PENSION FUND (PF)

Kwa Wazee Project is a cash transfer programme that targets poor and vulnerable people over the age of 60, including those caring for children without parents. Each household receives a monthly grant of TZS 10,500 with an additional monthly grant of TZS 6,000 for every child. It has started with a very small number of beneficiaries and by octtober 2012 nearly 1000 older people in five communities were receiving a regular monthly pension. There is no conditionality involved and, broadly speaking, it aims to reduce the vulnerability of chronically poor households, and combat the malnutrition of children.

PSYCHOSOCIAL SUPPORT (PSS LIGHT)

One of the most burning issues for older people is their health and the question of who will support them when they are sick. The problem has two faces: one is the financial problem if they have to go to hospital, the other is the care at home and who will do the household chores such as cooking, fetching water etc.

In our discussion with the three original groups it become clear that most of them are afraid to fall into the trap of helplessness. They saw the formation of mutual self-help groups as an affordable “insurance” for them against the consequences of illness. This understanding has influenced much of the work with the new groups who form what we call the PSS ‘light’ part of the project. 

Kwa Wazee defined the following “principles” for the further work with and through the older people
· Promote and develop self-help
· Networking and inclusion and building social capital: The core idea of the concept of “social capital” is that if the amount of human interaction increases, people are more likely to help one another (and even later become more politically involved and identify and defend their rights). The possession of membership in a group is regarded as an actual or potential resource.
· Building up human capital of older people i.e. the stock of skills and expertise of a person that are productive in the economic context and that has a value as income-earning potential. Although old age reduces the capacity to be economically productive, older people still have potential, which is often underestimated and underused. They possess useful abilities and skills; they can acquire additional abilities and skills or improve the existing ones.
· Enhance capacities for crisis management: Being extremely poor leads to crisis situations where emerging situational and social demands are beyond the existing capacity to act, react and cope. When it comes to “crisis management” evidence shows that most people in a crisis turn for non-professional support to their own environment: friends, neighbors, family members, faith-based institutions, peers etc. The new groups can be a source for increased capacity to deal with crisis.

These principles are translated into the following strategies:
· Form supportive neighborhood groups
· Create a sustainable nucleus for an organization of elderly: Kwa Wazee “dreams” that the mutual support groups will over time form the many pillars of an own organization of older people with an organizational structure (e.g. a membership organization with Board etc.). Such an organization could become involved in different task (e.g. lobbying at the community level, support the selection of potential beneficiaries, create small economic networks etc.)
· Promote savings: Group savings have a deep rooted tradition in rural Kagera and are very popular – mainly in the form of burial groups (support for the case of death). Nevertheless poor people are more at the margin of these institutionalized financial tools. Most groups of Kwa Wazee, once they have formed a group and experienced a certain coherence, decided as one of the first activities to start with small monthly savings. Apart from creating a tool for crisis management, it seems that to build up savings is in itself a good generator and promoter of further group life. Security is an important issue – either security from external thieves, or security against internal fraud. The offer of Kwa Wazee, to host and to administer the accounts of the groups, is obviously an important element to start group savings. Kwa Wazee tries to promote transparency with the group funds through promoting safe procedures so that all the members are aware about the state of their account. Kwa Wazee has decided to increase the savings from the group in 2008 at 50% which will build up internal capital for economic activities and for crisis management (health etc.). It is interesting to see that the health support (from the central Kwa Wazee fund) to individuals has decreased to nearly zero in the second semester of the year – and we explain it with the availability of small PSS “light group internal funds.
· Promote economic activities: Many of the pensioners would like to develop economic activities but they lack the capital to do so (and sometimes the skills and knowledge). At the same time, many of them fear to take loans – they feel that they might have difficulties with repayment. Kwa Wazee has developed a double system in order to promote economic activities:
- Loans in kind (e.g. goats) which can be repaid in kind
- Loans from the group saving to single group member where the pensions of Kwa Wazee could act (on request) as a security for the loan. If the loanee doesn’t pay back Kwa Wazee could deduct a small monthly amount in benefit of the group account. Kwa Wazee is also keen to explore possibilities to increase the income of already existing activities such as coffee cultivation through improving the quality of picked coffee and better marketing.
· Offer training which is highly valuated among the grandmothers
· Promote will writing: As already mentioned grandmothers and grandchildren are very concerned about the future of the grandchildren. Frequently members of the extended family and the clan try to grab properties – even while the grandmother is still alive. In this context will writing becomes important.

