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Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
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6
Mitigating the Impact of the Epidemic

INTRODUCTION

As noted earlier, even if transmission of HIV were halted today, millions of Africans who are currently infected would still develop AIDS and die over the next 10 to 20 years. But transmission has not ceased. To the contrary, evidence from a variety of populations in Africa suggests that seroprevalence either is continuing to climb or has leveled off at discouragingly high levels (see Chapter 3). Approximately a dozen countries lying in a contiguous belt across central and eastern Africa account for more than 80 percent of all estimated HIV infections (see Chapter 1). For at least the next several decades, the HIV/AIDS epidemic will continue to ravage African prime-age adults and their children with death rates as much as 10 times higher than they would otherwise have been.

Although not immediately visible, the cumulative mortality effects of this "slow plague" will be substantial. 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. Population growth will decline more rapidly than expected, and African populations in the year 2000 will be somewhat smaller than those projected in the absence of AIDS. In many of the worst-afflicted countries, deaths will more than double during the 1990s as compared with the number estimated without AIDS. These additional deaths will put increasing strains on already overburdened health-care systems and on individual households trying to manage with limited

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

economic resources. Care and support for orphans will be a growing concern, and traditional inheritance and other legal rights will be challenged.

AIDS is one of many diseases with potentially great economic significance for developing countries. Diseases such as malaria and measles are far more prevalent in Africa, yet there are reasons to believe that the economic impact of AIDS will be greater. First, the fatality of AIDS and the duration of the illness increase its impact per case relative to other causes of morbidity. The long incubation period of HIV implies that the economic impact of existing levels of infection will be felt for 10 years or more, even if all infection were to cease today. The benefits of averting a case of HIV (19.5 discounted healthy life-years) are very high relative to other diseases (Over and Piot, 1993). By this measure, HIV ranks lower than neonatal tetanus, but higher than other widespread illnesses such as malaria, tuberculosis, and measles.

Second, HIV is likely to have a greater economic impact than other endemic diseases because it affects primarily adults in their economically most productive years (see also Chapter 3). In Africa, illness and death due to AIDS are concentrated among two age groups: newborn children, who acquire it perinatally, and adults between ages 15 and 50, who acquire it largely through sexual transmission. If one were to weight the years gained by averting a case of HIV by their productivity, HIV would rank highest among all diseases in terms of the value of preventing a case (Over and Piot, 1993). 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.

Third, unlike many other endemic diseases, AIDS does not spare the elite. Levels of HIV prevalence among high-income, urban, and relatively well-educated men and women are as high as those among low-income and rural groups, if not higher. Because wealthier, more-skilled, and better-educated subsets of the population have higher levels of consumption and investment, command higher wages, and are more likely to be employers, any disease affecting this group relatively more than other groups is likely to have a greater economic impact per case.

It is becoming increasingly evident that there is considerable divergence of opinion between industrialized and developing countries about the appropriate allocation of resources among various components of an African national AIDS control program. Industrial countries prefer to respond to the current and impending impact of the epidemic in Africa by donating their energy and resources to biomedical research and various prevention activities, while African governments feel an obligation to allocate resources not only to prevention, but also to mitigation of the direct impact on individuals and households already affected by the virus.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
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Whether directed at individuals with AIDS and their households or at other levels of social organization, mitigation interventions divert scarce resources from other uses, including efforts to prevent transmission. When individuals voluntarily devote their own time and resources to help persons with AIDS or their surviving family members, they demonstrate through their actions that they place a high value on these activities. However, if governments are to channel resources away from other useful objectives toward mitigating the impact of the epidemic, there must first be reason to believe that the value to society of the proposed government interventions is at least as great as the cost of the resources devoted to the effort.

Thus, research on this issue might improve the efficiency of current expenditures, as well as present a case for or against additional spending. 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. The obligation of governments and international organizations to support basic human rights need not be debated here. On the other hand, resources are limited.

There are two logical preconditions for adopting government interventions to mitigate the impact of the HIV/AIDS epidemic. First, certain social units or groups must have indeed been substantially harmed by the epidemic. Second, government programs designed to either limit the damage or target assistance to those who have been harmed must produce effects above and beyond any adjustments that would be made in the absence of any interventions. Assuming that such programs are feasible, policy makers need guidance in choosing which programs to implement and how much to spend on such programs in view of the many competing needs for government resources.

