The Burden of HIV/AIDS: Implications for African States and Societies
In 2009, an estimated 1.8 million new HIV infections occurred in Africa (UNAIDS, 2010), accounting for 69 percent of new infections worldwide; in the same year, 370,000 children began their lives with HIV, which is a decrease from the previous year when 390,000 African children were infected through mother-to-child transmission (UNAIDS, 2010; UNAIDS and WHO, 2009). Between December 2008 and December 2009, 961,000 patients in Africa began receiving antiretroviral therapy (ART), bringing the total receiving treatment to 3,911,000, just 36 percent of those in need of treatment in Africa according to the 2010 guidelines of the World Health Organization (WHO) (WHO et al., 2010). In 2009, 1.3 million Africans lost their lives as a result of AIDS1 (UNAIDS, 2010). Also in
2009, an estimated 14.8 million children in Africa were estimated to have lost one or both parents to become “AIDS orphans” (UNAIDS, 2010). Beyond this devastating human toll, the high HIV/AIDS burden has compromised the achievement of key Millennium Development Goals in Africa (World Bank and International Monetary Fund, 2008), and many agree that HIV/AIDS has a negative effect on total gross domestic product (GDP) in the most affected countries (Haacker, 2009). Many of the very countries experiencing these declines in GDP growth due to HIV/AIDS are among those that require the most dramatic increases in health care spending to meet their treatment goals (Over, 2004).
The committee was charged with studying the implications of the HIV/AIDS burden for African governments and institutions. This chapter details these implications and some of the major issues confronting many African states and societies in managing their epidemics in the future. Given that the epidemics across Africa range from highly concentrated to highly generalized (Wilson and Challa, 2009), the committee recognizes that significant heterogeneity exists in the extent of the burden of HIV/AIDS and its implications. While all subregions of Africa require continued, long-term commitments that are responsive to the profile of the epidemic in individual countries, this chapter, like the report generally, focuses on the southern African epicenter of the pandemic (Wilson and Challa, 2009). The chapter explores the implications of the projected HIV incidence and overall HIV/AIDS burden (described in Chapter 2 and Appendix A) for four sectors of African society: development, health, the state, and academia.
IMPLICATIONS FOR DEVELOPMENT
The negative impact of HIV/AIDS on development outcomes in Africa, especially in high-prevalence countries, is well documented. High rates of HIV-related sickness and premature adult deaths compromise household stability and investment in children; stress extended family and broader social networks; and diminish labor supply and productivity while increasing costs for households, public institutions, and private-sector companies. These observations are generally undisputed. There is, however, less consensus on how these effects translate into overall impact on the welfare and well-being of nations and populations. Debate focuses not only on the long-term effects of the epidemic on economic growth, but also on whether the classic measure of economic performance (GDP per capita) suitably captures the full range of effects of HIV/AIDS on the overall well-being of populations in high-burden countries. Improved availability of treatment has certainly altered the landscape. However, few micro- or macro-level studies to date have considered the development and socioeconomic impacts of HIV/AIDS assuming different treatment access scenarios. This section reviews findings on the disease’s adverse effects on well-being from the household to the national level and presents results of recent studies examining the influence of treatment on mitigating these effects.
HIV/AIDS infects and kills young and middle-aged adults preferentially, the age group that comprises household heads, mothers and fathers of young children and adolescents, caregivers for the old and sick, transmitters of agricultural and livelihood knowledge and skills, and custodians of social safety nets (Commission on HIV/AIDS and Governance in Africa, 2008). The epidemic’s adverse effects on African countries’ long-term development thus begin in the household with an assault on the health of an adult member, and appreciating household-level impacts is essential to formulating an effective response to the epidemic. Sickness and possible death draw down the household’s existing financial reserves and compromise the sick member’s income-earning and food-producing potential. This erosion of household resilience undermines the care of and financial investment in children. In highly affected countries, placing children’s futures at risk potentially weakens long-term development prospects.
A Poverty Trigger
Findings from Booysen’s (2004a) study of income mobility and poverty in poor HIV/AIDS-affected households in South Africa reveal these starting-point dynamics. Comparing outcomes in a cohort of HIV/AIDS-affected households with outcomes in a control group, Booysen demonstrates an association between HIV/AIDS-related morbidity and mortality and downward income mobility in affected households. Households at the lowest end of the income distribution, which are more likely to be in a state of chronic poverty prior to HIV/AIDS stressors, show the least variation in mobility, whereas households at the upper end of the income distribution show the greatest mobility, downward. Additionally, the intensity of income mobility increases with the level of illness and death experienced by the household. Booysen concludes from the study that in addition to conventional determinants of poverty, effects of HIV/AIDS-related morbidity and mortality on income mobility push households into chronic poverty. Greener’s (2004) analysis of household income and expenditure data in Botswana supports Booysen’s findings. “Income shocks” stemming from the AIDS-related death of an adult household member produce almost all observed changes in household-level poverty status.
Many of the poorest are women, who often head the poorest households in Africa (Mbirimtengerenji, 2007). The characteristics of the poor are well known, as are some of the causal factors, such as early marriage, that contribute to a “culture of poverty”—the fact that the children of a poor community often become the poor of the succeeding generations. Another group—children on the streets—have extremely low welfare; receive much less education than other children; and are more exposed to health risks, prostitution, drug abuse, HIV infection, and crime (Ahmed et al., 2007). Street children and children orphaned
by AIDS are more vulnerable than others to the risks leading to HIV infection and perpetual poverty, with little to no access to health care.
The dynamic described above applies also to households whose livelihood depends on agricultural production. A study by de Waal and Whiteside (2003) postulates that HIV/AIDS has exacerbated the food shortage in southern Africa. This hypothesis is based on several observations: that household food shortages in southern Africa are widespread, including in areas not affected by drought; that the decline into household impoverishment is rapid compared with what was seen in earlier droughts; and that household vulnerability continues after the return of good rains. Some empirical evidence from the region bears out this hypothesis.
Studies from several countries in the region have linked declines in household food production to adult HIV infection (Arrehag et al., 2006). Government studies from Swaziland report particularly dramatic declines in food production and in agricultural land use (Naysmith et al., 2009). Findings from Kenya do not show declines in land use, but they do show changes in land use patterns, including stopping cultivation of labor-intensive crops and reducing farming management practices (Nguthi and Niehof, 2008). Vulnerability varies depending on household composition, as well as on the gender and stage of disease of the infected adult household head. Some research reports greater negative impact from the loss of labor of an adult male household head, while others suggest that impacts on household food security are more severe if adult females are infected (Gill, 2010). Appreciating the extended-family dynamic linking rural food producers to urban income-earning laborers, Crush and colleagues (2006) point out that HIV/AIDS impacts food security beyond agricultural households, extending into a wider system of family exchanges of food and cash remittances.
Whether the negative effects of HIV/AIDS on household food security produce negative effects at the community level has been questioned (Frayne, 2006). Conversely, others criticize studies’ household-level focus, arguing that the effects of HIV/AIDS on food security are broader and need to be framed explicitly within complex social and political–economic systems (Ansell et al., 2009). In this view, the negative impacts of HIV/AIDS can be fully understood only when considered within preexisting social, political, and economic structures that in themselves create inequality, poverty, and hunger. Ansell and colleagues (2009) contend that limiting the focus of analysis to the household level masks these structural determinants of social inequality of which HIV/AIDS is but one contributing part.