 

TATU TANO

Many old people no longer had sons and daugthers to look after them and many were also looking after their grandchildren. The Kwa Wazee Project began in 2003 initially as a project to provide cash transfers to needy elderly people in the area. During 2008 an evaluation of the impact of the cash transfer to the elderly was conducted. During this evaluation the evaluators worked with children to understand the impact of the cash transfer on the children living with the grandparents. At the same time a small qualitative study was conducted to find out about children who lived with their grandparents. It was clear from both the impact evaluation work with the children and the qualitative study that life was very hard for children living with grandparents. The biggest issue was that  they had a very heavy burden of work as there were no able adults in the house to earn money or to do the heavy labour.  
In response to this a group of the children who had been involved in the evaluation attended a workshop where they were asked "how can you support each other with your heavy workload?" The children made a decision to start small groups. Initially through these groups the children helped each other with the heavy work they had to do like collecting firewood and water. Presently there are 70 Tato Tanu groups.

 

Child-led groups for child-carers

Child-led groups for children looking after ill parents have also been set up in the  
Nshamba area. Similar to the Kwa Wazee project these groups grew out of a cash
transfer to adults made to adults made initially by the Novartis Foundation and later by
the Symphasis organisation. The adults who received the cash transfer meet regularly to
discuss their mental and physical health. During these meetings facilitators noticed that
they identified their children as their biggest support and they thought that this must
place a heavy burden on the children.

The children were invited to a workshop where they talked about the challenges they
faced, It was clear that the burden of work (similar to the KwaWazee children) they
carried was heavy but (also similar to the KwaWazee children) they carried a heavy
burden of emotional stress and worried about their future. Additionally they had to
contend with the discrimination against their family from community members because
their parents were ill and the lack of basic needs because their parents were often too ill
to work. During the workshops the children set up local neighbourhood groups where
they could begin income generation projects and support each other. By 2009 there
were 25 groups of children meeting regularly.

In reflecting on the growing understanding of how to facilitate a child-led organisation
Kurt Madoerin says that one of the lessons learned is

"the importance of basing any child-led organisation on the children's own
interests in order to create or release the energy needed to keep the groups
going." (Madoerin. pers.comm)

In all the projects in Nshamba the children defined their own interests as the basis for the
organisation. The biggest issue for the children who became the VSI was the stigma
attached to being an orphan so when the children formed the groups one of the issues
that informed its structure was the need to give them as orphans a new identity (see
below). With the child-carer groups (Kwa Wazee and Symphasis) the issue of concern
was the heavy workload and extreme poverty, so the group was formed to help each
other with work and to find ways of making money.

Meeting psychosocial needs through a child-led organisation
The nature of participation in the collective of child-led organisations in Nshamba is
informed by a body of principles drawn from a range of different disciplines. The first
principle relates to meeting psychosocial needs.

Meeting psychosocial needs
What is interesting about the child-led projects in Nshamba is that all of them have as a  
central goal "psychosocial well-being". This may be surprising as a child-led organisation
is a long way from what we have come to regard as typical of a psychocisal projects
(counselling and support groups for example). But the definition of psychological well-
being is a broad one based on the work of of Armstrong, Boyden, Galappatti and Hart
(2004) who see material conditions, human capacity and social ecology as essential
elements to work in if one is to create psychosocial well-being.

