ARHAP-WHO RESEARCH PROJECT: ZAMBIA AND lESOTHO

The study, "Appreciating Assets," documents the contribution made by religion and religious entities to the struggle for health and wellbeing in Zambia and Lesotho , in a context dominated by poverty, stressed public health systems and the HIV/AIDS pandemic. By mapping and understanding these Religious Health Assets (RHAs), the study calls for a greater appreciation of the potential they have for the struggle against HIV/AIDS and for universal access and offers recommendations for action by both public health and religious leaders at all levels. Through respectful engagement these assets have the potential to increase in strength and value and become more effective in the long-term sustainability, recovery and resilience of individuals, families and communities.

The full report can be downloaded from the publications page.

BACKGROUND

The year 2006 marks the 25 th anniversary of the first published description of HIV/AIDS and a pivotal year for the pandemic. Over the past quarter century, an estimated 60 million people worldwide have become infected with the virus, 20-25 million have died and millions more have been affected by the loss, pain and suffering that accompany the disease. Zambia and Lesotho , in southern Africa , the two study sites for this research, are among the countries hardest hit, with estimated adult HIV/AIDS prevalence rates of 17.0% and 23.2% at the end of 2005, respectively.

The World Health Organization (WHO) has called for an unprecedented humanitarian effort to stem the tide of this pandemic and to alleviate the suffering of millions through universal access to HIV/AIDS treatment, care and prevention services by 2010. Potential key partners in this effort are religious entities, including organizations, initiatives, congregations and individuals that are hold a considerable portion of the medical infrastructure in sub-Saharan Africa and an even greater degree of health-promoting religious assets

In this context, the African Religious Health Assets Program (ARHAP) undertook research to identify, map and assess religious health assets (RHAs) that can be marshaled in the fight against HIV/AIDS in these two high priority countries and to make this new body of information accessible to a diverse audience. This knowledge is urgently needed to mobilize current capacities, align resources, fill critical gaps, and target interventions. It is also critical to the long-term sustainability, recovery and resilience of individuals, families and communities.

Community Workshop, Livingstone Zambia - 2006

RESEARCH FINDINGS AND OVERVIEW

This study, which presents research findings comprehensively, is the first attempt to assess and map both the tangible and intangible assets of religious entities through a blending of Participatory Engagement Workshops and GIS Mapping. A suite of research tools, PIRHANA, (Participatory Inquiry into Religious Health Assets, Networks and Agency) was developed for this purpose. Over the course of nine months, November 2005 - July 2006, ARHAP research teams engaged more than 350 citizens and religious and health leaders, identified through purposive sampling, from the remote mountains of Mohlanapeng in Lesotho to the urban center of Lusaka in Zambia, in a participatory and appreciative inquiry into the nature and potential contributions of religious entities to the struggle against HIV/AIDS, to universal access to treatment, care and prevention, and to health and wellbeing more broadly. Our findings reflect the collective knowledge and deep wisdom of the participants who work in a daily struggle for survival and at the heart of the pandemic.

The report on the study lays out the theoretical basis of the research and, at its heart describes the results of mapping, understanding and translating Religious Health Assets in four regions of Zambia and three of Lesotho . Our findings make visible - and in many cases map for the first time - approximately 500 religious and partner organizations working in the area of HIV/AIDS, some 350 at the local level. These groups, in particular the community congregations, support groups and intermediary bodies, are seldom seen by policy-makers and often remain unknown even to their formal religious structures. Our findings suggest these assets could and should be more effectively mobilized and linked for scale up to universal access. Many have been identified as "Exemplars" by their peers and have "promising practices" to share and build upon. These findings underlie our call for an appreciation of those assets held by the religious community in Africa that are engaged in health.

Focusing on the research undertaken with the PIRHANA suite of tools and through the lens of fourteen key findings from each country, the study analyzes RHAs in a deeper manner and examines what happens when concepts like religion and health are translated into an African language and what we have termed a "healthworld". This concept acknowledges the complex and canny ways in which people mix their health-seeking strategies based on social and cultural norms and values of importance to them. It rests on holistic African perceptions of health that often differ hugely from that applied by policymakers and is somewhat alien to the public health community. The failure to understand the influence of religion in African healthworlds , or the failure to reflect on certain assumptions of western healthworlds , threaten the important work of organizations like WHO.