Family Coping to Support Orphaned and Vulnerable Children
The ways in which HIV/AIDS-induced food and income vulnerabilities affect children are critically important for understanding the long-term impact of the epidemic in Africa. A review of the literature on HIV/AIDS-affected households’ coping strategies by Drimie and Casale (2009) is useful in this regard. In response to increased health care costs and income reductions, families often adopt “erosive” coping strategies, such as taking children out of school, diminishing food intake, or selling and slaughtering animals prematurely. Households without health insurance or savings are especially at risk of adopting erosive coping measures. Meant to respond to the immediate stressor, such strategies jeopardize future livelihood options for the household and undermine children’s education and future livelihood potential.
Orphaned children are at greatest risk of a compromised future. Data from southern Africa consistently and unambiguously confirm that all forms of orphanhood—loss of a mother, loss of a father, and loss of both—have increased substantially in recent decades (Hosegood, 2009; Meintjes et al., 2010). Evidence from South Africa shows that in number and percentage, the greatest increase is among “double orphans”—children who have lost both parents (Meintjes et al., 2010). Advanced HIV/AIDS epidemics in these countries are associated with this rise in orphanhood.
Of interest is what happens to these children and who cares for them once orphaned. While significant attention and HIV/AIDS-dedicated resources target child-only households, reviews of demographic evidence from southern Africa generally (Hosegood, 2009) and South Africa specifically (Meintjes et al., 2010) indicate no substantive increases in such households. The majority of orphaned children have one surviving parent, and most are living with that parent. Moreover, contrary to common scholarly and popular depictions alike of disintegrated extended families in Africa unable to care for a growing number of AIDS orphans, Mathambo and Gibbs (2009) argue that families are coping along a continuum of caring abilities, although it has been observed that a large number of orphaned children are being cared for by frail, elderly grandmothers who often need to be cared for themselves and lack adequate support systems (de-Graft Aikins et al., 2010). At the same time, recent work by Akwara and colleagues (2010) suggests that orphanhood and coresidence with a chronically ill or HIV-positive adult may not be the best indicator of children’s vulnerability. Based on surveys from 36 African countries, their data show that a parent’s AIDS-related death or chronic illness could not consistently be tied to hunger, lower school attendance, or first sexual experience at an early age. What the authors did find reliably linked to vulnerability was the level of wealth in the child’s household. Accordingly, they recommend looking beyond the usual measures of vulnerability and suggest that measures of vulnerability be calibrated to account for each country’s unique conditions.
Care Options for Orphans and Vulnerable Children
Although recent data are scarce as to who is caring for orphaned African children, it appears that throughout Africa, household-based care is dominant (Subbarao and Coury, 2004). Most orphans reside in foster care within family lines. Foster care and adoption by nonrelatives are uncommon, in part because of a variety of cultural beliefs and taboos. Institutional care for orphans also is quite limited, although it appears to be growing in some countries. According to a recent Save the Children report from Liberia, there are 11 times more orphanages now than 20 years ago. In Zimbabwe, 24 new care institutions for children were built between 1994 and 2004, and the number of children in residential care doubled. In Ghana, the number of such homes increased from 10 in 1996 to more than 140 in 2009 (Csáky, 2009).
One reason for the relatively limited number of institutionalized care facilities for orphans is the cost of running them. The cost per child per year ranges from US $5,403 (with donated food) in Rwanda to $1,350 in Eritrea and $698 in Burundi. Placing just 1 percent of the 508,000 Burundian orphans in such institutions would cost $3.5 million each year. For most African countries, this cost per child rules out institutions as the preferred option for scaling up of orphan care (Csáky, 2009). A 2001 study comparing the cost-effectiveness of six models of orphan care in South Africa found that formal institutional care is the least cost-effective model, while informal models, such as community-based care and informal fostering, are relatively more cost-effective, although they fail to meet minimum standards of care (Desmond and Gow, 2001). Other studies have reached similar conclusions (Owiti, 2004; Subbarao and Coury, 2004).
Given the diverse cultural and socioeconomic settings in Africa and the complex needs of orphans and vulnerable children, most countries are adopting a cost-effective care model that considers multiple levels of care. In Malawi, for example, the National Orphans Task Force has developed a guideline for orphan care in which community-based programs are at the forefront of interventions, followed by foster care; institutional care is the last-resort option, as a temporary measure (Subbarao and Coury, 2004).
Policy Implications with a Long-Term Perspective
According to Booysen (2004a), dedicated resources that target HIV/AIDS-affected households with broad-based medical, educational, and social security systems could potentially prevent these households from declining into chronic poverty. The stakes of such policies are potentially very high for African countries’ long-term economic development. Bell and colleagues (2004) contend that “AIDS does much more … than destroy the existing abilities and capacities––the human capital––embodied in its victims; it also weakens the mechanism in which human capital is formed in the next generation and beyond.” Children deprived
of adequate childrearing and education will transfer their capacity and knowledge gaps to their own children, thereby transmitting and amplifying the HIV/AIDS-generated poverty trap in generations to come. Using projections from two high-prevalence countries, Bell and colleagues conclude that without aggressive and expensive policies to preserve the development and transfer of human capital in overlapping generations, highly affected countries risk progressive collapse of their economies. A recent review of studies in Tanzania and Uganda (Seeley et al., 2010) confirms lasting negative impacts on household poverty and on children, but does not confirm large societal impacts of the order predicted by Bell and colleagues (2004). Nevertheless, the latter authors’ focus on the injurious effects of HIV/AIDS from generation to generation rightly underscores the epidemic’s significance for Africa’s future.
HIV is sexually transmitted, debilitating, and fatal. Most of the sickness and death caused by the infection is in adults of (re)productive age. Even scholars who doubt the pertinence of disease for economic growth concede that these facts about HIV/AIDS compel special consideration in macroeconomic analyses for countries with generalized and severe epidemics (Acemoglu and Johnson, 2007). Alongside orphaning with its lasting effects, HIV/AIDS-related adult morbidity and premature death affect economic development in several direct and indirect ways.
Labor and Productivity
The disease’s impacts on labor and productivity are immediately relevant. In a study of HIV/AIDS and private-sector companies in Africa, Feeley and colleagues (2009) describe a variety of costs to businesses. Employee absenteeism and impaired function due to HIV/AIDS represent tangible costs to companies operating in highly affected communities. Both lead to lower productivity, the cost of which is felt most strongly by firms relying on skilled labor and having invested in worker training. Other costs to companies take the form of increased employee benefits (whether for treatment or for benefits to families in the event of death), costs of recruiting new staff, and increased management time spent on HIV/AIDS-related issues of infected employees. In the pre-ART era, empirical reviews of these extra costs to companies—the “AIDS tax”—showed them to account for 0.5 to 10.8 percent of total compensation costs, depending on the HIV/AIDS burden in the community and the workforce (Feeley et al., 2009). Although a 1–2 percent “AIDS tax” is more common, companies aware of these costs often seek ways to mitigate, cut, or shift these extra expenses (Barks-Ruggles et al., 2001; Reddy and Swanepoel, 2006; Rosen et al., 2007).
Following the initiation of ART, some loss of productivity may result from
the treatment itself, whether because of toxicities (side effects) of the antiretroviral (ARV) drugs or the queuing time required to obtain services in the public sector (queues at public clinics can last for many hours, and current ART guidelines typically require many clinic visits, especially in the first year) (Rosen et al., 2007). On the other hand, some data suggest that—using worker absenteeism as a proxy for productivity—ART is effective in restoring the productivity of infected workers over time (Habyarimana et al., 2010; Rosen et al., 2010).
Within the private sector, reduced labor performance combined with increased labor costs may discourage business investment in communities with severe epidemics (Arbache, 2009). A vicious cycle may ensue, whereby the disease negatively impacts labor supply and performance, leading to negative impacts on capital investment, leading to a decline in employment. As household incomes decline, a high burden of HIV/AIDS can ultimately lead to negative market impacts (Feeley et al., 2009).
