Preventing and Mitigating AIDS in Sub-Saharan Africa Research and Data Priorities for the Social and Behavioral Sciences (1996) / Chapter Skim
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6 MITIGATING THE IMPACT OF THE EPIDEMIC
6 MITIGATING THE IMPACT OF THE EPIDEMIC
Pages 204-250
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From page 204... ...
Through the year 2000, the impact of AIDS will increasingly be felt on populations in the sub-Saharan Africa region, particularly those lying in the main AIDS belt. Increases in infant and child mortality will be accompanied by increases in adult mortality and reductions in life expectancy.
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From page 205... ...
Adults aged 15 to 50 are usually the economic backbone of their families and their communities, on whom both young children and elderly parents rely for support. The illness and death of these economically active prime-age adults result not only in lower incomes for surviving family members, but also in all the other sequelae of poverty, including worsened health and reduced investment in the survivors' future productivity.
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From page 206... ...
Research questions arise about the degree to which resources should be diverted from efforts to prevent HIV infection or from other general development programs to finance mitigation interventions. On the one hand, these services provide access to basic human rights, such as an adequate standard of living, health care, and education.
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From page 207... ...
Annex 6-1 briefly surveys nongovernmental organizations currently implementing mitigation programs in sub-Saharan Africa. IMPACT ON PERSONS WITH HIV The ultimate fate of persons with HIV is well known.
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From page 208... ...
This, in its most extreme form, holds that the date of death is written and changes in lifestyle will not put off that event. The situation, even in most of West Africa, is usually more complex than this because of the concept of the employment of evil forces to cause premature death and the consequent need to identify this danger and take remedial action.
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From page 209... ...
As their health degenerates, illness results in the loss of income-earning potential, while at the same time many persons with AIDS spend their household savings in trying to treat various opportunistic infectic~ns or find a cure for AIDS itself. Anecdotal reports of workplace discrimination have been documented in a number of African countries affected by the HIV/AIDS epidemic.
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From page 210... ...
The challenge for researchers and the medical community is to devise ways of treating people with AIDS at lower cost without seriously compromising the quality of their care. Several African countries are already experimenting with various models of outpatient and home-based care as alternatives to hospitalization.
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From page 211... ...
Francis, Uganda; and the Salvation Army Chikankata Mission Hospital, Zambia recently developed a handbook for AIDS home care for use in sub-Saharan Africa (World Health Organization, 1993~. IMPACT ON EXTENDED FAMILY MEMBERS AND FRIENDS Early deaths due to AIDS are generating large numbers of people who are at increased risk of poverty.
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From page 212... ...
This observation raises the question of whether the epidemic, by reducing the willingness of individuals to trust one another, increases transaction costs and if so, whether government intervention could mitigate that increase. Many AIDS researchers have indicated that people in Africa are unconcerned about HIV because of its long incubation period.
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From page 213... ...
indirect costs to other households, associated with contributing to funeral expenses or caring for orphaned children (Ainsworth and Rwegarulira, 19921. Because AIDS manifests itself in a series of other diseases, the direct costs incurred by people with AIDS in seeking medical attention prior to their death can be considerable.
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From page 214... ...
Caring for Survivors: Children and the Elderly Among the survivors severely affected by HIV/AIDS are dependents left without economic support. The increase in the number of orphans resulting from the HIV/AIDS epidemic may overwhelm traditional systems of adoption or institutional-care alternatives, so that the development of feasible and culturally acceptable models of child care for the minor children of people with AIDS will become a major challenge in upcoming years (Preble, 1990; Obbo, 1993~.
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From page 215... ...
Furthermore, the frequently reported practice of property grabbing of the deceased's estate by the extended family results in the orphan's loss of property and household goods (Social Policy Research Group, 1993~. While the available anecdotal evidence cites a range of serious problems that orphans may confront, there is a need for reliable estimates of the frequency-or rarity with which orphans slip through informal safety nets to encounter these problems.
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From page 216... ...
It is necessary to have baseline demographic information and to gather data on the progression of HIV, perinatal transmission, the process of incubation, and mortality risk. Morbidity and Mortality In several African countries in the main AIDS belt, AIDS has already become the major cause of adult mortality, doubling or tripling the adult mortality rates over levels that were already eight times higher than those in developed countries.
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From page 217... ...
In Rakai, HIV mortality was found to have resulted in substantial slowing in the rate of natural population increase, although the population continues to experience a positive growth rate, even in that stratum of villages where adult HIV prevalence exceeds 30 percent (Sewankambo et al., 1994~. Although data concerning mortality due to AIDS are scarce in other countries, it is likely that AIDS is the leading cause of adult death in several African cities and possibly some rural areas, especially those in the main HIV belt (Kitange et al., 1994; Nelson et al., 1991; Sewankambo et al., 1994; Mulder, 1994b; De Cock et al., 19901.
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From page 218... ...
