Home-Based and Community-Based Care: briefing by Department

Meeting report

SOCIAL DEVELOPMENT PORTFOLIO COMMITTEE
26 September 2001
HOME-BASED AND COMMUNITY-BASED CARE

Chairperson: Mr Saloojee (ANC)

Documents Handed Out:
Presentation by Department
Status of HIV/AIDS programmes per province: September 2001
Impact of HIV/AIDS on Women and Girls
Status Report on HIV/AIDS in the Social Development Sector

MINUTES
Ms A Bester, Director General: Department of Social Development, outlined the department's initiatives concerning home-based and community-based care (HBC/CBC). They divided into three programmes:
- those run in association with the Department of Health,
- those run by the National Department from funds for HIV/AIDS and
- national projects which are funded by Poverty Relief funds and which take the form of support for existing, usually faith-based, projects.

The goals of the interventions are to mitigate the impact of the disease on families and communities, in terms of socio-economic factors. The focus is specifically on women and children, particularly orphans. The feeling from the department, when dealing with the community-initiated programmes, was not to take over the projects and 'reinvent the wheel', but rather to provided support and build on the work and experience of the community volunteers.

Ms. Bester said that by the end of the year the national projects would be up and running in all nine provinces, and that while some provinces did not seem to have such projects, this did not mean that there were no projects in these provinces. Rather, it meant that projects run by the national department did not as yet exist.

She indicated that the department was in the process of evaluating the poverty relief projects, and identifying areas where there was insufficient coverage. Among these were projects aimed at sex workers and research into the link between alcohol and substance abuse, and the spread and implications for HIV/AIDS. One particular area of concern was the need to improve access to social assistance (see presentation) and the need to strengthen food security.

One of the positive benefits of community-based projects was that they served to challenge the stigma of HIV/AIDS. An issue, which was repeated at several stages, was the need to standardise various procedures for all the provinces, to facilitate access to social assistance. Ms Bester also agreed to provide the committee members with a list of contact details for the various projects detailed in the reports, so that they could visit them when they returned to their constituencies.

Discussion
The Chairperson commended Ms Bester on her report, saying that there was a sense that a lot of work was being done. However, he said that on a visit to the Eastern Cape, they had visited a Tsolo project and had noted that although there were a number of social workers and staff, as well as a good building, there was not any equipment and vehicles, and consequently there did not seem to be any work being done. He also said that the delegation had visited Kidd's Beach, where it had been briefed on everything except HIV/AIDS, which is the concern of this particular committee. Thus while on paper everything appeared good, there was concern that this did not reflect the situation on the ground. He asked for comment on this, and issues such as the long waiting lists for disability grants etc. He also asked the Director-General to offer a precise definition of what was envisaged in the term 'home-based care'.

Ms Bester acknowledged that the presentation did show what was planned, but that detailed evaluation was needed, particularly in the form of site visits. She said that one of the problems was the need for health department involvement and that in this regard, certain basic things were not being provided. She said that, similar to the Poverty Relief issues which had been present initially, these needed to be identified and then dealt with.

In relation to social assistance she agreed that there were problems with delivery and communication with the potential beneficiaries, partly due to administrative delays at provincial level. This was due to the fact that the National Department could only make norms, but that implementation was the responsibility of the provinces. She also said that without improvements, there was likely to be further costly litigation, which would further stretch the already strained budget. She did however point out that the blame was not solely with the provinces, and the fact was that there was a limit on what could be done, due to budgetary constraints.

With regard to the Tsolo project, a member of the Department's staff, Ms Nwedamutswu, , explained that the building belonged to the Health Department, and equipment had not been provided. However, she said that Transnet was in the process of providing containers to serve as buildings for the social workers, volunteers had been trained, vulnerable families had been identified and HBC had started. There were transport problems, but the volunteers had said that they would walk if necessary. She also said that delays had resulted while funds were being transferred, but stipends were now being paid and food parcels provided. With regard to Kidd's Beach, she said that the idea here had been to provide training for HBC to those already involved in receiving training in environmental and health issues. She also said that representatives of the Province had made visits to the site, and it was their project.