While the economic impact of HIV/AIDS on households is well established, so is their remarkable ability to cope. Although potentially consequential for an individual entrepreneur, high morbidity and mortality among the labor force do not necessarily slow the overall macroeconomic growth of an economy as long as new firms arise to replace those hurt by the epidemic, and new healthy, equally productive employees are hired to replace those lost to illness and death. Many African economies suffer from extreme unemployment and underemployment of their labor forces, so firms may be able to replace lost workers at a low cost. Given that enterprise surveys in Africa typically find turnover rates among unskilled workers of around 11 percent per year in the absence of HIV/AIDS, a very high HIV prevalence is required to substantially increase annual hiring costs. Thus, the question of whether a high prevalence of HIV infection reduces per capita economic growth remains pertinent.
Early analyses of the economic impact of the HIV/AIDS epidemic down-played its consequences for GDP (Lovász and Schipp, 2009). Researchers drew these conclusions largely because of the way they assessed GDP (per capita GDP = GDP/total population), which takes into account the size of the population. With this formula, when the growth rate of the population declined along with GDP, a minimal economic impact of HIV/AIDS was found. Many of these studies were conducted at a time when the morbidity and mortality from HIV had not been fully realized. Newer analysis approaches take into account more recent data and use advanced modeling techniques. Using these approaches, several authors have found statistically significant negative effects of HIV prevalence on the growth of per capita GDP. One of the most methodologically sophisticated of these efforts is a recent study by McDonald and Roberts (2006), who found the negative effects of HIV/AIDS on economic growth in Africa to be statistically
significant. In their model, using data from the pretreatment era, poor health and loss of life reduce social and economic capital. In the Africa sample, an average reduction of 0.59 percent in income per capita results from a 1 percent increase in HIV prevalence (McDonald and Roberts, 2006). In contrast to reports reviewed by Feeley and colleagues (2009), the findings of McDonald and Roberts show that surplus labor supplies in poor countries do not diminish the negative effects of HIV/AIDS on economic growth. Slower growth reduces the tax base, while every new HIV/AIDS-related illness episode, death, and vulnerable child has financial implications for the public health and social sectors (Arbache, 2009; Haacker, 2006).
Lovász and Schipp (2009) also found a significant negative effect of the HIV/AIDS epidemic on the growth rate of per capita GDP in Africa. Their study—looking at the impact of the epidemic on the pace of economic growth in 41 countries—reports that the economic impact of HIV is not uniform across countries or even within countries. The economies of countries with low HIV prevalence appear able to absorb the shock of the epidemic and maintain relatively normal economic relationships. By contrast, the economies of countries with high prevalence, particularly in southern Africa, experience severe and significant difficulties due to the epidemic (Lovász and Schipp, 2009).
A crucial point that should not be lost in technical discussions of per capita GDP is that HIV/AIDS has a disastrous impact on the social and economic well-being of heavily impacted nations and on their development. The epidemic is reducing the stock of skills, experience, and human capital and, in turn, driving up costs and decreasing productivity (Nkomo, 2010). It is diverting resources away from savings and investment, interrupting generational transfers of knowledge, weakening the education system, and threatening food and human security. All these factors have a long-lasting effect on social and economic development and make it difficult for southern Africa to attain the Millennium Development Goals of eradicating poverty and achieving sustainable development.
Influence of Treatment on Household and Economic Well-Being
Whether for assessing ART’s effect on preventing orphanhood and vulnerability in children or on averting affronts to African economies, understanding the influence of treatment on the socioeconomic impacts of HIV/AIDS has now become imperative. One of the first studies of this kind examines the impact of treatment on labor supply in a rural region of western Kenya (Thirumurthy et al., 2008). Within 6 months of treatment initiation, adult labor supply and participation among HIV/AIDS patients increased dramatically. Simultaneously, labor participation of children in the patient’s household, especially that of boys, decreased significantly. The effects of the latter finding are larger and impact more household members in households with multiple patients (Thirumurthy et al., 2008).
A review of studies of the economic and quality-of-life outcomes of HIV/AIDS treatment in developing countries reports similar trends (Beard et al., 2009). Such studies consistently show improvements in physical health after treatment, as well as improvements in subjective well-being and outcomes related to depression, dementia, and anxiety. Other benefits reported in studies reviewed by Beard and colleagues include significant declines in absenteeism after 1 year of ART, coupled with increased work performance. These effects are found across different sectors. Other household-level benefits are reported as well. With increased ability to work among HIV-infected adults, child labor participation declined and school attendance increased. The first 6 months of treatment was also associated with increased consumption of nutritious foods in the household and with a decline in wasting among children under age 5—from 12 percent at baseline to 5 percent after the adult caretaker had been on ART for 5 months.
In South Africa, Booysen (2004b) investigated the role of social grants in mitigating the socioeconomic impact of HIV/AIDS at the household level (Booysen, 2004b). He concluded that social grants play an important role in alleviating poverty (bringing very poor people closer to the poverty line) in HIV-affected households, more so than in eradicating poverty (lifting people out of poverty). However, Booysen notes that the magnitude of the epidemic in South Africa also necessitates consideration of the fiscal affordability and sustainability of such a system in the longer term.
IMPLICATIONS FOR THE HEALTH SECTOR
The concept of the burden of HIV/AIDS is more meaningful if grounded in concrete consequences and resource demands (Parikh and Veenstra, 2008). Nowhere are the consequences of HIV/AIDS and the resulting resource implications more evident than in the health sector. The health sector has long been key in the response to HIV/AIDS, but its role has become more central with the relatively recent addition of clinic-based prevention, treatment, and care services.
Provision of treatment and care is pivotal to managing generalized and severe HIV/AIDS epidemics, and for many African countries, funding commitments for WHO’s 3 by 5 Initiative in 2003 represent a turning point in this regard. Financial resources in and of themselves do not make for success, however. Management and institutional capacity demands on the health sector are both substantial and evolving within a changing context of more treatment and care. The injection of resources for HIV/AIDS care, while providing tremendous opportunity to respond more effectively to the epidemic, also presents critical dilemmas concerning the sustainability of service provision over time and the future direction of HIV/AIDS policies and programs. This section reviews some of the challenges and possible trade-offs faced by the health sector in African countries in planning and managing responses to the epidemic.
Supply and Demand, Costs and Benefits
Changes in the supply and demand of health care are one macro-level expression of a shifting HIV/AIDS burden. Early in the global scale-up of treatment and care, Over (2004) described how HIV-related disease both increases demand for and reduces the supply of health sector outputs. The result is health care scarcity, leading to higher costs and national spending for health. Dedicated funding to increase access to HIV/AIDS treatment and care introduces another dynamic. As the supply of HIV/AIDS-related treatment and care increases, so, too, does demand for the new services. While increased supply and demand of HIV/AIDS treatment and care are partially offset by declining demand for treatment of opportunistic infections, they also can cause declines in supply in other health areas (Over, 2004). The provision of complex lifelong treatment to an ever-expanding number of patients will only continue to create extra demand for health care resources, driving up provider incomes and the price of all health care.
On the other hand, evidence from Brazil, where an early response to HIV/AIDS included universal access to ART for medically eligible patients, suggests that aggressively “fighting HIV/AIDS is good business” (Teixeira et al., 2004). As has been seen in wealthier contexts (Gebo et al., 2005; Krentz et al., 2006; Sherer et al., 2002), putting more HIV-infected people on ART in Brazil dramatically reduced deaths and HIV/AIDS-related hospital admissions (Candiani et al., 2007; Teixeira et al., 2004), saving the country’s public health sector close to $2 billion between 1997 and 2003 (Teixeira et al., 2004). Reductions in opportunistic infections also were seen with the introduction of ART, suggesting similar potential benefits in African settings (Badri et al., 2002; Jerene et al., 2006). Some scholars question the applicability of Brazil’s experience with cost savings for those African countries most challenged by HIV/AIDS (Over, 2004), while others argue that treating more people sooner results in net savings regardless of setting (Ford et al., 2009). Empirical evidence for both arguments is lacking, however.