In conclusion the report on the study presents and elucidates a composite set of key findings that confirm, contradict and challenge previous studies and conventional wisdom at the interface of religion and public health, especially in the struggle against HIV/AIDS and for future struggles against rising infectious disease, a deteriorating environment, abject poverty and increasing conflict. The findings, summarized below, form an important base for a way forward, marked by respectful dialogue and meaningful collaboration:

Summary of Key Findings

• Religion is ubiquitous in Zambia and Lesotho , yet often hidden from Western view. Given this, an engagement with religiously informed healthworlds is vital for the shaping of public health policy in southern Africa.
• Religion, health and wellbeing are locally and contextually driven. For those seeking to engage RHAs, religion cannot be viewed as a single, simple cultural "variable" - no "one size fits all."
• Religious involvement in health and HIV/AIDS is increasing - particularly since 2000 - and religious entities have expressed a strong local commitment and desire to be more effective in the area of HIV/AIDS. Interfaith engagement and dialogue require further exploration.
• Religious entities are perceived as contributing to health, wellbeing and the struggle against HIV/AIDS through tangible and intangible means. It is this combination that distinguishes them and gives them strength. Leading tangible factors comprise compassionate care, material support and health provision; leading intangibles are spiritual encouragement, knowledge giving and moral formation.
• Certain religious entities are acknowledged as "Exemplars" in the community and these demonstrate exceptional programmatic, operational and associative characteristics.
• An Assets-Based Approach to research and implementation of religion and health initiatives and HIV/AIDS scale up offers the potential for more rapid, sustainable and effective capacity-building and action.

RECOMMENDATIONS

Develop Religious and Public Health Literacy

Given the need for dialogue, it is crucial that as a first step religious leaders in Africa gain a basic level of public health "literacy", and that public health practitioners gain a basic level of religious "literacy". To this end we recommend that key agencies such as the World Health Organization:

• Invest in the development of formal courses and experiences to build religious/interreligious and public health literacy for the full range of leaders, policy makers, scholars and practitioners working in the fields of religion, public health and HIV/AIDS, and especially for those working at the intersection of all three.
• Develop and make available a "shared lexicon" and "knowledge base" of terms, tools, methods and results drawn from interreligious and public health disciplines, beginning with the definitions and schemas presented in this report.
• Provide joint training and orientation for religious and public health workers already in the field and for those to be newly deployed.

Community Workshop, Livingstone Zambia - 2006

Engender Respectful Engagement

Our findings make clear that "religion" is perceived by ordinary people to be extremely significant in the struggle for health and wellbeing in African communities. At the same time this "religion" only exists as specific religious commitments and practices in specific contexts. To take forward respectful dialogue means to engender respectful engagement. To do this we recommend that key actors in public health and religion:

• Build on local wisdom, context and commitment, and develop more formal ties to the individuals and organizations, such as those participating in this study and similar groups found in other nations and social contexts. The expansion of the PIRHANA tool to include local community engagement in community health issues from a religious perspective has great promise, given the positive impact experienced by those who participated in this field investigation.
• Develop a new approach to engage with religious and health leaders, academics, policy- and decision-makers, potentially based on an "Executive Sessions" model (see Hauser Center http://www.ksghauser.harvard.edu/) that allows for long-term engagement and collaborative policy development.

Align Religious and Health Systems, Beginning with Tangible Assets

Our research has found a great deal of public health activity being undertaken by Religious Entities that is not always effectively aligned with public health systems. To strengthen this alignment we recommend that key religion and public health actors:

• Use Health Mapping in strategic ways to recognize the assets on the ground and their potential connections.
• Strengthen local community "Support Groups" working in the field of health and wellbeing and link them to public health structures, including neighboring hospitals, clinics, dispensaries and laboratories.
• Support the replication of "Network hubs" "to leverage existing RHAs and develop and nurture additional ones.
• Further link to the Exemplar REs such as those identified in this study to understand "promising practices" and implications for adaptation to other settings.

Conduct Further Collaborative Research

The interdisciplinary nature of this research project and the nature of the findings suggest that the alignment of religious health assets and public health systems in Africa requires ongoing research and reflection. In particular, this calls for further research to:

• Extend Participatory Religious Health Assets Mapping to other African countries and other regions of the world and in particular in settings where Christianity is not the dominant religious tradition.
• Explore the link between "Compassionate Care", "Respectful Relationships" and "Decent Care" and their extension to the Community level.
• Further study the Exemplar Religious Entities and Existing Case Studies to determine "Promising Practices" and Effective Strategies for Alignment.
• Explore specific areas in which exemplar REs are vulnerable in the context of health systems that are fragile, and develop specific strategies to obviate the vulnerabilities so that the REs maximize.