Income generation projects  
At present there are 50 Tatu Tano groups. Most of them have an income generation
project that they run as a group. Training on how to start a small income generation
163
project was held with the young people from the groups. After the training some groups
were given a loan of between 5000 and 15000 TZS. Other groups started with very
small projects that did not need an investment (like cutting and selling grass). The
following is a description of the income generation projects implemented by 4 of the
Tato Tanu groups. Many of the groups have subsequently paid back their loans and all of
them have savings - the total of the savings is around 350 USD.

The following is a description of the projects run by two of the child-led groups.

Tweyambe group  
They took a loan from the Tato Tanu project and bought 4 breeding chickens.
They also sell cut grass and sweet bananas. They have saved up and paid the loan
back and now have a profit of 10,000TZS.

Upendo group
This group used their loan to set up a small firewood business. They cut and sell
firewood. They earn about 5,000TZS per month. They have paid their loan back and
have saved some money.

ELEMENTS FOR A HEALTH CARE POLICY IN KWA WAZEE

This section explores possibilities and strategies for improvement of the general health of older people in the Kwa Wazee program. It doesn’t mean that all the discussed proposals have to be implemented but this section should promote the conceptional thinking regarding health and guide an implementation program.

 

 

The strategies are divided in three areas of either already existing or possible activities: prevention, care and cure.

Prevention

The prevention of diseases covers mainly three areas: water, firewood and malaria.

Water

Water is usually taken from the rivers, where people also wash the clothes, the motorbikes, the cars etc. In some few cases water comes from clean sources. For many of older people (e.g. in Kabare) the river is very far (more than one hour one way). If they live alone or the grandchildren are still small, they have either to buy water or to depend on neighbors and their children.

HelpAge Germany / Soroptimists Germany have committed to support the construction of rainwater fed water tanks. In February 2010 a pilot tank (2000 l) has been constructed in Kabare at the costs of 230 Euro. The water tank will allow having access to clean water during about 9-10 months per year.

Firewood

Firewood might in many cases be an even more severe problem for older people. Older people and grandchildren told us that it happens that they had no food at night because there was no firewood. Without firewood the water also can’t be boiled – and the risk of a water-born infection is increasing. Firewood has often to be collected quite far from the home stead – too far for older people, but also far and time consuming for the grandchildren who are normally schooling. Girls consider collection of firewood also as a dangerous activity in terms of sexual harassment (information collected at the self defense course for girls in Unit 4: safe and unsafe places).

In 2008 Kwa Wazee has started to construct improved stoves which reduce the consumption of firewood at around 50%. One improved stoves costs about TZS 50’000.=

Mosquito nets

Nshamba area has a high incidence of malaria. In the first months of 1998 during the heavy rains due to El Nina the number of malaria cases was so high that the Minister of Health paid a visit supposing that an additional unknown infection has reached Muleba district. Every year it happens that the hospitals are overcrowded with patient, some of them forced to sleep under the beds.

The Government has started in 2009 to spray annually of all houses.

Kwa Wazee has distributed mosquito-nets to the children in the three PSS groups but has never done an effort to investigate in the possession and use of mosquito nets for older people.

Care

One of the urgent issues is the care when people get older and frail, and when they are sick. Those older people who live either with family members or with their grandchildren can normally count with the support of those although the task of care might overburden the grandchildren.

A number of the Kwa Wazee pensioners live alone. Kwa Wazee started in March 2010 to form two consultation groups of 33 alone-living older people in order to explore their specific situation, problems and needs. Three elements were emphasized:

The missing support when they are sick: cooking and buying food and other important items for them

Water is a big problem for them: they buy water (100 TZS per tin of 20 l), and sometimes they don’t find somebody to carry water for them, so they have to try to go themselves.

Firewood is less a problem for those who have improved stoves. With improved stoves they buy for 1’000 TZS firewood which is enough for about 3 weeks. Those without improved stoves are in a worse position.