While the cost/benefit debate continues, there is no question as to the clinical benefits of earlier treatment, as reflected in WHO’s recent recommendation to initiate ART earlier at a CD4 threshold of 350 cells/μL for all HIV-positive patients regardless of symptoms (WHO, 2009). In addition to the clinical benefits for individual patients, many experts believe that treating more people earlier also has a prevention benefit (see the discussion below and in Chapter 2), although this benefit is still under debate (Cohen and Gay, 2010; Mastro and Cohen, 2010; World Bank and USAID, 2010). Moreover, treating key coinfections decreases viral load, which has been shown to slow HIV progression; even small changes in viral load could translate into population-level benefits in lowering the risk of HIV transmission (Lingappa et al., 2010; Modjarrad and Vermund, 2010).
Strains on the Health System
However compelling the argument for a double—clinical and preventive—or even a triple—clinical, preventive, and cost savings—benefit of ART may be, there is no doubt that the ever-growing number of patients on lifelong treatment is placing significant strains on health systems (Boulle and Ford, 2007), strains that will increasingly be felt by outpatient services at the primary care level (Parikh and Veenstra, 2008). The result could be to detract attention from other essential primary health care services (Van Damme et al., 2006). Even in small countries where ART programs are faring well, the massive commodity, laboratory, and clinic demands associated with chronic disease management for an expanding HIV/AIDS patient population will present daunting challenges in the years ahead (Harries et al., 2006). Regardless of the programmatic successes seen to date, moreover, Veenstra and colleagues (2010) remind us that, in addition to weaknesses in health and drug supply systems, other crises in African countries can further compromise the delivery of ART programs, leading to drug resistance, treatment failure, and additional burdens on the health system. In addition, questions have been raised about whether poor integration of donor support to combat a single disease could weaken host country health systems (Oomman et al., 2008).
Thus, expanded access to HIV/AIDS treatment and care is in some ways transforming and in other ways amplifying the challenge for African countries. Unfortunately, the infrastructure in most African countries is not based on a chronic care model. The closest example in these countries may be a well-child or tuberculosis clinic (de-Graft Aikins et al., 2010). Effective long-term treatment of HIV/AIDS requires high-functioning health systems equipped with capacities for prolonged laboratory monitoring and integrated patient management to enable regular follow-up and changes in treatment. The service delivery models and expectations of care established decades ago have proven woefully inadequate for responding to the quality and complexity of care demanded for HIV/AIDS (Coovadia and Bland, 2008).
An additional stress on health care systems in Africa is worker migration. The mobility of health care personnel—within countries (from rural to urban locations), between countries (from weaker to stronger economies), to donor organizations and nongovernmental organizations (NGOs) (away from public clinics), and globally (to high-income countries)—further stresses already weak and fragile systems (Awases et al., 2004; Hagopian et al., 2004).
The outcomes of the world’s unprecedented effort to address a devastating health issue remain unknown. Over’s (2004) predictions of mounting health care demand and intensified health system stressors are well placed, however, and at this juncture demand serious consideration. For African countries whose HIV/AIDS treatment and care programs are largely or wholly dependent on donor aid, a pressing concern now is how to manage the transition in the face of stagnating
or decreasing donor assistance. For those rare countries that are shouldering a prominent portion of their health sector’s care and treatment burden, the question is how to sustain the response with an unending increase in the number of HIV/AIDS patients needing care. Managing the epidemic effectively will require that political and health leaders confront these questions forthrightly, a process that must begin with grasping the dynamic resource demands for sustaining an adequate response.
The significant challenges of sustaining a health sector response to the HIV/AIDS burden begin with testing. Considered the gateway for HIV prevention, treatment, and care, HIV testing has provided a foundation for African countries’ management of their epidemics. A negative test result presents an opportunity for primary prevention through test-linked counseling and education; a positive result presents an opportunity for secondary prevention and referral to support, treatment, and care services for patients and affected families.
Recognizing this important opportunity, WHO recommends provider-initiated HIV testing and counseling as part of the routine delivery of primary health care in countries with generalized epidemics (WHO and UNAIDS, 2007). Working toward implementation of this guidance, African countries substantially increased the number of testing centers and the number of tests per 1,000 population between 2007 and 2008 (WHO et al., 2009). While innovative community-, workplace-, and home-based testing approaches have been tried (see Box 4-1), expanded access to HIV testing has required massive investments in health
Innovative Testing Approaches
An innovative strategy for prevention being used in the Democratic Republic of the Congo is mobile HIV testing. A van—furnished with a sampling chair, a refrigerator, a laboratory, and a generator—arrives in public places such as markets and major intersections for immediate and free testing. The van is often surrounded by curious onlookers, and this basic system has encouraged many people to learn their HIV status. Those who test positive are referred to care centers (Séverin, 2010). Similarly, in Benin, The World Bank supports two mobile laboratories, equipped with a spectrophotometer and a cyflow, to help meet the increasing demand for HIV screening. The mobile laboratories facilitate the collection of blood samples in the most remote areas of the country and transport the samples to laboratories for screening (Afrique Avenir, 2010).
system infrastructure (private consultation rooms and upgraded laboratories), more health personnel (counselors and laboratory technicians), improved supply chain systems (to move reagents, test kits, and medical supplies), additional record-keeping functions, and improved referral systems. Yet despite the investments made to date and improved capacities to perform HIV testing, access to testing remains considerably below desired levels. Moreover, the test is merely a starting point for more complex and costly interventions. Benefit does not accrue from testing alone, but from successful referral to treatment and care of those found to be HIV-positive. While clearly essential to managing and controlling African epidemics, broader access to HIV testing has altered the resource demand landscape and presented critical new challenges for African health leaders to consider.
Need for Mental Health Care
Mental health conditions have been described as both a risk factor for and a consequence of HIV (Bodibe, 2010; Meade and Sikkema, 2005). Among patients with HIV infection, depression is the most frequently observed psychiatric disorder (Nakasujja et al., 2010). Cognitive impairment in HIV patients also is common, ranging from minor cognitive motor disorder to HIV dementia. Studies conducted in Africa have found alarmingly high rates of dementia in HIV-positive patients (Freeman et al., 2007; Wong et al., 2007). This finding raises great concern not only because the condition is treatable if recognized, but also because HIV-associated dementia can have adverse effects on adherence to HIV treatment.
Given the projected large numbers of people who will be diagnosed and living with HIV/AIDS in the next decade, the need for a strong mental health and neurological workforce is evident. According to the joint IOM/Uganda National Academy of Sciences workshop summary Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Reducing the Treatment Gap, Improving Quality of Care (IOM, 2010), the low-income countries of Africa have very few of these skilled professionals available to treat the large numbers of persons with such disorders. The report emphasizes the paucity of trained professionals in this field compared with developed nations:
In the clinical neurosciences (neurologists, neurosurgeons, psychiatrists), except for South Africa, the mean ratios for countries that have these medical specialists are 1 neurologist for 1 million to 2.8 million people (versus 4 per 100,000 in Europe); 1 psychiatrist for 900,000 people (versus 9 per 100,000 in Europe); and 1 neurosurgeon for 2 million to 6 million people (versus 1 per 100,000 in Europe). Most of the clinical neuroscience services are located in the capital cities, often the largest urban areas, where the professionals also often lecture at the medical schools. As a result MNS patients often must travel long distances to consult with a doctor in the city (IOM, 2010; Silberberg and Katabira, 2006).