A great deal of attention has been devoted to attempting to limit the further spread of HIV; considerably less thought has focused on identifying solutions to the problem of coping with the millions of persons already infected with the virus. To date, the small amount of research effort devoted to the effects of AIDS on households and societies in Africa pales in comparison with the magnitude of the problem. There is an acute shortage of quality studies on the economic, demographic, and social impacts of the disease on families in Africa (Caldwell et al., 1993). Perhaps the most widely cited book on the impacts of AIDS in Africa is based on a sample of approximately 130 households in Rakai, Uganda, of which only 20 were affected either directly or indirectly by AIDS (Barnett and Blaikie, 1992). Several other studies have been based on findings from fewer than 50 households (see Caldwell et al., 1993, for a brief review). The Paris-based International Children's Center is analyzing the impact of AIDS on 200 households that are the homes of people with AIDS sampled at a few selected health facilities in Côte d'Ivoire, Haiti, and Burundi.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

The largest study to date, and the only one based on a representative, population-based sample, is the World Bank/University of Dar es Salaam study of approximately 800 households in Kagera, Tanzania, which has not been completed as of this writing. This study promises to provide valuable information about the economic impact of fatal adult illness in Kagera and adjacent, culturally similar areas of Uganda, Rwanda, Burundi, and Zaire. The relevance of the study findings for Southern or West Africa, where modes of production, fertility and marriage patterns, female labor-force participation rates, and traditional gender roles are different, is unknown. Consequently, the field suffers from the continual recycling of a small number of research findings, liberally supplemented with enormous amounts of anecdotal evidence of varying quality (Caldwell et al., 1993).

In the rest of this chapter, we first consider the impact of HIV/AIDS in sub-Saharan Africa on people with AIDS, and then the impact on their extended family members and friends. We next consider the indirect effects of AIDS, both demographic and economic, on society at large. At each level of social organization, we review evidence regarding the magnitude of the epidemic's impact and explore the implications for the continent. We then examine the types of mitigation programs that are currently being implemented. Finally, we present recommendations on future research and data priorities. 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. Virtually without exception, within 10 years of contracting the virus, individuals develop full-blown AIDS and die.1 But before the symptoms of AIDS develop, people living with HIV infection face ostracism, poverty, physical pain, and fear of impending death. Many individuals refuse to believe that they could be infected, and many who suspect they may be seropositive refuse to be tested. Given the harsh reality of the disease, some researchers have identified a surprising ''underreaction" to AIDS in Africa (Schoepf, 1988; Caldwell et al., 1994). There are numerous explanations for such an underreaction, including denial, shame, misunderstanding of the true risk of the disease, and a desire for silence because of the disease's association with illicit sexual behavior. These and other more obvious reasons for the silence about AIDS are discussed in detail in a seminal article by Caldwell and colleagues, who suggest that fatalism may also play a strong role:

1  

See below for a discussion on the length of the latency period from HIV infection to an AIDS-defining opportunistic infection in Africa. See Chapter 3 for a discussion of the differences in the voracity of HIV-1 and HIV-2.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

The most fundamental reason why the great majority of Africans are more sanguine than might have been predicted with regard to the AIDS epidemic is that they are not fully convinced that biomedical determinism is the only force operating in the world. … [The] African attitude toward illness and death rests on two partly related complexes of belief. The first is that there are different levels of causation. One is certainly the "natural" biomedical one, but this is triggered by other forces, chiding, punitive, or malevolent. The natural cause can be checked and reversed if the underlying force can be identified and appeased. The other is the belief in destiny, stronger in West Africa than in the East and South but probably not nonexistent in the latter areas. 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. AIDS can, and almost always does, result in premature death in that it occurs before old age, but such deaths predating the prescribed time are never solely biomedical. The HIV virus is merely the instrument (Caldwell et al., 1994:233-234).

Whatever the correct explanation, this underreaction has obvious implications for the speed with which African governments are forced to respond to the epidemic and for the probability of persuading Africans to change their behavior to contain the epidemic.