Mutual support groups

The idea of mutual support groups was developed within the three PSS-groups after one grandmother with three young grandchildren had to be hospitalized and two staff member of Kwa Wazee have been fully absorbed for one week. Kwa Wazee made clear that we are not a home-based care service, and that the care for M. was a unique exception. From a number of discussions the idea of neighborhood-based support groups emerged and was in June to a number of pensioners presented. Today (April 2010) there are around 50 groups with three main activities:

Savings

Mutual care and support in cases of illness

Income generation activities

Each group has its own rules and constitution. Nevertheless there is a common basic structure which distinguishes two scenarios:

When the member is sick but not admitted, the other members (or a delegation) have to visit and support her or him – either with food, firewood, sugar etc., or /and with money.

When the member has to go to hospital, the group support her or him with a certain amount between 10’000 TZS and 15’000 TZS.

Support from the grandchildren

In the ethnographic study “Living with the Bibi” by Glynis Clatcherty (2008) the grandchildren gave clear evidence of their caring activities beyond the (often many) house chores and the need to earn some small money in order to buy food or other basic needs. We read in the report:

 

“Children living in elderly-headed households have extra work related to looking after their grandparents. They wash their grandmother’s clothes, cook for them when sick and do basic hygiene tasks such as shaving their hair, taking sand fleas (jiggers) out of their feet and even cutting their fingernails.

- What are some of the things you do especially for granny?

- Shaving hair.

- Taking out jiggers (sand fleas) from her feet.

- Cutting her nails.

- Cooking for her.

- Washing her clothes

- When she is sick I go to look for herbs in the field.

- When she is sick I cook for her.

-I am fetching water and then cooking for my granny.

The fact that many of the children lived with very old grannies who were often sick added to their burden.

I feel bad having the granny who is always sick. Because when she is not sick we come from school and we find food ready and then we do other activities. But when she is sick we don’t get food and we have to cook. When she is sick we sometimes even don’t go to school. You may wake up and find she is sick. She tells you she needs porridge so instead of going to school you have to stay home and prepare porridge for her. Then you stay home until a neighbor comes and then you go to get herbs for her.”

There is little evidence (with exceptions KM) that this interdependence is harmful for the children. Rather it seems to be beneficial. When children were asked which work they most liked to they consistently chose tasks that were related to looking after granny. The children display a sense of pride in being able to look after their granny and it is also a way in which they show their love for her.

We are happy to look after our grandmothers because they are old and we feel responsible to take care of them.

She is the one who brought me up so whatever I am doing I am paying back what she gave to me so it is a gift I am giving back.”

Until present Kwa Wazee has not yet invested a special effort in order to improve the caring capacities and skills of grandchildren but there is certainly a big potential.

Cure

Out-of pocket payment for medical services

“Before we used local herbs and you could spend a year without going to the hospital. Bit now there is a difference. Even if you don’t have money you can get a loan from someone knowing you will pay them back. (pensioner)

There are a number of government and church based dispensaries (Biirabo, Rwantege, Kagongo, Buganguzi etc.) and three hospitals (Rubya, Ndorage, Kaigara – Rubya and Ndorage are chuch-based but with agreements with the Government) which offer user fees based medical services. Additional there are a number of drug stores which offer testing (malaria, pressure, urine and stool analysis) and sell drugs. Prices are, compared with prices in Europe, not very high (e.g. a dose of five days of the antibiotic Amoxillin costs 2’500 TZS), the prices for testing have increased in the last six months from 200 to 500 and even 1000 TZS (in one store).

It is evident that – with a pension of 7’000 TZS – there is little space of maneuver for health expenditures. The household survey Kwa Wazee did in 2008 including 31 households with grandchildren indicated an expenditure in one month of 1’610 TZS per family or 514 TZS per household members.