Need for Social Services
Given the number of highly vulnerable children in Africa and the limited capacity of its child welfare sector, some have suggested that investments are needed to build a cadre of professionals and paraprofessionals with social work skills (Khumalo, 2009; Lombard, 2008; USAID, 2009). Yet few particulars are known about the child welfare sector and the social work workforce in Africa, and there have been few country projections of the demand for these services and related workforce needs.
The Global Health Bureau of the U.S. Agency for International Development (USAID) commissioned a study to assess the opportunities for and constraints on building the social work workforce within the child welfare sector in Africa (USAID, 2009). A key observation resulting from this study is the existence of a historically rich social work profession in Africa built on a community ideology and focused on meeting the needs of vulnerable children and families, especially those living in poverty. At the same time, the study identified the underdevelopment of the profession and the need to build the capacity of child welfare and social work education systems in Africa.
As with the profession in general, little is known about social work education in Africa. The available data are anecdotal and self-reported, and obtaining accurate and current information on the numbers of schools, students, and graduates is difficult. However, the projected shortfalls of graduates suggest the need for systematic evaluation of the capacity of African social work education (USAID, 2009). Evaluation of social work teaching methods and curricula also appears to be needed. Several apparent shortcomings have been noted: many faculty received training in the West and are therefore more familiar with the Western literature than their own indigenous knowledge; social work teaching methods tend to lack the participatory models necessary to engage students in active problem solving; and field education experiences in rural community settings are inadequate (Hochfeld et al., 2009; USAID, 2009).
Health Systems: Needs and Opportunities
WHO’s Global Strategy for Health for All by the Year 2000 called for strengthening health systems through sound coordination mechanisms combined with adequate infrastructure, human resources, logistics support, and referral and health information systems (WHO, 1981). Thirty years after this call to action, weaknesses in African health systems have been identified as the major obstacle to reaching WHO’s 3 by 5 treatment targets (Schneider et al., 2006; Van Damme et al., 2006).
Not only are weak health systems a baseline problem, but they are also at risk of undergoing further weakening and distortion from HIV/AIDS-focused interventions (De Maeseneer et al., 2008; McCoy et al., 2005). Recent concern about
the potential of HIV/AIDS programs to undermine public health systems is part of a long-standing debate over disease-specific versus health system approaches (Freedman, 2005; Unger et al., 2003; Van Balen, 2004). Yet while some negative effects on health coordination and harmonization have been reported with the implementation of HIV/AIDS treatment and care initiatives (Biesma et al., 2009), a growing evidence base shows mainly positive contributions of these initiatives to key functions of health systems (Embrey et al., 2009; Harries et al., 2009; Sherr et al., 2009; Yu et al., 2008).
Specifically, Embrey and colleagues (2009) describe how the great need for HIV/AIDS-related products for treatment and care scale-up in Africa has led to improved capacities in pharmaceutical procurement and supply chain systems more generally, although a number of interrelated constraints in procurement and supply management remain. In particular, recurrent “stockouts” of ARV drugs are common among almost all health facilities in west and central Africa, mainly as a result of inadequate forecasting and information flow among stakeholders (UNICEF et al., 2008). A similar situation has been noted in east and southern Africa, where stockouts of ARVs and other life-saving drugs have also been a problem (IRIN, 2010; Thom and Langa, 2010).
HIV/AIDS care similarly demands improved laboratory capacities at all levels of the health care system (Spira et al., 2009), as well as better medical record keeping and data management (Forster et al., 2008). Supply chains, laboratories, and medical records are basic components of any health care system. For many African countries, new attention to these essential system components represents catching up to basic standards as much as meeting special demands for managing HIV/AIDS patients. Moreover, while more evidence is needed on the impact of HIV/AIDS programs on service delivery in other health areas, data from Rwanda (Price et al., 2009) and Haiti (Walton et al., 2004) suggest an association between the introduction of HIV/AIDS care and increased delivery and uptake of other primary health care services. Conversely, a recent retrospective analysis of publicly available WHO data found little or no country-level impact of PEPFAR funding on non-HIV/AIDS health outcomes that were not explicitly targeted (Duber et al., 2010).
While both positive and negative effects of AIDS funding have been asserted, available evidence on the effects of the scaled-up response to HIV/AIDS on health systems is slim. Many arguments suggesting impacts of HIV investments on health systems are based on anecdotes and speculation, on small pilots, or on early stages of programs that cannot yet be generalized, and a number of systematic impact studies are still under way (Yu et al., 2008). Therefore, the question of positive, negative, or neutral spillover effects of HIV/AIDS-targeted programs remains an important topic that demands further examination (Rabkin et al., 2009). At the same time, Jeena (2005) and Bodkin and colleagues (2006) remind us that in and of itself, HIV/AIDS care is an important aspect of maternal and child health care.
Human resource demands related to HIV/AIDS care remain a significant concern. (See Chapter 5 for further discussion of the human resource crisis in Africa.) In Africa, HIV/AIDS adds to the demand for and sometimes decreases the supply of health workers (Herbst et al., 2009). For example, HIV in health workers is a contributing factor to absenteeism, resulting not just from the primary HIV infection but also from immunocompromised workers’ increased risk of occupationally acquired illnesses such as tuberculosis (including its multi- and extensively drug-resistant forms). Poor infection control practices leading to these infections place further strains on the health care system. From a resource perspective, a key element of health system strengthening is protection of the health care workforce—in the same way that any scarce resource would be protected.
Although multiple actions are needed to address systemic problems of production, retention, and allocation of health workers (Philips et al., 2008), scaling up of HIV/AIDS treatment and care has resulted in several innovations in care delivery in Africa. Substantial evidence shows that alternatives to physician-centered treatment, such as community-based support for patient enrollment and follow-up (Sanjana et al., 2009; Torpey et al., 2008), are both feasible and effective (Bedula et al., 2007; Gimbel-Sherr et al., 2007; Sanne et al., 2010; Shumbusho et al., 2009; Stringer et al., 2006). Tasks related to initiating and managing ART often are shifted to nurses, with good clinical outcomes, and there is some evidence that other nonphysicians, such as clinical officers (who have 3 years of clinical and practical training beyond grade 12) can also fill this need (Bolton-Moore et al., 2007).
Researchers in Uganda estimated the cost and personnel impact of task shifting from physicians to nurses and pharmacy workers for ART follow-up. They demonstrated a US $0.5–11.0 million savings and the freeing up of 4.1–14.8 percent of nationally available physician full-time equivalents (FTEs) annually. Applying the same methodology to all of Africa—with 9.7 million patients in need of ART (31 percent access) and 150,714 practicing physicians—the researchers found that task shifting could save $0.476–2.769 billion and free up 4.1–5.9 percent of available physician FTEs on the continent (Harling et al., 2007).
Overall, documentation of positive effects of HIV/AIDS programs on African health systems suggests that recent investments in treatment and care are beginning to fill unmet system needs dating back to WHO’s strategic plan to operationalize the declaration of Alma Ata. While aid recipients and donors alike need to overcome weaknesses in coordination and health governance with respect to HIV/AIDS (Spicer et al., 2010), the benefits to health systems might be expected to amplify over time as programs mature and services become mainstreamed.
Prevention: A Necessary Health Sector Priority
Attention needs to be focused not on the false debate pitting health systems against disease-specific interventions and primary health care against HIV/AIDS care, but on the overarching question of how many more new HIV/AIDS patients even the best-resourced and best-performing health systems can absorb and provide with quality care. The essential problem for African countries is unchecked HIV incidence. HIV infection and associated diseases are overwhelming health systems, and there is an urgent need to curb new transmissions. Now more than ever, strong health systems with sophisticated patient management capacities are needed in Africa not only to care for HIV-infected patients, but also to deliver biomedical and behavioral prevention services.