Stigmatization of the Seropositive

Despite the reports of an underreaction to the epidemic by some Africans, there is no doubt that many people with AIDS in the subcontinent have been subjected to trauma and isolation. In much of Africa, AIDS is still highly stigmatizing, in part because of beliefs concerning its association with illicit sex. In Ghana, for example, the disease has come to be widely viewed as a disease of women, and more specifically of female prostitutes (Porter, 1994). Even in countries hardest hit by the epidemic, such as Tanzania, AIDS is still very much perceived as a disease of sin in certain provinces (Kaijage, 1994b).

Discrimination against people with HIV/AIDS may be directed not only at those with the disease, but also at their families, friends, and caretakers and others with whom they have contact. In some cases, family members continue to be isolated, abused, or attacked after the death of the infected relation, partly because, as explained above, in many societies in sub-Saharan Africa the disease may be ascribed to supernatural causes, often associated with earlier misdeeds (Castle, 1994). Families who care for their chronically ill relatives may try not to let the nature of the ailment become known (Lwihula et al., 1993). A person with AIDS in Burundi explained:

Now I am lonely, nobody comes to visit me except the doctor and the nurses. Yet, I have many relations here. I have many friends! But everybody has

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

abandoned me. I am disappointed! They certainly suspected that I had AIDS (Ministère de la Santé, 1992, cited in IRESCO, 1995:35).

Although the various dimensions and repercussions of stigmatization may be difficult to quantify, they are an extremely important aspect of the burden of AIDS in the region. Increasingly, counseling in preventing new infections and limiting the destructive forces of stigmatization and discrimination is being recognized as an essential part of caring for people with AIDS.2

Economic Hardship Due to HIV

Evidence about the magnitude of the economic impact of AIDS at the individual level is scarce and generally qualitative in nature (see below) (Ainsworth and Over, 1994a, 1994b). Certainly, people with AIDS face high medical bills and an uncertain economic future. 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 infections 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. For example, in some areas of sub-Saharan Africa, employers are reportedly subject to prison terms and fines if they hire HIV-infected people (Danziger, 1994). Government officials in another country have encouraged employers to test workers and dismiss those who are infected (Cohen and Wiseberg, 1990, cited in Danziger, 1994). The experience of AIDS-related discrimination can include social ostracism and exclusion from usual networks for accessing emergency resources. Ignorance of modes of transmission of the virus can result in abandonment of people with HIV/AIDS by their relatives and expulsion from the family safety net, leaving the infected completely destitute (Awusabo-Asare and Agyeman, 1993).

Care for People with AIDS

In those parts of Africa where the epidemic is already fairly advanced, AIDS has become a part of everyday life, and the need for care is most urgent. Extensive treatment protocols have been developed for people with AIDS in industrialized countries. However, these protocols are less relevant in Africa because of a shortage of manpower and resources for the treatment and care of people with AIDS and regional variations in the prevalence of certain opportunistic infections, such as tuberculosis and Pneumocystis carinii pneumonia (Schopper and

2  

 See M'Pelé et al. (1994) for a recent review of the impact of counseling programs in Africa.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

Walley, 1992). Diagnosing HIV-related diseases and providing care for people with AIDS in Africa is further complicated by the fact that HIV-related diseases often develop atypical clinical manifestations and may occur simultaneously, even in the same organs (Colebunders and Kapita, 1994). Furthermore, treatments are not available for some HIV-related diseases, and people with AIDS often experience serious side effects of drugs (Colebunders and Kapita, 1994).

