Summary of evaluation of The Salvation Army Swaziland Community Care Programme

Background:
In 1990, not long after its official launch, The Salvation Army initiated a HIV/AIDS programme in Swaziland.  Since 2003, Norway/BN has supported TSA in continuing its activities directed at community care services with a focus on providing home based care in three peri-urban areas of Mbabane City. The programmes aims are to provide care to the sick (at their homes) within the carers community to patients who would otherwise would not access hospital care
The approach of The Salvation Army home based programme is to train community volunteers selected by their communities to carryout  home care for all patients who are ill at home and to refer serious cases to the next competent facility such as clinic or hospital. To date there are 55 carers covering Msunduza, Sidwashini and Fonteyn.
The care and support services provided by the carers include washing of patient, administration of medication, helping with house chores, and counselling to name a
few.

Purpose/objective:
The purpose of the evaluation was to assess the implementation of the programme in relation to its efficiency, effectiveness, outcomes and impact based on the intended objectives and also to learn from the experience for future programming.

Methodology:
The evaluation was conducted using mainly a qualitative approach which was participatory in nature, including a desk review of relevant literature and field visits of three areas covered by the programme. The respondents were from various focus group discussions and key informant interviews including clients receiving home based care services from the cares. Also the evaluators had an opportunity to observe a home based care services being provided to one client.

Key findings:

Relevance:
The home based care programme is quite relevant and responsive to the needs and situation on the ground related those who are sick at home suffering from various ailments including HIV related conditions in an environment of poverty and unemployment.

Efficiency:
The Salvation Army home base care has proved to be efficient in its operation with sound management and skilled carers that are highly commended by the communities they work in. The Salvation Army provides services with deep compassion, integrity and value for life, consciously making the link between spiritual life and social life. Systems seem to be in place, and steadily improving including monitoring and evaluation components which until recently were lagging. Fiscal oversight for the project, in addition to other projects and programmes run by The Salvation Army is provided by the Finance officer. 
The project activities are relatively low-cost because of the way The Salvation Army has designed the implementation process using volunteer carers living in their own communities. However, equity in access of care services appears to be limited due to the current way of operating, whereby, a carer has a maximum number of five families to look after in his or her area. There is also an urgent need to fill in the position of Community Care Coordinator.

Effectiveness:
The CCP seems to be achieving results in the area of its objectives.  Home-based care clients are becoming well, especially since the advent of treatment.  Treatment-literacy is increasing amongst people living with HIV, and the greater community.  There is a notable decrease in the numbers of bed-ridden patients, many of whom are returning to work. Nevertheless, the effectiveness of the programme is also challenged by inadequate nutrition among most of the clients as a result of lack of employment and poverty as well as the lack of referral linkage between the carers and the Mbabane Government Hospital including the VCT department.

Sustainability:
The Salvation Army programme administrative team is a very capable, highly efficient, highly skilled group in whom much time, energy and resource has been invested. However, the long-term stability of this group is fragile as a result of lack of  job-security for programme employees. There is also no succession plan to sustain the current successes and momentum of the programme at a leadership and management level.
There is no doubt that the delivery of the programme services is sustainable from the carers side, as carers are motivated to serve their communities by passionate and not necessarily material benefit. However the programme still require to improve its engagement with community leadership and to draw in more men to support care and support activities within their communities.

Impact:
The project is making significant progress in developing tools, frameworks and indicators that can capture data, record numbers from registers, and monitor outputs of the project.  But the project is finding it difficult to measure significant impact or evidence of change.   
At this stage, apart from anecdotal testimony from home based care beneficiaries and family members, there is no system to measure the overall impact of the programme.  Anecdotal reports and testimonies points out that The Salvation Army is perceived to be reaching the poor beyond the Mbabane peri-urban area boundaries, and providing invaluable support and services to communities. There is a sense that the carers through community care programme are making real impact in communities with respect to services provided. There are clear results for  the Community Care Programme- people who were very sick, with no hope, are now living and hopeful.  Many clients who were bedridden are working again.  Orphans and other vulnerable children are being support through TSA’s bursary scheme all the way through up to high school level. 
Impact of the programme is faced with challenges related to the lack of  protective clothing - gloves or masks for carers in a situation where there is the risk of personal exposure to infection, not only to HIV, but also MDR-TB as well as lack of access to home-care supplies and the absence of a formal forum for community leadership to meet and interact with TSA management team.

Recommendations:
(i) Design a strategy to enhance sharing, learning and transfer functions. 
(ii) Consider the ‘AIDS Competence’ process as a model for linkage, learning and peer-influence between communities.  There are helpful tools and approaches that could build confidence and quality through contrast, comparison and connection between Msunduza, Sidwashini and Fonteyn.
(iii) Consider the possibility of a cross-border collaboration with TSA Mozambique, also involved in HBC, PSS and treatment-support.  (in light of high numbers of Mozambican immigrant/refugees in Swaziland).
(iv) Community Leadership and TSA administration should meet bi-annually for planning and engagement purposes to ensure capacitation of community leadership to address the HIV epidemic in their communities.
(v) Establish a functional income generation approach using external service providers through a collaborative model, not requiring financial costs.
(vi) TSA should emerge as a strong advocate that address issues of poverty, lack of supplies for caring for patient sick at home, and championing alternative ways of involving men in addressing the epidemic including the care and support activities.
(vii) Review the home based care approach in the context of the emerging issue – related to growing children having HIV and taking ARVS – where traditionally, counselling had largely focused to guardians and parents and not necessarily focussing on the children.
(viii) TSA should  strategically plan to become a refill site for ARV in the future in view of the number of people requiring treatment and to graduate to become a one  a ‘1-stop shop’ for comprehensive care, treatment, testing and support.