Noted April 23, 2008: Adjusted amount to 2nd CN approved funding level (see Namibia FY08 COP Memo

for details).

Project HOPE Namibia (HOPE) has been working in Omusati and Oshana Regions for the past year with

the Village Health Fund (VHF) methodology to empower caregivers of orphans and vulnerable children

(OVC) with the skills and opportunities to access small scale micro-credit loans. It has established a track

record and the capacity to expand its activities. It proposes to replicate these micro-credit activities while

integrating services to address the societal issues driving cross-generational sex (cross-gen), transactional

sex and multiple partner concurrency. This initiative arose from the expressed needs of young women in

Caprivi, Kavango and Ohangwena regions and discussions with SMA, Nawa Life Trust/JHU, the DAPP and

Acquire (Engender Health) which has been tasked with implementing a cross-gen intervention addressing

societal norms with girls and young women, their families, the communities in which they live and the men

with whom they have cross-gen sex.

HOPE proposes to evaluate the impact of micro credit combined with prevention messages in the reduction

of high risk sexual behaiviours. It proposes to conduct this intervention in the form of a quasi experimental

design with two arms. A full intervention arm that will consist of micro credit and prevention education and a

second arm with prevention education only. Project HOPE is partnering with Catholic AIDS action to

conduct this evaluation. Both arms will use Catholic AIDS Action Stepping Stones Curriculum for the

education. The curriculum addresses abstinence, promotes fidelity (within marriages or through other

sexual relationships), and subsequently reducing overall exposure to HIV/AIDS.

The anticipated activities include:

• Conduct baseline data collection on all the participants for both arms.

• Facilitate Stepping Stones to 300 participants over a period of 4 months and recollect data

• Stepping Stones is a curriculum that works to establish an empowering community environment which

denounces cross-gen sex, transactional sex, rape, incest, and other forced sexual activity.

• Coordinate with other USG organizations and stakeholders (Global Fund, EU) working with high risk

young women such as school drop-outs to identify other potential participants.

• Provide orientation and training to help them form VHF, including electing leaders, implementing group

policies & procedures, and assisting with group organization.

• Provide seed capital through micro loans to 1,080 participating young women to invest in income

generation activities. As they repay, they will be offered a subsequent loan of higher amount so their

business can grow.

• Mobilize and empower the young women and their VHF groups to be advocates in their communities.

• Conduct continuous progress monitoring and evaluation of activities to ensure quality and address

challenges.

Project HOPE Namibia is currently implementing a model referred to as the Village Health Fund (VHF). This

model combines health messages with the provision of seed capital to start or expand a small business

(economic strengthening). This model is being implemented in 7 other countries since 1993; the impact of

this model has been assessed through intake clientele questionnaires (member profile) which are

recollected after 1 year of participation. Results to date show a favorable link in the combination of both the

health sessions and micro credit, in particular with improved socioeconomic status, leadership, governance

and self esteem building. The model started in Namibia since 2005 targeting caregivers of OVC in the north

central regions (4Os) of Namibia and has now expanded to young women/girls in the north east.

The objective of the Village Health Fund is to enable participants to generate sufficient income to address

their socioeconomic needs, including access to health services. This model is proving successful with

caregivers of OVC in the following manner: care givers learn how to prepare balanced meals and learn how

to recognize signs of malnutrition, basic signs of child illnesses and have the resources to access health

services and buy more food. Based on the results achieved through this model, Project HOPE proposed in

COP07 to extend these services to young women in the Kavango and Caprivi region by providing

appropriate prevention and behavioral change messages together with the provision of seed capital to start

their own small businesses. The underlying objective here is to mitigate the risk of these women getting

involved in cross generational or transactional sex. The hypothesis is still under review in both regions, but

initial focus group discussions with staff and beneficiaries of SMA and Lifeline Child Line indicate that such

an intervention will be helpful to compliment existing prevention and behavior change efforts.

Young women and girls in both regions lack employment opportunities due to lack of education and

employment skills. Without income they can't sustain their basic needs and are at high risk of engaging in

cross generational or transactional sex as a means of survival. Project HOPE will work with 720 young

women and girls in COP07 who will participate in ongoing prevention activities with SMA, Nawa Life Trust,

LLCL, TCE and others. These prevention efforts will be coupled with training at local vocational training

centers. For the purposes of this program youth/young women are defined as females between the ages of

15 and 30, who represent 25.4 percent of the population of Rundu in Kavango (11,280) and Katima in

Caprivi (5,764). For COP08, the previous 720(4% of total young women/girls population in both regions)

women of COP07 will continue participating in the program an additional 944 new women will enter the

program in Rundu and Katima making a total of 1,664 (9% of total young women/girls in both regions).