A great deal of debate and controversy surround the level of appropriate care for people with AIDS (see, for example, Katabira and Wabitsch, 1991; De Cock et al., 1993; Biggar, 1993; Foster, 1994). For example, De Cock et al. (1993) set forth the treatment and care needs at different stages of the disease process: the seropositive person without symptoms of full-blown AIDS needs outpatient care and prophylaxes for opportunistic infections; the mildly to intermediately ill person needs to be actively treated for opportunistic infections as they arise; and those in the end stage of the disease need access to hospice care and continuing pain control. Unfortunately, providing extensive medical care to people at all stages of the disease would be prohibitively expensive in Africa (World Bank, 1992a; Biggar, 1993; Foster, 1994; Ainsworth and Over, 1994a). Given the magnitude of the problem and the corresponding amount of money that would need to be transferred into the health sector from elsewhere, the question of what constitutes adequate care for those with AIDS is, in all likelihood, more likely a political than a research question. 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. Home-based care is also an effective way to involve families and communities in AIDS care and support (World Health Organization, 1991). Preliminary results from a study of the costs of home-based care in Zambia indicate that community-initiated care is considerably cheaper than hospital-initiated alternatives. Furthermore, the average duration of a visit by a health-care worker was typically longer with the community-initiated home care, indicating substantial variation in the types of service provided under alternative health-care models (Chela et al., 1994). A study of AIDS treatment costs in Tanzania found that a shift from in patient to outpatient care can produce considerable cost savings to the health-care sector (World Bank, 1992a). In Rwanda, a training course designed to teach families how to care for people with AIDS at home appears to have enabled the families to do better with managing AIDS-related problems; moreover, the volunteer trainers seem to have provided family members with much-needed emotional support (Schietinger et al., 1993). A review of six home-based care programs in Uganda and Zambia seems to confirm the hypotheses that home-based care can improve the quality of life for people with AIDS and reduces pressure on hospital beds (World Health Organization, 1991).

At the same time, the results of a research project undertaken in South Africa

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

indicate that a substantial proportion of the burden of caring for people with AIDS could be borne in primary health facilities (Metrikin et al., 1995).

The need for medical, economic, and emotional support implies that the best care might be provided by a "multidisciplinary team" (Brugha, 1994). Perhaps the best-known model of hospital-initiated outreach service is the Chikankata program in Zambia, initiated in 1987. (Chikankata Mission Hospital is a 240-bed general hospital run by the Salvation Army that serves a predominantly rural community of approximately 150,000 nearby residents.) The mobile home-care team consists of a clinical officer, a nurse, an assistant AIDS educator, and a driver who visits between five and eight people each day, three days a week (Chela and Siankanga, 1991).

Regardless of the level of outside medical attention that is available, however, much of the care received by people with AIDS is provided by household members. The largest portion of this burden is borne by women (Caldwell et al., 1993; Kaijage, 1994a, 1994b). Individuals, families, and communities need to be better educated about how best to provide safe and compassionate AIDS care at home. In this regard, WHO—in collaboration with The AIDS Support Organization (TASO), Uganda; the Nsambya Hospital, Order of St. 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. A death in the household or the family as a result of AIDS or any other illness can have profound implications for resource allocation, production, consumption, savings, investment, and the well being of survivors (Ainsworth and Over, 1994a).3 As noted earlier, the age structure of the infected population is heavily weighted toward those in their most productive years (see Chapter 3), so that many of those who die are the sole breadwinners in the household. Therefore, AIDS has an unusually devastating effect on the entire household, both through loss of income and through dissolution of normal social relationships within the family. Adults aged 15 to 50 are usually the economic

3  

 One of the most striking features of African social organization is that it downplays the role of the nuclear family and, in its place, stresses the importance of kinship and clan networks. Consequently, the interpretation of what defines a household or a family can vary considerably across societies. Obviously, one cannot do justice to the complete range of patterns of social organization in Africa here, but suffice it to say that the terms "household" and "family" in Africa often refer to quite different collections of individuals. This distinction is important to remember when comparing household-and family-level impacts across different societies.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

backbone of their families and their communities, providers on whom both young children and elderly parents rely for support. Consequently, the illness and death of these economically active prime-age adults result not only in higher medical expenses and lower incomes for family members, but also in many other sequelae of poverty, including worsened health and reduced investment in the future productivity of their survivors. Because deterioration from AIDS is such a slow process, many families exhaust their entire savings before the person with AIDS dies. Furthermore, families lose income not only from the infected person, but also from other family members involved in his or her care. This loss is especially significant in families with more than one infected person. Finally, apart from losing a valuable contributor to household labor supply, survivors may also lose access to land, housing, or other assets.