Ms Makasi (ANC) indicated that during the visit, members of the project had said that it had been an initiative from National, and that the evaluation was meant to be from National.

Mr Mabete (UDM) said that when the committee had visited, staff said that they had spent R138 000, and this had come ostensibly from Ms de Beer and Ms Moodley, both of whom were from the National Department. The staff had said that the money was spent on assessments, but they could not show the committee any figures. The MEC had said that it was National's responsibility and she had no knowledge of what National was doing.

Ms Bester replied that it was not possible to remember who had brought the proposal, and indicated that National did not have the capacity to monitor all levels and all projects. The provinces did not appreciate the national department going in and funding things without consultation, so this was highly unlikely. She asked for the time to investigate before making a detailed report.

The Chairperson agreed that it was unnecessary to labour the point, but that it should be recognised that there were problems.

Ms Mabetoa, Director: Advocacy in the Department, indicated that there were other problems with HIV/AIDS programs, not least the fact that people tended to shy away from such programs and for this reason it had been found that it was easier to get people involved if HIV/AIDS was part of another program. She also said that in most instances, they worked well with the Provinces, but there were instances where the MEC was not kept informed. In terms of a definition of home-based care, it was explained that this referred to treating people at home, instead of in hospital. They thus received medication at home, and died at home, with implications in each regard. She said that communities took the responsibility, and that professionals, such as doctors, gave their services to people in their homes, often on a volunteer basis.

Ms Bester said that they could assess and carry out on-site visits but without ongoing monitoring it was difficult to keep track of everything. She said that the tranche system from poverty relief programs was being adapted to social assistance and HBC.

Dr Bulawa (ANC) said that a woman had approached her in her constituency, saying that when she had applied for a grant, the official at the Welfare Department had said simply "some are lucky, some are not". She raised a concern that people were becoming frustrated at the lack of delivery and the complications with the system. She also raised a concern over the FBOs (faith-based organisations). She asked who was represented by these FBOs and whom they were responsible to. She cited the example of the African Faith Mission in the Eastern Cape, who had seemed reluctant to work with other FBOs, but was receiving funding. She asked how the department was monitoring the impact of FBOs, to ensure that they were not only catering to their own members.

Mr McNamara (DP) drew attention to page 5 of the presentation, where he said that it appeared that the amounts given per person were very different, depending on the programs. He asked how decisions were made in this regard. With regard to the expansion of social assistance, he said that he had heard the Minister saying that the foster care grant needed to be broadened, and that ultimately a risk would need to be taken and grants would have to be provided. Mr McNamara asked what was holding up the foster care grant, and what could the department do to speed up its delivery. He also asked what action there was that could be taken against officials who misled the public about grants.

A member of the ANC said that the presentation had focussed on children, but that there were many adults who needed grants as well. She said that many programs were struggling to interpret the confusing forms to receive funding, since it was not always clear what specific programs were entitled to. She also raised a concern that some families had inherited illnesses, and that all members were entitled to a grant, but that the department said that they could only receive a certain number of grants per family. She asked why this was happening.

Ms Bester said that, in relation to officials, the national department did not have any direct disciplinary control, but names should be lodged with the MEC and the provincial department, because in similar situations at national level, this would be the procedure. She also asked for copies of the complaints, so that National could follow up. She said that this was a major reason why the social security system needed changing, because people were confused and there was a need to standardise the system and provide information and feedback to the community. She said that they had been attempting to simplify the forms, and had even resorted to going to the programs to get information from them, which was necessary before funding could be provided. However, this was not an ideal situation, since there were insufficient staff to make this a workable long-term solution. She also suggested that part of the problem of standardisation would be overcome through the department's taking control of the National Development Agency.

Ms Nwedamutswu explained that the criteria for FBOs had not been clear initially and national FBOs had been targeted as a result. She went on to say that smaller local churches were now being contacted so that interaction with them could be initiated. The AFM was involved in the training of young people to promote AIDS awareness in their communities and it was unclear exactly why this was a problem, provided they did not abuse their position to spread their faith. But she acknowledged that this was a problem area, and would be monitored.