In most African countries, the crude death rate is relatively low as the result of a young age structure and recent declines in mortality. By the year 2000, AIDS will double the number of deaths and the crude death rate in many of the countries most affected by the epidemic, as compared with the levels expected in the absence of AIDS (Figure 6-11.
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From page 219... ...
/////////////////////./// _ ', ////////////////////////////////_ ///////////////////////// _ ', . ///////////////////i _ /////////i/////_ ~_~ 2~ //////////////////////// ', ////////////////////i/////_ //////////i/////////i.////_' i/////////i/////////i,///// - ' 21 No AIDS | I MAIDS J 1 _ 0 50 100 150 200 250 Deaths Ages 0-4 per 1,000 Live Births FIGURE 6-2 Child Mortality Rate With and Without AIDS, for Selected Countries: 2000.
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From page 220... ...
Will family planning programs become redundant as the population of country after country begins to decline? All indications are that these extreme outcomes will not take place.
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From page 221... ...
An additional, potentially important impact of the HIV/AIDS epidemic may also be noted: its possible impact on family planning programs. Populations 4In rural Rakai district, Uganda, trading centers with an HIV prevalence of 35 percent among adults had an annual rate of natural increase of 1.1 percent (Sewankambo et al., 1994)
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From page 222... ...
Purina raso Burundi CAR Congo C6te d'lvoire Tanzania Uganda Zaire Zambia 0 10 20 30 40 50 60 Population in Millions ~ AIDS El No AIDS FIGURE 6-5 Total Population Size With and Without AIDS, for Selected Countries: 2000.
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From page 223... ...
Population growth will decline more rapidly than expected, and African populations will be somewhat smaller in the year 2000 than they would have been without AIDS. In many African countries affected by AIDS, deaths will more than double during the decade of the 1990s as compared with the number expected without AIDS.
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From page 224... ...
This assumption that the risk of HIV does not "compete" with the baseline risks is approximately valid unless seroprevalence rates become extremely high. the number of deaths from HIV infection that would occur under two different extreme assumptions regarding the median incubation period of the epidemic in Africa.
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From page 225... ...
It is obvious that a higher mortality rate is a terrible way to achieve a lower rate of population growth and that a decrease in population growth caused by the HIV/AIDS epidemic will generate immense human suffering that would not exist if the same decrease were caused by a voluntary family planning program. However, setting aside this difference, is it possible that the reduction in population
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From page 226... ...
F4. Increased worker attrition due to AIDS sickness and death increases employer costs per worker.
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From page 227... ...
growth caused by the epidemic could benefit the survivors? The differing conse quences of the two processes in slowing population growth are worth comparing to see why the HIV/AIDS epidemic might slow per capita income growth, while the family planning program might speed it up.
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From page 228... ...
In the case of the family planning program, unless a national policy of targeting the program to the poorest households is extraordinarily effective, higher-income households will demand more family planning services and make more use of the program than will the poor. By slowing the growth of the educated labor force more than that of the uneducated, the program will have the unintended consequence of decreasing the proportion of the work force with more education.5 For HIV, the argument rests first on the ubiquitous observation that infection rates are higher in urban areas, where average levels of education are the highest, and second on the hypothetical link between male socioeconomic status and casual sexual activity.
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From page 229... ...
Second, high levels of seroprevalence may engender a reduced concern for the future, with potentially deleterious effects on all formal or informal, explicit or implicit contractual relationships in the economy. Table 6-2 should make clear that similar declines in the rate of population growth caused by family planning and by the HIV/AIDS epidemic could be expected to have quite different impacts on economic growth.
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From page 230... ...
SOURCE: Over (19921. that of the less educated, as is likely to be the case while HIV/AIDS remains a predominantly urban epidemic, the disease may slow growth in gross domestic product by more than it slows population growth, thereby slowing the growth of per capita gross domestic product by as much as half a percentage point.
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From page 231... ...
While we can be certain that Africans will seek some medical care for opportunistic infections and illnesses, research has yet to ascertain the percentage of Africans with AIDS who seek professional medical care, the type and amount of care they seek, or how much they pay for it. Nevertheless, the effects of an increase in the demand for medical care in sub-Saharan African countries, where this kind of service is already in short supply, cannot be welcome.
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From page 232... ...
Given that the demand for resources associated with caring for HIV-infected individuals competes with other similarly urgent health concerns, it is essential that we ascertain the most cost-effective approach to treating people with AIDS. How the health sector will and should adjust to the increasing demand and
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From page 233... ...
The direct impacts of HIV/AIDS in most economic sectors may therefore be difficult to detect. The Agricultural Sector Agriculture constitutes the primary economic sector of most of the African countries severely affected by the epidemic, employing a large percentage of the labor force and accounting for a major portion of gross domestic product and export earnings.
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From page 234... ...