Understanding and accurately predicting the long-term impact of HIV/AIDS on society depends critically on our understanding of how individual decision making is affected by the epidemic. For example, if individuals trust both in the future and in their fellow citizens, they are more likely to save a portion of their current income and invest those savings in risky, but potentially profitable, enterprises. Savings from current consumption can be invested (directly or through the intermediary of a savings bank or association) either in physical capital (e.g., a new irrigation pump) or human capital (e.g., a child's education or training). Thus, the HIV/AIDS epidemic makes immediately relevant the question of whether an individual's belief that he or she is or is likely to become infected causes that person to save or invest less.

Some economists have argued that one of the underlying causes of slow development in Africa has been the failure of states to develop dependable judicial and social mechanisms for enforcing contracts and thereby lowering the transaction costs for all concerned. Will people continue to choose to invest time, energy, and capital in social relations and the economy if they know that they, or others around them, are HIV-infected? Normal social relations, built on a degree of faith in the future and mutual trust, may be one of the most neglected casualties of HIV/AIDS in Africa. Relationships of trust that depend upon the participants' both knowing that they will be trading together for years to come may dissolve quickly if one or both of the participants become aware that either is infected with HIV. 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. Apparently, in the calculus of everyday life, the slow plague is a low priority for many (Caldwell et al., 1994). By the time one dies from AIDS, the logic goes, one could well have died from other things many times over (Schoepf, 1988). If a disinterest in long-term planning is independent of (or even partially causes) the sweeping prevalence of HIV, we would not anticipate transaction costs to increase perceptibly

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

with the rising prevalence of AIDS. In this scenario, AIDS would not add significantly to all the other reasons for uncertainty or doubt already endemic to the continent.

Most of the evidence produced so far on the impact of the epidemic at the household level has been of extremely variable quality and often anecdotal in nature. In one of the few field studies of the economic effects of AIDS in Africa, Barnett and Blaikie (1992) describe the results of their fieldwork undertaken in 1989 on a sample of 129 households in the Rakai district of Uganda. The authors were able to provide many rich anecdotes of how the 20 households in their sample might have been affected either directly or indirectly by AIDS, including a reduction in the production of food crops, a gradual depletion of household assets, a withdrawal of children from school, and an increase in household malnutrition. However, they were unable to show that the epidemic had affected producer-consumer ratios in these households, or indeed that any of the supposed effects of AIDS were suffered more frequently or to a greater degree by the 20 AIDS-affected households than by other households. Furthermore, there was no discernible impact on total agricultural production in the Rakai district. The authors (Barnett and Blaikie, 1992:102) conclude that:

… by 1989/90, AIDS had not yet drawn adaptive responses in production and consumption on a scale that dwarfed the many other adaptations households make all the time in response to other rapid processes of socioeconomic change. However, we believe that in certain localized areas AIDS is beginning to be the major determinant of socioeconomic change.

The ability of a household to cope with an AIDS illness and death is clearly a function of many factors, including the socioeconomic characteristics of the household, the economic role of the person with AIDS within the household (particularly how his/her illness affects household income), the household's access to alternative sources of income or support, the level of social and material support available to the household, and so forth. It is analytically convenient to divide the costs to the household of incurring a case of AIDS into three components: (1) direct costs associated with medical expenses; (2) indirect costs to the household directly afflicted with AIDS in terms of forgone earnings; and (3) indirect costs to other households, associated with contributing to funeral expenses or caring for orphaned children (Ainsworth and Rwegarulira, 1992).

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. The average cost of health care per HIV-seropositive patient admitted to Mama Yemo Hospital in Kinshasa, Zaire, was US $170, compared with US $110 per HIV-seronegative patient (Hassig et al., 1990). The direct costs of medical treatment of AIDS in Tanzania have been estimated at between US $104 and US $631 per person (Over et al., 1988). More recent estimates from

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

South Africa and Zimbabwe indicate that the direct costs of treatment can sometimes reach several thousand dollars per person (Ainsworth and Over, 1994b).