Ms Bester added that work was done with people from the Jewish and Muslim religions, and the department made it a requirement that people not be excluded from any project or program on the basis of their religious affiliation. Work was also being conducted in association with the National Religious Association for Social Development.

Mr Saloojee remarked that there were certain powerful feelings built into the issue of religion, which made it somewhat problematic.

Ms Bester stated that there were currently attempts to see who was representing whom, and this would be continued at the next meeting.

Mr Saloojee reiterated that it would have to be carefully looked at.

Ms Bester noted that the idea behind involving FBOs was linked to the President's calls for a national moral regeneration.

Ms Nwedamutswu answered the question about the different amounts for each project, agreeing that the amount per person did differ, but that this was due to the environmental dictates of the specific projects.

Ms Bester pointed out that the Minister's comments related to the finalisation and prioritisation of the legislation on child-care. She said that a meeting with the Law Commission had been scheduled to discuss this. Some of the delays in foster care related to some magistrates' reluctance to place children with relatives, and magisterial interpretation of the law was an area which the Department of Justice was examining in this regard.

Ms Chalmers (ANC) said that in her constituency, among the rural AIDS sufferers, there was a desperate need for sheets and towels etc. for those who were bed-ridden. She asked how the basic materials for HBC could be accessed. She also asked how the food security issue was being addressed i.e. were food parcels envisaged, or vouchers etc.

A member of the committee asked whether the deep rural areas were considered when food security was addressed. She also asked if soup kitchens were part of the solution, and if they were, how many existed. She requested information on how the department monitored whether or not the right people were accessing the services. She also reiterated the request for information on the projects so that, as part of their oversight functions as MPs, the members could visit the projects in their constituencies.

Dr Baloyi (IFP) endorsed the comments made by the Chairperson at the outset that reports do not always capture the situation on the ground, and they were always open to interpretation. He asked what specifically was meant by 'support', and what the various levels of government were responsible for in this regard. In particular, he asked what the role of local government was, and whether there were clear stipulations for each of the three levels. He also asked how cross-funding and double-funding was prevented and monitored. He also raised the point that if the youth were sought to be involved in advocacy, what it was that this entailed, how 'youth' was defined and what they would be required to do. He cautioned that asking young people to work as volunteers when they had Matric or degrees and were still unemployed might not be successful, and if this was the case, then it might be necessary to offer financial incentives, a move which had financial implications. He said that youth understandably were looking for a sustainable career path, and that they would therefore be reluctant to engage on a voluntary basis unless this had some relevance to them. He cited experiences from his work in the health field, that illustrated that when you relied on volunteers, you were at the mercy of people coming and going, particularly if they were seeking more gainful employment.

Ms Chalmers said that she favoured voluntarism and had some experience in this regard. She said that for volunteer-driven initiatives to be successful, there needed to be clearly defined structure. It also helped if you were able to give the volunteers something back in the form of a reference for a CV, which assisted them in their careers.

Ms Bester said that there was no intention to exploit unemployed youth, and accepted Dr Baloyi's point that the youth were not a homogenous group. She said that poverty relief focussed on skills development and that the aim was to involve the youth not only as targets for awareness campaigns, but as active participants in the fight against AIDS. She said that the Student Volunteers Association was involved to seek ways to make volunteering an attractive option for youth. One proposal which had been received from an FBO was to use unemployed youth as youth care workers, which provided them with training and experience and which opened up a career path into the social services. She did however acknowledge that the diversity of the youth had been insufficiently dealt with, and that the Youth Development Strategy, nearing completion at the moment, would enhance understanding of this issue.

With regard to cross-funding, she said that people were required to state all sources of funding on their application forms, and when the NDA joined the department, closer monitoring would be possible since this was likely to be the other major source of funding for projects in the country. She did however caution that the reality was that organisations needed more than one source of funding, but stressed that checks had been built into the system.

