A Purpose-built Tool Provides Transparency for Enrollment in Services

Orphans and other vulnerable children and the households in which they live typically have multiple issues that have led to, or are a result of, their vulnerability. They may have an insufficient source of income, or not enough food to eat. They may be headed by a child, and they or a family member may be HIV-positive. Often, children in these households are not attending school, are lacking in basic water and sanitation where they live, and may be in danger of violence or exploitation.

Addressing these complex issues is a priority for national governments and the global health community. Programs to address comprehensive household well-being, in addition to improving lives, are an important component to reach USAID’s goals of 90-90-90[1] and achieving an AIDS-free generation. In order to implement comprehensive services, those who work directly with orphans and other vulnerable children (OVC) and their families face daily decisions about which children to refer to which services. These may include referrals for HIV testing, testing, treatment, and follow-up. These referrals can provide important linkages to two PEPFAR programs aimed at children and youth: the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) program, which targets adolescent girls, and Accelerating Children on Treatment (ACT).

A difficulty arises, however, in determining who should be enrolled in services, because—in most instances—there are more families who need services than there are funds to provide them. Each country and program must first identify whom to target and enroll in services, with some level of confidence that the neediest households will be the ones identified. This is complex, given the integrated nature of OVC programming, and there is no global standardized approach.

Uganda had used an “index” tool to determine enrollment criteria for all programs, but a MEASURE Evaluation assessment of the tool documented shortcomings, including concerns that the tool was not reliably capturing the most vulnerable. In addition, the tool took a long time to administer and asked dozens of detailed personal questions, even though the answers were no guarantee that families would receive services.

“Various stakeholders implement interventions for vulnerable children,” says Obadiah Kashemeire, monitoring and evaluation (M&E) advisor for the Ugandan Ministry of Gender, Labour, and Social Development (MGLSD). “A key challenge in OVC programming is to ensure that the most vulnerable children are reached and their priority needs are addressed as provided in the National Strategic Program Plan of Interventions (NSPPI2) for OVC.”

The MGLSD in Uganda addressed the issue, with support from the Uganda OVC M&E Technical Working Group and MEASURE Evaluation, and, in a two-day workshop, revised the tool by first clarifying its purpose—which is to identify and prioritize households for enrollment.

A community may identify, for example, 100 households that need support, but there may be funds enough to support only 25 of them. The tool assists community-based organizations to figure out which 25 of the 100 families should be enrolled, based on priority vulnerability indicators. The tool—the Uganda OVC Identification and Prioritization Tool—is in final stages of development and could become a model for programs elsewhere.

Molly Cannon, senior M&E specialist at the Palladium Group, a MEASURE Evaluation partner, says the Uganda OVC M&E Technical Working Group assembled to “fix” the tool, so that it is purpose-built—that is, they began from the ground up, asking what information was needed for the purpose stated and then designed the tool to fit the purpose. This was done by working through the Information Needs Framework developed by MEASURE Evaluation.

First, the tool had to consider what the OVC programs can realistically achieve and what types of vulnerabilities it will address. As this can vary within a country, the tool needed to be flexible. For example, in a post-conflict area, vulnerability will manifest in a way that is different from how it might look in an area of high HIV prevalence; urban vulnerability will differ from that in a rural area. The revised tool therefore allows for a three-layered, automated prioritization process. Any household that has experienced a child protection issue (e.g., teen pregnancy, sexual abuse, or other harm) would be automatically enrolled. Next, households experiencing one of the four “high vulnerability” indicators would be listed in order of the number of those indicators existing in the household: 1) a child is the head of household, 2) any child not eating for a 24-hour period in the last month, 3) existence of any HIV-positive individuals, and 4) where at least one child is not in school. Remaining households will be listed according to existence of other types of vulnerability indicators.

The tool also needed to be easier to administer. The old tool had a multitude of questions and took up to two hours to administer in homes with many children. After that amount of time invested, households often wondered why—sometimes with frustration—they had not been enrolled. The new tool can be implemented in less than half an hour, and has just 16 questions, all of which have yes/no responses.

MEASURE Evaluation is supporting the MGLSD in developing training and guidance materials that accompany the tool. The project will conduct a training of trainers in late October or early November, after which the tool, guidance, and training will be rolled out nationally.

“It’s a big deal,” says Ms. Cannon. “Only a few countries have done this at the national level. We helped the government clarify what they mean by vulnerability and now this tool will help them prioritize households accordingly.”

Mr. Kashemeire agrees: “Having a national tool to guide the process creates a uniform approach to identifying the most vulnerable and makes the whole process systematic and transparent.”