Mutual support groups: an informal quasi-health insurance

As mentioned above one important service of the mutual support groups consists in the financial support of its members in times of illness. The concern to be sick and not be able to get medical assistance was the main reason to start savings. The groups contribute between 200 and 1000 TZS every month. All groups follow the principle of cross-subsidization i.e. the members pay for those who are in need. Some groups use their account in Kwa Wazee for (bigger) hospital expenditures, which normally needs a decision of the whole group while they have a smaller amount in the house of one trustful member for immediate support if one member or a grandchild gets sick. Some groups have already accumulated a considerable amount – end of the 2010 the savings of all groups passed the three millions (

Exemptions and waivers

In 2003 (??) free access to health care was granted to people over the age of 60 on a loosely defined means-tested basis. Nevertheless the implementation “has been patchy as a result of lack of awareness of policy amongst local health care professionals, lack of clarity on procedures for verifying age and the apparent “unsustainability” of means-testing procedures at local level. (“The rational and feasibility of universal pensions In Tanzania”, Draft, p. 21). This has been confirmed in Kwa Wazee’s consultation with Ward and Village leaders. They gave the following explanations:

“The village executive officer explained that they normally write letters for exemption for poor older people but some are exempted while others are turned away or asked to pay. He explained that even the medical personnel at the health center seem not to have clear cut direction as to how to implement these polices.

The Ward executive officer said that he is aware about the policies but has no information how they are supposed to be implemented. The normal government procedure requires that a circular is issued from the head offices of the relevant ministries giving direction as to how the policies will be implemented. The exemption of children and pregnant women is very clear, while information about the exemption of elderly people has not been forthcoming.” (From the report on the consultation in February 2010).

It seems that the Ministry of Health and Social Welfare has recently universalised the user fee exemption to cover all older people (“The rationale …. p.22). The draft says: “However, it is likely that implementation will remain challenging for some time yet. Moreover, the full impact of the exemption policy are unlikely to be felt while older people are unable to meet the private costs associated with accessing medical care for chronic illnesses. In addition, it is important to note that increasing numbers of poor older people are caring for children who do not have access to user fee waivers.”

Community Health Fund

The main challenges of the CHF have been listed above. The feasibility study observes that “the scheme appears to continue to suffer from a number of design and institutional challenges’ and concludes “the coverage of the poor (and older people in particular) remains negligible”.

Muleba district has introduced the CHF. Humuliza plans, as part of the PACT-financed and implemented program, to cover a large area ( a number quoted was 6’000 families with vulnerable children). Kwa Wazee is in contact with the Muleba district responsible for the CHF.

Traditional medicine

Traditional medicine remains often the last affordable resort in the search for cure. Many of the old people have profound knowledge to use local herbal medicine, e.g. for the cure of malaria, coughing and stomach disorders.

Kwa Wazee has started – through the Symphasis program – to collect herbs which are used for health care and to explore the methods of applications (kind of illnesses, way of preparations and applications) .

Physiotherapeutic exercises

Kwa Wazee has selected 10 exercises which help to mobilize the joints (knee, hips) and the back. They have been applied in the Symphasis program (was an excellent feedback about the impact) and tested with a few groups of older people. They encouraged Kwa Wazee to popularize these exercises.

Piet van Eeuwijk of the University of Basel reports from Indonesia the use of kinesiology and “touch for health” exercises which helps to keep the body fit, to strengthen the muscles and to have a straight position of the body. These exercises have been qualified by a number the about 100 old people – many suffer from joint diseases – as “agreeable”. Addititionally the “Health Club” has engaged an advisor in nutrition in order to support the many people who suffer from diabetes and high blood pressure with very concrete advises and tricks for cooking and eating.

 

STUDIES

Salt, soap and shoes for school

The impact of pensions on the lives of older people and grandchildren in the Kwa Wazee project in Tanzania’s Kagera region. The report has been published with financial support of SDC - Swiss Agency for Development and Cooperation, REPSSI and World Vision International. Please visit www.kwawazee.ch/E for our reports.

 

(Not translated)