, initial research has been undertaken to provide relevant data to support advocacy arguments. Research has been carried out in various districts in the province on the thematic issues that have been raised in the districts as advocacy issues.
It is important to identify advocacy audiences. In the various districts in the province, advocacy targets have consisted of a cross section of government officials and key stakeholders who have contributed immensely to changes in policies, practices and programmes. The advocacy committee has systematically identified target audiences who make decisions or influence the decision making. In local level advocacy, it is important to identify who makes decisions in the local community and who can influence decision making.
Building partnerships and coalitions is important to strengthen the advocacy voice. The power of advocacy is found in the number of persons or organisations who support your objective. Non-governmental organisations, government health workers, business leaders, politicians and church leaders have all been part of the broader network of partners identified by the Masvingo advocacy committee for the work in the province. Besides facilitating political support, large numbers of people from diverse interests assist in amplifying the voice for the agreed cause.
The Masvingo advocacy committee has adopted innovative ways of framing advocacy content and presenting it. Formulating advocacy messages allows for the proper framing of issues using the appropriate language and data. This will also allow for persuasive presentations to be made to the appropriate audiences without wasting time. Usually policy makers do not have enough time to deal with many problems that are presented to them daily so it becomes critical to be able to package advocacy messages for efficiency and effectiveness within limited resources of time and limited opportunities to be heard.
Lastly, evaluation is crucial in advocacy because it enables you to see if the strategies being employed are working or not and to work on any improvements on current strategies in future actions. This is one area where serious effort is needed to effectively measure advocacy work in the province.
World AIDS Day Advocacy Initiative
The year 2011 World AIDS Day commemoration was held in Mutare. The theme was, “Zero new infections, zero discrimination, zero HIV related deaths: Leaders make universal access a reality”. Basically the theme drives at leaders partaking and assuming influential roles in making universal access to treatment and human rights for PLHIV possible. It was also driving the issues of zeroing new infections, discrimination and new HIV related deaths. The commemorations were celebrated by a lot of stakeholders and partners from all over the country.
Batanai together with its strategic partners Zimbabwe Lawyers for Human Rights and Zimbabwe National Network for People living with HIV were also part of these commemorations with Batanai bringing in advocacy team members from all over the province to participate on this day.
In retrospect of the theme Batanai and its partners ZLHR and ZNNP+ facilitated a march initiated by PLHIV as a way of advocating for at least 15% of the national budget being routed to the health sector thereby increasing the funding that had already been allocated towards the sector. The health sector had been allocated 8.7% which is insufficient for health care in Zimbabwe especially with the issue of HIV where treatment is necessary and is on demand which drives our plight as Aids Service Organizations and various partners who work towards the betterment of the lives of PLHIV through positive living and treatment is part of it.
In this regard, a petition was prepared by PLHIV, which was delivered both orally and tangibly to the Minister H. Madzorere from the health department. This approach was effective because key government officials were present including Minister H Madzorere, Lucia Mativenga from the public service sector as well as Doctor Timothy Stamps who is the Health advisor to the president. From the civil society sector also were top officials from coordinating organizations like Zimbabwe AIDS Network who is vital for resource mobilization and advocacy in the health sector, the National AIDS Council which is the mother coordinating board, UNFPA representatives and other key partners. Thus these issues are considerably going to be deliberated due to the efforts and influence of these people. This anticipation was raised as the Minister Madzorere assured that he was going deliver and pursue the petition to the responsible authorities. PLHIV were happy as this has shown light that there is going to be a change.
The march was also supported by the Zimbabwe National Army, Zimbabwe Republic Police, youth and church groups and peer educators who vibrantly took part in efforts to make the goal of this initiative realized. This served as an indicator that even the state security agencies have the same cry towards the issues of universal access and human rights. Many groups (youth, children and church groups) have also engaged into these efforts and it has shown that people are realizing the intensity and the need that is there for the issue of access to be addressed fully or otherwise be redressed.
