Field Note

Community Realities in Africa Show FBO Partnership Key to Global Scale-Up

By The Rev. Canon Ted Karpf
Partnerships Officer
Department of HIV/AIDS World Health Organization

Amidst the ongoing, often fierce, debate about the role of faith-based organizations (FBOs) in combating HIV/AIDS, a pilot study by the World Health Organization (WHO) and research partners in sub-Saharan Africa put to rest any doubts about the huge role played by faith communities in HIV care and treatment. It also reconfirmed the urgent need for partnerships with the public health community to achieve better health outcomes.

With the rate of HIV treatment scale-up still averaging 50,000 new people per month, it is evident that government-sponsored or supported health services alone will not come close to reaching the target of universal access by 2010, which is another 6 or 7 million persons living with HIV. It is also evident from an examination of multilateral and bilateral funding programs and health policies that there is a failure to understand the influence of religion in African ‘health worlds.’

Since the outset of the HIV/AIDS pandemic, the role of FBOs has been controversial, in part due to the moral judgment passed on the “perpetrators” and “victims” by such organizations. Often missed, however, is the wide array of health and support services that have grown up alongside the apparent contradictions of faith-based communities engaged in care and support for those living with HIV.

One researcher said: “Like housework in the economy … absolutely foundational to economic life yet almost never shows up in standard economic analyses … religion is so overwhelmingly significant in the African search for well-being … and so deeply entwined in African values, attitudes, perspectives and decision-making frameworks that the inability to understand religion leads to an inability to understand people’s lives.”

More important is the reality of FBOs offering care, far beyond the stereotypes, that “touches the hearts” of those living with and affected by this disease.

According to one of the patients in the Masangane (“let us embrace”) project in South Africa sponsored by the Moravians: “Last month I went home; all the people came out of their houses. It was as if they were seeing a miracle, a person raised from the dead!” This statement indicates the power of religious faith during a health catastrophe and underscores the need for public health officials to understand the role of FBOs in health care, support and prevention. Because of this phenomenon, enrollments in the ART program tripled over six months, where before there was no real uptake in treatment.

To respond to the noted lack of clarity and collaboration, WHO selected two sites in sub-Saharan Africa where health services were fairly well-documented. The WHO Study, Appreciating Assets: Mapping, Understanding, Translating and Engaging Religious Health Assets in Zambia and Lesotho www.arhap.uct. ac.za/), included the Masangane Project. The pilot study was undertaken by partners in the African Religious Health Assets Program (ARHAP) at the Universities of Cape Town, KwaZulu-Natal, and Witwatersrand in South Africa and researchers from the Interfaith Health Program in the Rollins School of Public Health at Emory University in Atlanta.

As much as 70 percent of Africa’s health infrastructure is currently owned by FBOs. Yet, the study found that there is often little cooperation between these religious organizations and mainstream government public health programs. Because they are so ubiquitous, health services often go unnoticed and FBOs continue doing what they have always done for the past century and half, namely caring for people.

Lesotho and Zambia
Focusing on Lesotho and Zambia – countries with well-documented HIV prevalence rates of 23.2 percent and 17 percent respectively in 2005 – research partners found that Christian hospitals and health centers already provide about 40 percent of HIV care and treatment services and that almost a third of the HIV/AIDS treatment facilities are run by faith-based organizations.

From November 2005 through July 2006, the ARHA engaged more than 350 citizens, religious and health leaders, from remote mountains of Mohlanapeng in Lesotho to the urban center of Lusaka in Zambia, in a participatory inquiry into other health issues and the potential contribution of religious entities to the struggle against HIV. The findings reflect the collective knowledge, deep wisdom and true partnership of participants who work in the daily struggle for survival at the heart of the pandemic. Likewise, it was evident that health maps of any location are not necessarily accurate unless they have been verified by those who live there.
The research tool known as PIRHANA (Participatory Inquiry into Religious Health Assets, Networks and Agency) was developed for training and investigative workshops held at the community, provincial/district, and national levels in the two countries.