Ms Nwedamutswu said that 'support' entailed approaching initiatives that exist and finding out how they can be empowered, and this idea of support merely reflected the ideology that the experience that exists in the communities needs to be acknowledged and promoted.

With regard to local government, she said that the aim was an integrated approach, but that local did not always have the necessary capacity. She did however stress that the advantage of making use of local government was that their budgets were more closely linked to the issues and problems in the communities.

In terms of monitoring, she said that they were currently engaged in developing tools for this purpose - there was one for HIV, and tools for the monitoring of poverty relief projects were being developed.

She also said, in connection with the deep rural areas, that the projects tended to focus on the poverty areas identified by Cabinet, and thus the deep rural areas did receive attention, as 'nodal points' where development was a key concern.

Ms Nwedamutswu also indicated that the soup kitchens were not a focus, but that existing soup kitchens were identified and an effort was made to support and sustain them. Food security mainly took the form of food parcels, linked to the establishment of food production clusters, so that there was a market for the food produced in these poverty relief schemes.

Ms Chalmers asked for clarification on how exactly the food parcel system worked.

Ms Mabetoa explained that this was linked to HBC, in terms of which provision was for food parcels. At the end of each month, the family received a food parcel. The provinces and the NGO's worked out what exactly they should consist of, and it varied depending on the region, but the idea was to include the basics, such as mealie meal, peanut butter, sugar etc. The contents of the parcels and the way they were worked out were also dependent on the amount of money available. Funding came from the conditional grants made to provinces as well as from the provinces' own budgets as well as from the social relief funds, where possible. Some provinces preferred food vouchers for a certain range of basic necessities. These sometimes entailed the assistance of a volunteer in making the purchases where the family had difficulties getting to the shops. Other basic groceries were also provided in the parcels, such as soap etc. She also explained the home-based care kits, which were meant to have been provided by the Department of Health, which had received R6 million for this purpose last year. But there were problems and the provinces had exhausted the supplies at the clinics, which are meant to always be stocked with these kits. Steps were being taken to address this issue, but the feeling was that in the longer term, the service provider would be required to cater to these kits, which provide essentials such as blankets and towels.

There was a follow-up question on the food issue. It was asked if it would not be possible to include formula feeding in the food parcels, to allow mothers with HIV to not breastfeed their babies. It was recommended that this should not be milk-based, so that it could not be used in tea etc. by adults.

Ms Gandhi said that the Health Department had informed her that HBC was a philosophy, and not a particular set of practices, and this had caused some confusion. She asked if there was going to be in-home care, or whether there would be the creation of hospice-type homes for the care of the ill. She also said that poverty relief was a confusing issue, because the Department of Trade and Industry and the Department of Arts and Culture had poverty relief and job development initiatives, and it was slightly unclear how things were being co-ordinated. She raised the concern that this could lead to unnecessary fragmentation.

Ms Bester agreed that there were a number of departments which had their own poverty relief programs and there was a concern over duplication. This was the reasoning behind the Urban Renewal Program and the programme in the rural areas, to try and co-ordinate the governments efforts in this regard. She also pointed out that National Treasury was responsible for the funding of these programs and thus also bore the final responsibility for ensuring that there was no duplication. However, she reiterated the point that there was an attempt to create a comprehensive government evaluation of all these types of programs.

She went on to explain that the Department of Social Development viewed HBC as a program with certain activities and practices involved. The department's focus had always been on children, and HBC was seen as an alternative to institutional care.

Ms Mabetoa said that HBC was a reality, rather than just a philosophy and the department was moving fast towards developing services in each community. She agreed that there could be individual families trained to look after the members of their families who were ill, but that the focus was on training volunteer community care givers trained to do a variety of things related to HBC. She said some of these volunteers were multi-skilled, where others focussed on certain specific activities, depending on the context in which they operated. They conduct visits to people's homes to provide them with services.

The Chairperson had to bring the meeting to a close due to time constraints. In conclusion he drew attention to the need for efficient services, saying that there were problems but also a great deal of good work being done.