Besides the cost of medical care for the chronically ill, when the person with AIDS eventually dies, the household encounters further costs associated with the funeral and with lost production during a period of mourning. If the deceased lived away from the village, the family must usually pay for the body to be transported back to his or her home area, as well as for the transportation, food, and lodging of mourners. These costs can be considerable. For example, in Kinshasa, Zaire, families have been estimated to spend an average of US $320 for the funeral of a child who died of AIDS (Foster, 1993, cited in Ainsworth and Over, 1994a). In 1991, in the Kagera region of Tanzania, families were estimated to spend approximately US $60 for a single death, of which 60 percent was spent for the funeral (Over and Mujinja, 1993). Such expenditures are a substantial burden in a country where gross national product per capita was US $100 in 1991 (World Bank, 1993). Households in Kagera also contribute to expenses associated with the death of relatives who live outside the household. In 1991, this contribution was estimated to be approximately US $7 per death, of which 79 percent was for funeral expenses. At the same time, the period of mourning may have been reduced in Kagera from 7 to between zero and 3 days, a change implying that the annual cost of lost production has become quite high (Lwihula and Over, 1993).

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). At the same time, elderly persons who have lost their adult children face potential economic hardship and the prospect of raising their grandchildren on their own.

Several studies have estimated the number of AIDS orphans that will result from the AIDS crisis. The reliability of these studies is uncertain, and the estimates they yield vary widely. Nevertheless, the bottom line is that no matter what the actual number, orphanhood as a result of AIDS will become an increasingly large problem (see Ainsworth and Over, 1994a, 1994b). In Africa, the extended family usually takes the place of the social welfare systems in industrialized countries. Furthermore, in some parts of the continent, but particularly in West Africa, there is a strong tradition of children being raised by people other than their biological parents (Page, 1989). These foster parents assume both the costs and the benefits associated with childrearing. In Sierra Leone, foster parents can be relatives, friends, neighbors, or patrons, and many may not even be

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

related by blood or marriage to the children they rear (Bledsoe and Isiugo-Abanihe, 1989). It is unclear, however, whether extended families can cope with the large increase in orphans resulting from AIDS (Obbo, 1993). If they cannot, orphans will have little social and economic support. For example, in 1990, there were only 34 orphanages in the whole of Tanzania, sheltering a total of 1,083 children (Ainsworth and Rwegarulira, 1992). Compare this statistic with the fact that in 1988, in Kagera region alone, there were an estimated 47,000 children who had lost at least one parent and 8,000 who had lost both (Ainsworth and Rwegarulira, 1992).

One problem for researchers has been to distinguish between AIDS orphans and other orphans in societies where, for a number of reasons, orphanhood and fosterage are not uncommon. In Kenya, the number of AIDS orphans is estimated at about 250,000 in 1995 and is anticipated to rise to more than 1 million by 2005 (National AIDS Control Programme [Kenya], no date). In Uganda, estimates of the proportion of children orphaned range from 7 to 16 percent (Shuey, no date, cited in IRESCO, 1995). Some 40 percent of Zambian households are estimated to have at least one AIDS orphan in their care (Social Policy Research Group, 1993); those estimates are rising.

How will the loss of their parents early in life affect the lives of these unfortunate children? The short answer is that we do not know. Ryder et al. (1994) found no considerable health or socioeconomic effects of AIDS-related orphanhood in a longitudinal study in Kinshasa, Zaire. The authors argue that the mitigation of additional hardship for orphans was due to the presence of concerned extended family members. However, as noted above, it remains to be seen whether this mechanism will continue to suffice as the numbers of AIDS orphans increase. Furthermore, societies may differ in the degree to which neighbors and relatives serve as an informal safety net to protect the survivors in an AIDS household. In Tanzania, a national assessment of families and children affected by AIDS found that some orphans received the same treatment at home as biological children, while others were distinctly disadvantaged (Tanzania AIDS Project, 1994). Some orphans face many social and economic problems, ranging from higher morbidity and mortality to a higher probability of dropping out of school (Tanzania AIDS Project, 1994). In Zambia, some orphans face food and clothing shortages, as well as a lack of access to education and health services (Social Policy Research Group, 1993). 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.