In Masvingo advocacy team members are the voice of reason, the opinion leaders and drivers of social justice, speaking out on issues and being proactive. Key highlights of this local level advocacy effort include action for policy and programme change in Gutu ART services, which have been de-centralised to 14 local clinics and provided on a no-cost basis (including for OI infections, other essential medicines, diagnostics etc.).
Key results from local advocacy efforts on HIV and Human Rights in Masvingo include:
• The increase in ART sites from one site, charging user fees, in Gutu District in 2010 to one initiating site and 14 local clinics providing no-cost, comprehensive ART and opportunistic infection services in Gutu.
• 73 police and prison officers agreeing to undergo training on the rights of PLHIV and two support groups being established in established subsequently.
• User fees for ART services being done away with following a sit in, petitioning by 1’000 PLHIV and a series of meetings at district and provincial level.
• An apology being printed in the local press and a HIV column being following stigmatizing coverage of the advocacy team’s user fee action.
The result of this work is often qualitative, with PLHIV taking actions that advance the realisation of their right to prevention, treatment, care and support. It also results in PLHIV feeling that they have the ability to influence the agenda, to seek greater accountability from decision makers and to bring about change. When given the right support, these teams are a strong model for providing the space and structure for people living with HIV to create a shared vision for a rights-based community health agenda, to advance the Meaningful Involvement of People Living with HIV (MIPA) principles, and to advocate for the realisation of Universal Access in Zimbabwe.
Case 2: Decentralization of ART sites
Gutu as a district has a population of 31’715 PLHIV. There were 1’700 PLHIV on ART in Gutu, and the target is that by the end of 2013 a total of 12’000 people will be able to access ART in the district. However the district had only one initiating site at Gutu Mission Hospital covering the whole district. All the services were being charged for and this forced PLHIV to travel long distances, furthest being 56km, to Buhera looking for ART services.
PLHIV were concerned with the distances they were travelling to collect ARVs, a fact they indicated was discouraging others to be tested. They didn’t see it wise to know their status and then face challenges in accessing drugs due to the transport costs of travelling to Gutu Mission Hospital for diagnostic tests and monthly ARV supplies. PLHIV who accessed ARVs in Buhera were so also concerned about the ever flooding Nyazvidzi River since it was now into the rainy season.
In an advocacy stakeholder meeting the advocacy district team drummed up support of all stakeholders for this issue to be addressed once and for all. The advocacy committee led a consortium of community stakeholders, which included the Gutu Business Community Association, and approached MSF Belgium (who were assisting the majority of the PLHIV in Buhera) to come and operate in Gutu. The committee helped in mobilizing those who were accessing drugs outside Gutu to register at their local clinics. The registers were then used by the District Nursing Officer (DNO) as evidence to convince MSF to come into the district. MSF assessed the clinics and indicated that there was need for renovation and to address security at the premises to secure the medical supplies. MSF gave a deadline of 30 December 2010.
The advocacy committee and the DNO tried to make health committees take responsibility but out of the targeted 15 health centers only one managed to put screen doors and window burglar bars. With the MSF deadline looming, BHASO had to take the responsibility of putting screen bars, ceilings, burglar bars, doors and window panes into the targeted 14 clinics to be used by MSF.
Challenges: The District Aids Coordinator and District Nursing Officer differed on which sites to be targeted. The team took a holistic approach of including both ideas.
Methods used: Stakeholder meetings, community meetings.
Results of advocacy: Since 1 Jan 2011 Gutu has one initiating site and mobile initiating clinics reaching 14 local clinics providing a no-cost (including for OI infections, other medications, diagnostics, etc). By May 2011, 600 PLHIV have been initiated on ARVs
*Joshua Mavundu, the Advocacy and Gender officer of Batanai HIV and AIDS Service Organisation (BHASO) in Masvingo, Zimbabwe, has been the key driver of the local level advocacy program and the Meaningful Involvement of People living with HIV and AIDS (MIPA) in Masvingo Province. BHASO is a partner of fepa, partner of aidsfocus.ch. http://www.bhaso.org, http://www.fepafrika.ch/batanai Contact: firstname.lastname@example.org; email@example.com