Project HOPE proposes to provide a minimum prevention package for a concentrated and generalized

epidemic in collaboration with partner organizations such as DAPP, CAA, SMA, Nawa Life Trust, MoHSS

and others (as per COP Technical Guidance). Activities that will be part of the package are: Target media

use such as Take Control, LLCL and YELULA radio talks, distribution of condoms, promotion of VCT, STI

and TB screening, male involvement, access to treatment, support groups and palliative care. The VHF

methodology is delivered in bi-weekly meetings with groups of 13 women on average. During these

meetings participants repay their loans, share small businesses challenges and opportunities and receive

90 minute prevention and behavior change training sessions, the curriculum used for training will be from

DAPP but will be reinforced with promotion in delay of sexual initiation, abstinence, monogamy, reduction of

sexual partners, cross generational sex, age appropriate family planning, use of condom, negotiation skills,

male circumcision and others (As per COP07 guidance). It is expected that the 1,664 women will participate

in 128 Village Health Funds (VHFs). Peer educators of partner organizations will use the 90 minutes to

strengthen learning and follow up on agreed issues with the participants. Additionally each VHF elects two

health activists, who again reinforce learning and act as community mobilizers with partners (male

Activity Narrative: involvement) of participants, head mans, constituency councilors, religious leaders and others to

acknowledge and practice safer sexual behaviors and cultural practices (Social Capital, as per COP

Technical guidance). Peer educators and health activists will be supervised by two trained staff of Project

HOPE, namely the Community Health Worker and by the Health Coordinator/Supervisor. Partners'

curriculum delivered to the groups will be strengthened by the "Stepping Stones" curriculum of CAA. This

curriculum will be delivered by CAA trained peer educators in communities where CAA operates and for

other communities Project HOPE staff will be trained by CAA as peer educators and will deliver the training

themselves. All these curricula will be strengthened by a Psychosocial Support Curriculum developed by

Project HOPE in cooperation with partners, especially LLCL and Philippi Namibia.

Outcome evaluation of a HIV-prevention-via-microcredit intervention (previously activity #19878)

Total projected budget

Total project cost for COP07 = USD$ 789,015, budget for PHE USD$19,000

Total project cost for COP08 = USD$1,030,000, budget for PHE USD$17.025

Local co-investigator

• Nelson Prada, Project HOPE, Project coordinator and chief of party for Project Hope.

Project description

Project HOPE is implementing a micro-credit and health-education program called Village Health Fund

(VHF) among 15-24-year-old women in order to prevent girls from engaging in unprotected cross-

generational sex. This initiative arose from the expressed needs of young women participating in the

activities of Development Aid From People to People (DAPP) Total Control of the Epidemic (TCE) program,

which is working in HIV prevention, who is tasked with designing an intervention that makes unprotected,

cross-generational sex less likely. Project Hope and Catholic Aids Action will provide the health education

component of the intervention, while Project HOPE will provide young women with sources of income as an

alternative to relying on transactional relationships with older men, who are both more likely to be HIV-

positive and less amenable to demands that condoms be used during sex.

The main evaluation questions will be:

1. Are the young women who received microcredit loans and health education more likely to report

practicing safer sex (abstaining, being monogamous, using condoms, not having a cross-generational sex

partner) than similar young women who received only the health education and similar young women who

received neither?

2. Are the young women who received the health education intervention more likely to report practicing

safer sex (same outcomes as above) than similar young women who were not exposed to the intervention?

Programmatic importance

The evidence on whether poverty is associated with an increased risk for HIV infection is unclear. In

Namibia, however, it's commonly stated that poverty - especially among young women - is a major cause

of transactional and cross-generational sex and thus contributes to risky sexual behaviors and HIV

transmission. If the micro-credit loans to young women do decrease their likelihood of engaging in risky sex

behaviors, this pilot intervention will be rolled out to other regions in Namibia, and other countries might also

consider replicating such interventions.