As discussed in Chapter 2, whether to focus resources on prevention or treatment is another false debate (Creese et al., 2002; Marseille et al., 2002). The ability of countries to sustain treatment programs will require averting more new infections, and ART as pre- and postexposure prophylaxis rather than just for therapeutic purposes will be critical in holistic prevention strategies. A comprehensive response that balances prevention, treatment, support, and care is needed. This response must include a strong emphasis on the disclosure of prevention outcomes. African nations need to share their prevention experiences and best practices with one another; greater transparency on the part of African ministries of health in disclosing their countries’ prevention outcomes and impacts would help create a demand for prevention.
Nearly two decades ago, Cates and Hinman (1992) advocated for all-inclusive prevention strategies drawing on the full range of technologies and approaches available at the time. Leaders in the field continue to make the same plea for approaches that link prevention, treatment, and care (Piot et al., 2008). Prevention is in everyone’s interest, including HIV-infected persons. Predicting the difficult questions and trade-offs now confronting African countries with severe epidemics and high treatment burdens, Over (2004) suggests that “to the extent that HIV-positive groups assist in reducing new infections, they will help ensure the affordability of continued treatment and thus serve their own long-term interests.”
IMPLICATIONS FOR THE STATE
A product of the world’s most recent, efficient, in many ways brutal, and short-lived colonial encounters, modern African states have long faced challenges to their security, capacity, and attempts at democracy (Young, 1994). The severity of HIV/AIDS epidemics in many African countries and the disease’s potential to have long-term negative societal effects have exacerbated these challenges and have provoked multidisciplinary investigation of the consequences of HIV for African states (de Waal, 2010; Patterson, 2005a). While the gravest predictions of national vulnerabilities stemming from high infection rates and HIV/AIDS-
related deaths have largely been revised, the implications of the epidemic for state security and governance in Africa remain pertinent and in some countries possibly profound.
Security and Conflict
As the scale of HIV/AIDS epidemics became apparent, concerns about how the disease influences armed conflict and security increased. Presumed high infection rates in the armed forces produced concerns that national militaries would be weakened by HIV/AIDS-related deaths, that infected troops were a source of infection of the general population, and that war and conflict were associated with the spread of the disease (Eboko, 2005; Whiteside et al., 2006). The evidence supporting these concerns, however, is inconsistent.
One review of data from 21 African countries found that in all cases, the prevalence of HIV/AIDS was similar or higher in military samples compared with the general population, and in some countries dramatically so (Ba et al., 2008). Recruits in all the samples further showed higher prevalence compared with the general population of males aged 15–24. These findings contradict an analysis published 2 years previously by Whiteside and colleagues (2006), which challenges the common wisdom as to the impact of HIV/AIDS on the security of African states. Referring to available data on HIV infection in the military as of 2006, the authors argue that new recruits and serving soldiers have infection rates paralleling those of their civilian counterparts. In a recent report on studies commissioned by the AIDS, Security and Conflict Initiative, de Waal (2010) also questions findings and assumptions that the prevalence of HIV/AIDS is higher among armed forces than in civilian populations and concludes that fears of much-elevated HIV rates among soldiers, with disastrous impacts on armies as institutions, have been overstated. For example, regarding the assumption that high losses of troops to HIV/AIDS were endangering the functioning of national armies, the authors contend that the “built-in redundancy” in armies, which expect casualties in times of war, protects military forces from weakening because of disease-related deaths, as do policies to discharge HIV-positive soldiers (Whiteside et al., 2006).
The assumption that war and conflict contribute to the spread of HIV has also been questioned. A study commissioned by the AIDS, Security and Conflict Initiative found no correlation, for example, between conflict and war and national HIV/AIDS prevalence rates (de Waal, 2010). Further, with the exception of the 1994 genocide in Rwanda (Ba et al., 2008), command-approved sexual violence whereby HIV-infected troops are deployed for rape has not been reported in conflict situations (Whiteside et al., 2006). However, studies conducted for the AIDS, Security and Conflict Initiative that focus on the gender impact of conflict suggest that the link between sexual violence and HIV has yet to be fully understood and that gender-associated vulnerabilities remain inadequately conceptualized
(de Waal, 2010). Additionally, more attention to postconflict conditions that may favor the spread of HIV/AIDS is needed, including gender-associated vulnerabilities in periods of postconflict transition (de Waal, 2010; Whiteside et al., 2006).
State Capacity and Governance
Like national security concerns, the impact of Africa’s HIV/AIDS epidemic on state capacity and governance systems has received attention in the last decade. High numbers of HIV-infected citizens can affect governance in several ways, such as through the loss of civil servants and political representatives, the depletion of social networks, the high cost of treatment programs and dependence on donor aid to finance and sustain such programs, and citizens’ discontent with the inability of government to provide services. A limited but growing literature examines such issues.
State Capacity and Citizen Expectations
Early predictions of how HIV/AIDS might negatively affect African governance were often quite dire. According to de Waal (2003), by undermining civil society, fueling intergroup tensions, and straining governance systems through mounting demand for programs, severe epidemics could impede the building of capable states in Africa, possibly halting or reversing “the Weberian model of modernity, progressing from traditional or charismatic authority to rational bureaucratic power” (p. 12). Moreover, de Waal suggested that, instead of bolstering rapidly changing African states, major inflows of new HIV/AIDS-dedicated aid resources would present substantial management burdens that could further compromise state capacities.
As with prior assumptions about the impact of HIV/AIDS on security and conflict in Africa, understanding of the consequences of the epidemic for state capacity and governance has been revised and become more nuanced over time. Overall, HIV/AIDS-induced crises in capacity and governance in highly affected countries have yet to materialize. A main reason for this is that, relative to other pressing social issues, HIV/AIDS simply is not a priority for most African citizens (de Waal, 2007; Patterson, 2006). In 2008, respondents in the Malawi Longitudinal Study of Families and Health—conducted as part of the Afrobarometer survey—were asked to rank the importance of five public policy priorities. AIDS services ranked last among the five. The most important priority was clean water, followed by agricultural development, health services, and education (Dionne et al., 2008). One important exception is HIV/AIDS treatment activism in South Africa (Patterson, 2006). More often, however, competing social and economic needs, combined with continued denial and stigmatization of HIV/AIDS in some countries, have constrained public demand for HIV/AIDS-related services. Furthermore, underdevelopment of democratic institutions has limited citizen
demand for state accountability for a response to the epidemic. It is not surprising, then, that case studies in Uganda, Swaziland, South Africa, and Zimbabwe found that elected officials did not fear repercussions in elections as a result of a lack of attention to the epidemic and its consequences (Patterson, 2006).
The most recent studies resulting from the AIDS, Security and Conflict Initiative also discount links between HIV/AIDS and state fragility, capacity, and quality of governance at the national level. The studies do, however, provide evidence that negative impacts are being felt at the subnational and local levels. In a summary of these studies, de Waal (2010) describes situations of increasing pressure on local governments to expand the quantity and scope of HIV/AIDS-related services as “vortices of crisis” that in some contexts are contributing to poor service delivery to the public. He concludes that there is an urgent need to mitigate this impact on local governments and communities and to enhance service delivery in weak and struggling states.