The workshops included many religious and health leaders with the aim of finding a way for religious health assets and public systems to understand one another through this grassroots participatory technique. The research blended qualitative and quantitative information from participatory workshops with data from WHO’s Public Health Mapping and GIS Programme and its HealthMapper and Service Availability Mapping (SAM) programs.

In Lesotho, the workshops draw attention to the ambiguous, yet important, role of Basotho traditional healers. On the one hand, they are isolated from public and Christian health networks. On the other hand, they remain an important feature of both the religious and ‘health worlds’ of many communities, particularly in remote mountainous, rural areas. In addition, because few have easy access to formallytrained doctors, self-initiated community support groups, independent of churches and the public health system, are among the most important health-care providers in the communities. Their members tend to be women, many of whom are deeply religious, drawing upon their own resources to feed, clothe and care for patients.

In Zambia, religion is ubiquitous and a major contributor to public health. Workshop discussions reveal that FBOs have been providing HIV services since the mid-1990s, and that worsening unemployment and the erosion of public services create even more demand on them, bringing the system to a near breaking point. More than 80 percent of the religious health assets mapped are engaged in some aspect of HIV prevention, care, treatment or support. Many participants rate highly their services and financial support and said that these are superior to those provided through the state sector.

The most highly-rated of these include home-based care groups, churches, mosques and orphanages. They are praised for their effectiveness in caring for the sick; providing treatment and health education; and addressing poverty (for example, the digging of wells and income-generating projects). Participants also highlight the talent of these religious health assets in networking with other organizations; their level of leadership; good financial management systems; presence among the poorest people; and commitment to caring from their caregivers.

As with the “resurrection” example, the researchers learned from the communities that religion, health and well-being are deeply influenced by local context – and cannot be understood as a single, simple, cultural variable. They employ a holistic African perspective, which considers health, religion, cultural norms and values as part of an indivisible “health world.” This term is derived from the Sesotho word “bophelo.” Sesotho is the main indigenous language of Lesotho, but the researchers discovered that the concept of a “health world” was also very similar to Zambian concepts of health and religion.

Lessons from the Study
Clearly the workshops and other data show the mutual need for those involved in religious health and the public health managers and policy-makers to have a better and more complete understanding of each other. The study has recommended developing religious and public health literacy through formal courses, joint training, and shared materials to improve understanding.

Respectful engagement of more FBOs in community health work would naturally bring together religious and public health leaders in “Executive Sessions,” and create the space to encourage long-term collaboration in policy-making and project implementation.

Time is of the essence for identifying religious health assets that could help to scale-up services, strengthen community support groups and religious entities, and further link them to nearby state-run hospitals, clinics and dispensaries.

Further examination of the nature of intangible (spiritual encouragement, knowledge and moral formation) health assets is needed to more fully document the full extent of possibilities for religious health assets.

There is an astonishing capacity possible in religious communities to greatly enhance health services, along with supporting people in their care, stimulating the will to live, and building communities. These are the added value of enrolling FBOs as full participants in the health system: Building communities, saving lives, and preventing the further spread of HIV.

WHO Follow-up
This study only confirms what WHO has recognized, namely, that spiritual wellbeing may well be a crucial to “good health.” In 2000, the World Health Assembly nearly approved the inclusion of “spiritual well-being” as part of the definition of health. While other issues were raised and the amendment never came to a vote, the possibility of expanding the definition of health may be the signal needed for member states to count religious health as part of a fully functioning public health system. There is a need for more research in this area.

Meanwhile, it is essential that WHO continues to encourage government ministries to engage constructively and creatively with FBOs, which are providing health and support services for those living with HIV. The public health system and those operating religious health assets must seek out one another and find ways to open a conversation and explore the health of their communities and nations. The conflict between religion and public health is not based in the reality of the situation, but on the prejudice towards faith community pronouncements regarding HIV transmission. Their common concerns outweigh their differences.

For further information, contact.

For further information contact: karpft@who.int.

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