Methods

We propose a quasi-experimental study design, with 2 study arms: (1) full intervention (microcredit + health

education); and (2) health education only. Participants in the intervention arm will be selected through

convenience sampling as they will be agreeing to participate in the micro-credit scheme and/or the

education activities. However, it is possible and recommendable that the control group be selected

randomly from neighboring villages/townships with similar characteristics to the study groups in the effort to

minimize bias. Data will be collected at 3 points in time: baseline, mid-term and final follow up. Quantitative

KAP surveys will be administered by program staff. Target outcomes will be increase in knowledge of

means of transmission and prevention of HIV, improved understanding of unprotected transactional sex and

subsequent risk for HIV, and decreased high-risk sexual behaviors. Interviewers will be trained in unbiased

interviewing techniques. Survey instruments will be translated into local languages. Interviewers will be the

same gender as interviewees. The protocol is being developed with technical assistance from Project

HOPE headquarters, but additional assistance may be required from CDC and USAID, both in-country and

in the US.

Formative research will be conducted among the target population in the effort to more fully comprehend

the dynamics of transactional and cross-generational sex, and within what context transactional sex takes

place. Additionally the formative research will explore self assessment of risk for HIV infection based upon

varied sexual behaviours including transactional sex. Focus groups will also be conducted among both

intervention arms in order to assess perceptions of the context in which transactional sex occurs and

perceived ability to control behaviours in this context.

Project HOPE Headquarters and a doctoral candidate from the Johns Hopkins Bloomberg School of Public

Health will participate in the research providing inputs and technical assistance in study design, instrument

development, quality control of data collection, and analysis and interpretation. The data analysis will

compare targeted outcomes between the 2 study arms, using multivariate techniques to adjust for

confounding variables.

The study will gain informed consent from all participants taking part in the study. The participants in the

study arm without the microcredit intervention will be given the option to receive the microcredit loans after

the study has completed.

Population of interest

Young women, 15-24 years old, will be recruited into the intervention and evaluation. For the full

intervention arm, participants will be selected from those recruited who choose to take part in the

microcredit intervention. These beneficiaries will be identified through young women participating in the

activities of Project HOPE; they will be invited to participate in a promotional meeting on which principles of

group lending, solidarity and accountability will be explained. A pillar of group lending is self selection and

interested women will form Village Health Funds (VHFs) with women that they know very well and trust,

they could even invite women from their neighborhoods to join the group. There will be 780 participants in

the full intervention arm, which is the number of participants that Project HOPE has budgeted for.

For the health-education-only arm, participants will be identified from among those young women whom

Catholic Aids Action is providing health education via its community-based peer educators. The sample

size for this arm will be 780.

Information dissemination plan

Project Hope will collect the data and refine the research design and data-collection tools. Peace Corps

Activity Narrative: volunteers will also be involved in refining the study design and study instruments, and may even help in

analysis. A doctoral candidate from Johns Hopkins Bloomberg School of Public Health will also take a lead

role in the design of this study and the analysis and interpretation of results. USAID and CDC are providing

technical assistance during the study's entirety. Study participants will also be informed of the results.

Should the intervention prove successful, those who were in the study but not invited into the intervention

will be invited to participate. Results will be shared with the local communities from which the study

participants come and from other prevention partners working in Namibia. Results will also be shared more

widely via conferences and peer-reviewed journals.

Budget justification (in USD) For COP08

Salaries/fringe benefits:

Equipment:

Supplies:

Travel:

Participant Incentives:

Laboratory testing:

Other: USD$17,025 (Consultancies)

Total: USD$17,025

In 2005 Project HOPE (HOPE) began the "Sustainable Strengthening of Families of Orphans and

Vulnerable Children" project, which delivers health messages and training on parenting skills combined with

access to micro credit. To date, over 1,600 caregivers of OVC in the Oshana, Oshikoto, Ohangwena and

Omusati Regions are participating in this program. Additionally, 300 households headed by either elderly or

OVC were added during COP07. Project HOPE is a Track 1 partner (3779.08) with an agreement in place

for 2005 - 2010 and also receives funding from the field. In FY07, Project HOPE underwent an assessment

of their program direction and implementation which resulted in a new project alignment between the field

funding program and Track 1 scope of work. Under the Track 1 agreement HOPE works mainly with

caregivers, while the field funding program supports the new prevention activities, work with grannies and

households. Although the project works with existing government and non-governmental organization

(NGO) and faith-based organization (FBO) partners in Namibia, there is scope for additional cooperation.