Albeit inadequately documented, most evidence to date suggests a feedback loop of low state responsiveness to the epidemic, which begins with low public demand around the disease and its immediate consequences. That is, minimal public demand for services leads to minimal government commitment. Where an aggressive response is mounted, high dependency on external support is typically necessary. As a result of the combination of citizens’ preoccupation with other issues and the international community’s support for the response in many African countries, citizen discontent with government’s lack of response has yet to be manifested. A reduction or withdrawal of donor aid for recently scaled-up HIV/AIDS care and treatment programs will likely result in fewer services and less patient care; however, the African public’s response to losing this new health care entitlement is uncertain (Lyman and Wittels, 2010).
Impacts on Electoral Processes and Outcomes
Although critically important at this juncture of maturing democracies in Africa, empirically based understanding of the impact of HIV/AIDS on electoral processes and outcomes is scarce. Chirambo’s (2009) examination of the effects of HIV/AIDS on electoral governance systems in Namibia, Malawi, Senegal, South Africa, Tanzania, and Zambia is an important exception. In studies conducted between 2003 and 2007, Chirambo tested the hypothesis that HIV/AIDS undermines the electoral processes in these countries. Paralleling HIV/AIDS-related deaths in the population in the same age range, the studies presume high mortality among elected representatives (members of parliament [MPs]). While the causes of death among MPs are unknown, Chirambo notes that in the mid-1990s, many southern African countries recorded significant losses of MPs to natural, undisclosed illness.
Chirambo (2009) concludes that HIV/AIDS likely has important consequences for electoral governance, which vary depending on the form of govern-
ment. Majoritarian systems based on small voting districts require by-elections upon MP losses. As high HIV/AIDS-related mortality accelerates the rate of MP vacancies, majoritarian systems bear the greatest costs in both political and economic terms. Constituencies may lose voice as frequent by-elections attract fewer voters and the organization of multiple by-elections consumes state and political party resources. Having fewer resources to devote to by-elections, smaller parties are especially unable to recapture lost seats and so are disproportionately affected by HIV/AIDS-related deaths relative to larger parties. Governments based on proportional representation, in which large voting areas or an entire country constitutes the constituency, are less burdened by having to hold multiple local by-elections and bear the lowest costs due to HIV/AIDS. Mixed forms of government offer some insulation against high mortality among MPs.
Chirambo’s (2009) exploration is unique and important for fully understanding the implications of HIV/AIDS for African states and societies. His analysis of the interaction between HIV/AIDS and political and electoral governance, in particular, provides a starting point for understanding the implications of the epidemic for African countries’ transition to democratic forms of government.
Eboko (2005) emphasizes the substantial diversity in African responses to the HIV/AIDS epidemic and cautions against using a generic concept and term—“African”—in describing and understanding those responses. He contends that trends in African epidemics since the early 1980s can essentially be explained by the level of political commitment and proposes the concept of “political culture” to describe the variation in commitment. As the South African state was preoccupied postapartheid by (re)claiming African autonomy, a political culture of “active dissidence” and outright “denial” amounted in effect to low political commitment to mounting an effective HIV/AIDS response. In Côte d’Ivoire and Cameroon, Eboko argues, a political culture of “passive adhesion” resulted in responses led by biomedical professionals that sometimes involved divisions between biomedical elites working with international actors and others working with intended beneficiaries of public health programs. A political culture of “active participation” in Uganda and Senegal represents in many ways the continent’s most cohesive and inclusive responses, based on leaders’ perceptions of societal networks, both social and scientific.
More than mere theorizing, such intellectual framing of government responses helps us comprehend the variable success in confronting HIV/AIDS in Africa. Given that Uganda had one of the world’s most severe epidemics in the 1980s and 1990s, Ugandan state legitimacy and governance could have been compromised. Instead, by embracing an “active participation” response rather than being undermined, the Ugandan state reinforced its legitimacy and governance. Consistent with Eboko’s (2005) interpretation, Parkhurst (2005) notes
that Uganda reacted early, forcefully, and with a broadly inclusive approach. “By shifting a large portion of its sphere of activity from direct service provision to indirect management, the Ugandan state found an area of policy and intervention that it was able to handle with limited capacity, and which it could undertake without competition from other service providers” (Parkhurst, 2005, p. 583). By assuming the central role of coordinating the inputs of various actors and by not competing with nonstate actors in waging a response, the Ugandan government circumvented challenges to its legitimacy. Repeatedly cited for its good health governance practices, Uganda has also succeeded in mobilizing substantial international financial assistance for HIV/AIDS programs. However, the question of crowding out domestic funding while mobilizing international funding is one that needs to be seriously considered. Some argue that explicit policy choices are behind the crowding out and that the effects unfold very differently depending on the individual countries’ situations and choices (Ooms et al., 2010).
A more thorough analysis of African state leadership in the fight against HIV/AIDS lends further clarity to effective state responses. Using Uganda, Swaziland, South Africa, and Zimbabwe as comparative case studies, Patterson (2006) examines leadership on dimensions of centralization of power, neopatrimonialism, state capacity, and security concerns to determine how these elements affect HIV/AIDS policies in those countries. Despite relatively low state stability and capacity, Uganda made a strong HIV/AIDS response effort compared with the other countries. Patterson concludes that the combination of a highly centralized yet inclusive response and high donor funding compensating for low state capacity was key to Uganda’s successful response. In particular, President Musevini’s early and active engagement in making HIV/AIDS everyone’s business helped create a context for broad ownership of and participation in the response.
Complementing Eboko’s (2005) analysis, Patterson (2006) explains that despite South Africa’s relatively high stability and capacity and decentralized structures, President Mbeki’s “state knows best” ideology interfered with an effective early national response to HIV/AIDS. In Swaziland, in contrast with Uganda, high state centralization and neopatrimonialism have compromised the response to the epidemic, as has a mix of “modern” and “traditional” approaches, which are sometimes at odds. Likewise, Zimbabwe’s high level of state centralization has had negative effects on the country’s HIV/AIDS response. The recent political crisis in the country has displaced HIV-infected persons, interrupting their access to care and treatment services. Power concentrated in the presidency has further curtailed the political space in which HIV/AIDS groups can contribute to policy making and implementation. Given the country’s political crisis and high level of neopatrimonialism, the need also has not been filled by external donor support.
Civil Society Participation and Governance Practices
When able to engage in social mobilization, activism, and service delivery, civil society groups can contribute to state capability, accountability, and responsiveness (Jones and Tembo, 2008). However, despite decentralized structures, such as district-level HIV/AIDS committees, and rhetoric in support of community participation and ownership, meaningful civil society participation has often eluded HIV/AIDS programs in Africa.
Civil society’s uneven role in the HIV/AIDS response is often linked to weak organizational capacity. In reviewing the characteristics of strong organizations that influence policy, Patterson (2006) cites financial resources, leadership capacity, and internal structures that facilitate transparency and accountability as key. Also important is inclusive networking, capable of creating “united fronts with differing views” and remaining separate from yet collaborating with the state. Possessing all of these characteristics and further bolstered by linkages to global networks, South Africa’s Treatment Action Committee is one prominent example of the success of civil society participation in Africa, according to Patterson. Where resources are available and leadership development has been supported, community mobilization can also produce an effective response. Hayes (2009) documents the role of a women’s home-based care alliance in Kenya that has focused on partnering with district HIV/AIDS committees to improve the accountability of the HIV/AIDS control program, to secure more resources for home-based care in the community, and to highlight women’s contribution to the fight against HIV/AIDS as opposed to their simply being victims of the disease.
An important aspect of programmatic action is the accountability of those in authority. Accountability, however, is too often limited and one-sided, as Harman (2009) illustrates using the World Bank’s Multi-Country AIDS Program (MAP). Based on earlier concepts of community development, the MAP was intended to mobilize broad-based community action. Its mandate, however, was to work with states that, in turn, were to enlist community contributions and provide resources for communities to use in taking action through national and local HIV/AIDS committees. Harman’s conclusion is that governance of the MAP led to funding delays, top-down decision making with bottom-up and unidirectional accountability (accountability of community groups to the government and the government to the Bank), uneven dialogue and representation of participating organizations, and competition for resources and access to decision making rather than coordination. Such a critical assessment surely cannot be applied across the board to all MAP countries, but it does suggest a need for better understanding of how to engage civil society in an effective multisectoral response to HIV/AIDS.