Research on the economic impact of AIDS in the agricultural sector is still too preliminary to indicate whether this substitution will occur and what further impact it will have. It may also be noted that AIDS is just one of the many stresses on the rural labor force.
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From page 235... ...
, but this study has yet to be replicated widely throughout the region. Impact of the Epidemic on Firms There are multiple anecdotal accounts of the impact of the epidemic on the labor costs of individual firms, but there has been no systematic study of the impact of AIDS on a random sample of firms in a severely affected African economy.
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From page 236... ...
To examine the reality of worker attrition in sub-Saharan Africa, we exploit a new and unique survey of firms in Zimbabwe, Kenya, and Ghana. Coordinated by the Africa Region Private Enterprise Development (RPED)
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From page 237... ...
. Other data from the Africa Region Private Enterprise Development Project (World Bank Regional Program on Enterprise Development, personal communication, 1995)
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From page 238... ...
Further examination of this question would require combining the RPED data on worker attrition with data on firm profitability in order to study the impact of the former on the latter. Unfortunately, the RPED data do not categorize all hires and departures by grade level.
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From page 239... ...
If, in the absence of AIDS, attrition among professionals and managers is much lower than the 6 to 12 percent attrition rates among the general work force, then a seroprevalence among managers of 45 percent would, according to Table 6-1, increase the mortality rate among this group by a factor of 10 (from 5 to 50 per 1,0001. However, the results
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From page 240... ...
These beliefs are unchallenged by any broad-based, representative, empirical information about what kinds of programs are currently under way to mitigate the impact of the epidemic on the survivors and how successful they have been to date. Current interventions to mitigate the deleterious effects of HIV/AIDS in sub-Saharan Africa are implemented by a variety of organizations, governments, local and national nongovernmental organizations, international aid organizations, and grassroots groups, and are targeted to a variety of recipients.
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From page 241... ...
Furthermore, all such targeting criteria, once known to the public, are vulnerable in varying degrees to opportunistic behavior intended to divert assistance to recipients who would otherwise not qualify. Providers of Mitigation Assistance Providers of assistance can be family members, neighbors, local communities, formal or informal financial institutions, local or international nongovernmental organizations, or government agencies.
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From page 242... ...
On the cost side, little is known regarding the unit cost of delivering a package of welfare services of known quality. A rather superficial investigation of nongovernmental organization social and economic support activity reported in the annex to this chapter indicates that large numbers of organizations are engaged in these activities and
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From page 243... ...
Such research would inform, for example, the development of criteria to be used in judging the relative competence of alternative nongovernmental organizations bidding for a given contract. RECOMMENDATIONS The following are recommendations for future research in the area of mitigating the impact of the HIV/AIDS epidemic.
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From page 244... ...
Discovering the optimal roles of government, nongovernmental organizations, and donors in HIV/AIDS prevention and mitigation is critical and requires further study. Governments are now moving to decentralize and privatize AIDS programs by contracting, licensing, or franchising activities to various types of nongovernmental institutions.
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From page 245... ...
TABLE 6A-1 Sample of Nongovernmental Organizations by Country, and Whether Prevention or Mitigation of the Impact of AIDS is Among Their Objectives or Goals Percent Naming as Number of Goal or Objective Questionnaires Country ReceivedPrevention Mitigation Cameroon 25100 32 Cote d'Ivoire 580 60 Kenya 580 40 Tanzania 2245 27 Zambia 138 8 Zimbabwe 5100 80 Total 75 65 32
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From page 246... ...
That is, they have 43 percent more workers and four times as many salaried workers. The average dollar budget of the 14 non-AIDS NGOs answering the questionnaire is almost 12 times as large as the average budget of the 28 AIDS NGOs interviewed.
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From page 247... ...
However, they have smaller budgets and fewer workers, use a smaller percentage of volunteers, and serve fewer individuals and firms, although they serve more communities and are more urban, than those which do not mention mitigation. Figure 6A-1 presents the types of mitigation interventions offered by the NGOs in the sample.
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From page 248... ...
With due regard to the small sample, which renders the differences statistically insignificant, and the fact that almost all the non-AIDS NGOs are in two countries, Table 6A-3 communicates the strong suggestion that AIDS-related NGOs are doing less than they could to raise funds. Similar analysis of only the AIDS NGOs shows that those which profess mitigation as one of their objectives are slightly more likely than those which do not to gain funds from both religious and nonreligious sources, while having equal access to bilateral donors and beneficiary fees.
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From page 249... ...
The figures listed in column 3 of Table 6A-3 are estimates of the multiple by which an organization could increase its monthly budget if it took advantage of one of these funding sources, having not previously done so. Note that organizations that are successful at tapping the resources of local community groups achieve monthly expenditures 885 percent larger than those which do not.
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From page 250... ...
However, the proportion of the 114 components operated by other NGOs that includes social or economic activities is 50 percent, almost as large. The lesson here is that governments should not look only to AIDS-related NGOs as potential operators of mitigation programs.
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