The UNICEF OVC Situational Analysis in 2001 indicated that the number of families caring for OVC and the

number of OVC in these households (HH) is increasing at an alarming rate. It is projected that by 2021

there will be approximately 250,000 OVC under the age of 15 in Namibia. A lack of economic opportunities

and a high unemployment rate constitute a serious challenge to heads of households (HH) who bear the

financial responsibility for these OVC. A baseline study conducted by Project HOPE (8025.08) in 2006 and

regular data collected by Family Resource Persons (FRPs) (community volunteers) indicate that 54% of the

caregivers are elderly (60 years and above) and the main source of income for the HH is the N$370 monthly

pension for the elderly. The baseline study also revealed that 1% of the caregivers are OVC themselves

and regular surveillance data from the FRPs show that the older OVC are leaving their siblings with

neighbors or community members and leaving to pursue economic opportunities elsewhere. Caregivers

who can earn income are stressed by the constant search for income to contribute to the HH needs, often

resulting in the neglect or abandonment of children, and at times a hostile environment for the OVC who

bear the brunt of the stress experienced by their caregivers.

To address some of these issues HOPE proposes the following objectives: To expand the coping

capabilities of families of OVC by 1) improving economic status and quality of life within HHs; and 2)

strengthening the capacity to provide care and support to OVC. During COP 2008 300 HH (COP 2007) will

continue participating and will receive larger loans to enable business growth and market expansion. They

will also receive a host of business development services from Business Development Officers (BDO).

Community Health Workers (CHW) will continue providing the Parenting Skills/Listening Skills curriculum

"Happy Children at the Heart of the Community" during the bi-weekly meetings and FRPs will continue

facilitating access to services for OVC including, but not limited to, psychosocial support (18235.08),

bereavement counseling, access to maintenance and foster grants, as well as food donations for

malnourished under 5. Leveraging with other partners, including prevention (see activity #) with a stronger

focus on health and promoting health seeking behavior and preventative health care will be developed as

Project HOPE expands. The demand for these services is increasing and HOPE proposes to expand the

program in the currently active regions to reach an additional 450 HH (making a total of 750 HH).

HOPE proposes to hold promotional meetings with interested groups identified by stakeholders like Ministry

of Gender Equality and Child Welfare (MGECW), Catholic AIDS Action (CAA), Lifeline Childline (LLCL),

Regional AIDS Coordination Committees (RACOS), Evangelical Lutheran Church in Namibia (ELCIN)

(6471.08) and others. After the promotional meeting, interested OVC Caregivers will form Village Health

Funds of self-selected caregivers. They will be provided a pre-loan training (five to six sessions depending

on their level of understanding). Identified OVC heads of HH will receive scholarships for vocational training

(3782.08)and or apprenticeships. Linkages for future public-private partnerships may occur with

apprenticeship programs in conjunction with other USG OVC business partnerships. Established Village

Health Funds (VHF) will receive financial services ranging from savings, loans and (for more mature

groups) leases. Bi-weekly meetings will be held to repay their loans/leases and to receive the "Happy

Children at the Heart of the Community" curriculum as mentioned above. HOPE will provide services to

three field teams: the Loan Team (LT), the Health and Psychosocial Support Team (H&PSST) and the

Business Development Team (BDT). All teams will have representation in the groups through the elected

management committee that will include a President, Treasurer and a Secretary who will work closely with

the LT to ensure good governance and repayment of loans.

Family Resource Persons will work closely with the Health and Psycho-social Support team (H&PSST) and

the MGECW to conduct activities mentioned above while Business Activists will work closely with the BDOs

in identifying business opportunities and ensuring participants are exploiting opportunities in the market.

Caregiver/Family resource persons will assist in providing OVC support and community care. The program

will have a stronger focus on health and promoting health seeking behavior and preventative health care.

One of the business opportunities the VHFs will pursue closely is the industrialization of local agricultural

produce into E-PAP, a nutritional supplement for people living with HIV and OVC. VHF members will be

encouraged to form associations to produce and supply the demand of partner organizations such as CAA,

TKMOAMS, YELULA, ELCIN, Church Alliance for Orphans (CAFO) and others (6471.08).