This example points more generally to a need for broader accountabilities and good health governance practices in responding to HIV/AIDS at the global level (Harman and Lisk, 2009; Patterson, 2005b). In framing a study of the politics of HIV/AIDS in Africa, Patterson (2006) offers the concept of “institutional-
izing” the response into a comprehensive political sphere inclusive of the state, civil society (local and global), and bilateral and multilateral donors. That all of these various actors have a long-term interest and political stake in the epidemic is for Patterson the key to institutionalizing the response. Patterson argues that more must be done to institutionalize the fight against HIV/AIDS by addressing questions of unequal power and representation in HIV/AIDS decision making, by empowering civil society associations, and by giving all global citizens a stake in combating the epidemic (Patterson, 2006). Accomplishing this will require not only enduring resource commitments, but also good governance practices. To ensure the most effective use of future resources in the fight against HIV/AIDS, understanding the multiple and variable elements of good governance will be critical for both African countries and donors. More and better documentation of the links between good governance practices and outcomes and impact on the African epidemic is also in order.
IMPLICATIONS FOR ACADEMIA
The need for more trained health care workers to respond to the HIV epidemic is already evident in most African nations and will likely grow as the numbers of people living with HIV/AIDS increase. Obtaining the numbers and types of workers required to meet the unique challenges of each individual country’s situation will require planning to determine not only the necessary mix of workers but also the ability of a country’s education system—including universities; public health, nursing, and medical schools; technical and vocational institutions; and other academic training programs—to absorb additional students and provide the needed training.
Training for Physicians and Nurses
The need for more physicians and nurses has been well documented and is discussed in Chapter 5; however, the expense of educating high-level health care providers in Africa often prohibits expanding school enrollment. In Kenya, the cost of educating a single medical doctor from primary school to university is $65,997, and the cost of educating one nurse from primary school to college of health sciences is $43,180 (Kirigia et al., 2006). In addition to expense, a number of countries in Africa lack the indigenous capacity to produce enough physicians and must turn to medical training abroad for their students, who often opt not to return home to practice. This is especially true for the five Portuguese-speaking (Fronteira and Dussault, 2010; Villanueva, 2010) and war-torn countries in Africa (Crowe, 2005; Sillah, 2005). Those countries possessing the capacity to train may not have the absorptive capacity to expand their programs, which would require more teachers, more health facilities, and the ability to manage more programs.
Attempts are being made, however, to assist in improving and expanding medical education in Africa (NIH, 2010; SAMSS, 2010).
Training for HIV/AIDS Professional Support Staff
In addition to doctors and nurses, the HIV health workforce includes clinical officers, pharmacists, laboratory technicians, epidemiologists, phlebotomists, counselors, program managers, statisticians, data clerks, ancillary staff, and community health workers. The function of each category of health worker depends on the local model of care delivery and is influenced by tradition, legislation, and local regulations. Variation in health worker roles can be an obstacle to adapting generalized training tools and curricula to a specific setting (McCarthy et al., 2006).
Another category of health worker needed to respond to the HIV/AIDS epidemic in Africa consists of professional epidemiologists and other public health workers needed to manage and optimize health systems and the public’s health. Unfortunately, there are critical gaps in advanced public health education in Africa (IJsselmuiden et al., 2007). On the continent as a whole, there are 29 countries without graduate public health training and 11 countries with only one such institution or program. Training is provided mainly by small units that lack the critical mass needed to expand the field of public health into the multisectoral effort it should be. The greatest shortages occur in lusophone and francophone Africa and in the one Spanish-speaking country (Equatorial Guinea). There are only 493 full-time faculty in public health for the entire continent (854 if part-time staff are counted as well). The overwhelming shortage of academic staff in public health in Africa is clear. While there is no clarity about an optimal number, fewer than 500 full-time academic staff distributed in small groups across Africa are unlikely to provide the public health leadership needed for nearly a billion people (IJsselmuiden et al., 2007).
Training for Less Specialized Workers
To respond to their human resource needs, African nations may be using or considering a health systems model that encourages the health workforce to share roles and responsibilities with other, less trained workers who can perform an aspect of HIV/AIDS care through task sharing (see Chapter 5). In May 2005, Family Health International’s Zambia Prevention, Care and Treatment Partnership began training and placing community volunteers as lay counselors to complement the efforts of health workers in providing HIV counseling and help reduce their burden, using the national HIV counseling and testing curricula (Sanjana et al., 2009). This national training package includes a 2-week classroom component followed by a 4-week supervised practicum component. Utilizing a training
system already in place in Africa could be a way of training less specialized workers in needed areas of HIV/AIDS prevention and treatment.
Technical and Vocational Education and Training (TVET)
Technical and vocational skills development has existed since the 1960s as a way of easing the problem of unemployment among primary school dropouts. In the last decade, such training has been gaining momentum in Africa, in large part as a result of evidence for its transformative role in East Asia and its continuing importance in Organisation for Economic Co-operation and Development countries (African Economic Outlook, 2010b). Students enrolled in formal TVET programs in Africa typically receive 3–6 years of training beyond primary school, depending on the country and the model. A recent survey conducted by the African Union on the state of TVET in 18 African countries suggests a number of priority areas for such training in Africa (African Union, 2007). The agricultural sector is of the highest priority, followed by public health and water resources, energy and environmental management, information and communication technologies, construction and maintenance, and good governance.
Although TVET could play a role in scaling up the supply of unskilled workers, enrollment in TVET programs in Africa remains marginal to poor. This low enrollment signals stagnation and overall inadequate public training capacity. Formal TVET is seriously underfunded, and obsolete equipment and weak managerial capacity affect the quality of programs. In addition, gender inequalities in TVET reflect the lower enrollment rates of women in secondary education generally (African Economic Outlook, 2010a).
The delivery of quality TVET depends in large part on the competence of teachers (African Union, 2007). Partnering with and learning from successful TVET programs in other African and non-African nations and utilizing twinning relationships as described in Chapter 5 could take advantage of a system already in place to develop the numbers and types of workers needed to respond to the challenges of scaling up HIV/AIDS services in Africa.
Recommendation 4-1: Develop 10-year country roadmaps. In parallel with the U.S. strategic planning called for in Recommendation 3-2, individual national HIV/AIDS coordinating bodies in Africa should develop, articulate, and update national 10-year roadmaps for combating HIV/AIDS. Each roadmap should take into account the implications of long-term projections of the national HIV/AIDS burden for institutions, communities, and resource requirements. As part of their roadmap, African governments should:
invest sufficiently in HIV/AIDS prevention, following globally accepted best prevention practices;
disclose national and subnational prevention outcomes and impacts and how they vary geographically and over time; and
perform yearly evaluations to determine success as measured by change in HIV incidence data, as discussed in Recommendation 2-1.
Recommendation 4-2: Develop and promote more efficient models of HIV/ AIDS care and treatment. African countries should invest in, evaluate, and apply more efficient models of HIV/AIDS care and treatment and promote those models through South–South learning exchanges.
Recommendation 4-32: Establish a governance contract. African countries should establish a negotiated contract with U.S. agencies that includes programmatic targets and delineates each partner’s responsibilities and expectations within a shared-responsibility approach. African governments should fully maintain the role and function of leadership and stewardship for policies and program implementation in their countries’ health sector.
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