In order to ensure that the implementation of activities goes according to plan, regional supervisors as well

as team supervisors will visit field activities between two to three times a week and daily activity reports will

be entered into a database to keep track of all activities. Each teamwill have a set of monitoring and

evaluation (M&E) tools to assess impact; some of them will be collected at baseline and recollected after a

year of participation. One of these tools is the member profile, which provides socio economic data for each

member. All tools will be kept by groups in files as well as entered into a database. VHF files contain the

following information about each member: member profile (collected by field staff), household assessment

(collected by FRP), house visitation reports, growth monitoring assessment (in under-5), evidence of

referrals and recollected information. All data is entered into the databases through data entry personnel

and will be linked to the national OVC database (17364.08)Process data will be analyzed by the regional

supervisor and Acting/Country Director to adjust and correct interventions and also to report back to USAID.

HOPE will participate and advocate for OVC in different networks such as the OVC Permanent Task Force,

OVC Regional Forums, RACOC meetings and Home Based Care Forums to strengthen access to services

for OVC. HOPE will support activities of the MGECW, like the OVC National Database, OVC Forums and

other community structures. HOPE will also collaborate with other USG partners to develop prevention

materials and behavior change communication (BCC) messaging, to train home care volunteers and

community action forums and integrate reproductive health. HOPE will also participate in microfinance and

Activity Narrative: small business forums to strengthen the services provided to the small businesses that caregivers are

operating. Theses networks include the Rural Microfinance Task Team, Namibia Chamber of Commerce

and Industry, Ministry of Trade and Industry and the Joint Consultative Committee. HOPE together with

other micro finance institutions will establish a Microfinance Institution Umbrella Organization/Forum.

Project HOPE has been actively involved in the process in Namibia of developing minimum criteria and

quality standards, especially in the area of economic strengthening. The program will align its curriculum to

the standards and expanding service delivery to provide quality core services.

Project HOPE Namibia (HOPE) has been working in Omusati and Oshana Regions for the past year with

the Village Health Fund (VHF) methodology working with caregivers of orphans and vulnerable children. It

has established a track record and the capacity to expand its activities. It proposes to replicate these micro

credit activities with young women at risk for cross-generational sex while integrating activities to address

the societal issues driving this problem. This initiative arose from the expressed needs of young women in

the Caprivi, Ohangwena and Kavango regions and discussions with SMA, Nawa Life Trust/JHU, the DAPP

and Acquire (Engender Health) which have been tasked with implementing a cross-gen intervention

addressing societal norms with girls and young women, their families, the communities in which they live

and the men with whom they are having cross-gen sex.

This project proposes leveraging other partners' activities addressing these issues (see AB and Other

Prevention), integrating a micro-credit program and developing referral links with other implementing

partners' services at community level, including how and where to access counseling, support and gender

violence services, etc..

Project HOPE plans to establish 60 VHFs in one year, whereby 780 young women will be able to access

loan capital in sufficient quantities to start small scale income generating activities. The mutual guarantee

mechanisms will require that these groups meet regularly to review and manage loan repayments and self-

govern themselves within a capacity building environment. Project HOPE's VHF program represents a

successful model for economic strengthening whereby interested women in target communities select each

other to form an organized group of between 12-20 members who elect a management committee to

govern themselves. Project HOPE staff trains the management committee and the members to operate as

a community institution following democratic principles and established rules and procedures and serve the

economic and health needs of its members.

Each VHF receives seed capital from Project HOPE, and in turn invests in the income generation activity of

each member. The group collectively and each individual woman are both accountable for repaying the

seed capital using principles of group solidarity. The group meets every two weeks to discuss proper

business management and to make payments as well as to receive the targeted education and training. The

focus is upon strengthening the capacity of the participants to manage the group themselves, and overcome

whatever problems they face, by developing skills in leadership and collective action in an empowering

environment.

As the women repay their loans they benefit from the increased income, new confidence from successfully

managing money, and gain the capacity to influence control over their lives. The educational approach

emphasizes being informed about and promoting responsibility about health matters. It uses highly

participatory activities, builds upon peer-experience, and uses key behavior change messages. Participants

learn how to use their increased income to reduce risks, and to live more healthy lives. Just as important

for long-term well-being, the successful handling and repayment of the loans by participating women

contributes to improved self- confidence and self-esteem that strengthens the women's bargaining power

and participation in decision-making.