Orphanhood and the loss of traditional support mechanisms for the elderly as a result of AIDS will unquestionably become increasingly large problems. We

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

need to know how many orphans and unsupported elderly there will be; what social mechanisms are being employed to care for them; what effects orphanhood has on children's own development and on the welfare of the nation; and what services could usefully be provided to these individuals, given resource constraints.

INDIRECT IMPACT OF AIDS ON THE REST OF SOCIETY

This section addresses the indirect impact of the HIV/AIDS epidemic on society at large, focusing in turn on demographic and economic impact.

Demographic Impact

AIDS has a number of demographic and related consequences. Among the more important are effects on future population growth, demand for health services, the size of the potential labor force, educational needs, and support for the elderly. Moreover, household composition and living arrangements are influenced by the AIDS pandemic through orphanhood and widowhood. To understand the consequences of AIDS, a wide range of data is needed. 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. AIDS is also a growing cause of infant and child mortality, threatening to reverse the reductions in infant and child mortality rates achieved to date. In countries such as Uganda, where an estimated 1.3 million persons out of a total population of 17 million are infected, AIDS looms as the predominant health problem for the entire population.

The excess female morbidity and mortality from HIV infection have important implications for the social and economic roles of women. The rising infection rates among women are accompanied by a corresponding rise in the number of children with perinatal HIV infection, estimated at around 1 million cumulative infections as of 1994 (World Health Organization, 1994) (see also Chapter 5). Transmission rates of HIV infection from an infected mother to her child in Africa are estimated to average about 30 percent, so the 70 percent of infants who remain uninfected are potential future orphans as the result of the premature death of one or both parents from AIDS (Chin, 1990).

AIDS has become the leading cause of hospital admissions in such cities as Abidjan, Côte d'Ivoire, and Kinshasa, Zaire. In Abidjan, where the first AIDS

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

cases were recognized in 1985, AIDS has rapidly become the leading cause of death among men and the second leading cause of death, after complications related to pregnancy and abortion, among women (De Cock et al., 1990). In a 1990 study, 41 percent of male and 32 percent of female cadavers were found to be infected with HIV. AIDS kills people in their most productive years, and now ranks among the leading causes of potential healthy life-years lost in sub-Saharan Africa. In the Abidjan study, it was estimated that 15 percent of adult male deaths and 17 percent of male years of potential life lost resulted from AIDS, whereas among women, AIDS accounted for 13 percent of deaths and 12 percent of years of potential life lost. These figures probably underestimate the true mortality due to HIV infection. Factors leading to an underassessment of AIDS-related deaths include the exclusion of pediatric patients, the rigidity of the case definition used, a lack of clinical information concerning cause of death, and the desire of seriously ill persons who leave Abidjan to die in their home areas. Moreover, death due to pulmonary tuberculosis, the third-ranking cause of male adult death, was not specifically counted as caused by AIDS, although 50 percent of these cadavers were HIV-seropositive, and an important fraction of these deaths was probably attributable to HIV infection (De Cock et al., 1990).

In two community-based rural studies, in Masaka district and Rakai district, Uganda, mortality among HIV-infected adults, at over 100 per 1,000 person-years of observation, was found to be 10 times higher than that among adults not infected with HIV (Mulder et al., 1994b; Sewankambo et al., 1994). In both districts, which have an underlying adult HIV prevalence of 8 and 13 percent, respectively, HIV was found to be the leading cause of death among adults. For example, over 80 percent of deaths in the 20-29 age group occurred among those who were HIV-infected. 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., 1990).

The demographic impact of AIDS will continue to expand in the remainder of this decade and into the next century as the epidemic continues to spread and mature. The deaths to date have occurred among those individuals infected relatively early in the epidemic, through the mid-1980s. In future years, those infected since the late 1980s will develop AIDS and die. In general, in the countries of sub-Saharan Africa, characterized by high population mobility and urbanization, high levels of STDs, and a doubling of infection rates in less than one year, there is a very limited time within which to curb the spread of HIV

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

infection. AIDS has the potential to undo many of the current health, social, developmental, and political gains in Africa.

Anticipated Future Impact

Mathematical modeling can help us anticipate the demographic impact of the HIV/AIDS epidemic. The anticipated impact through the remainder of this decade would occur even if AIDS prevention and control programs were able to reduce the incidence of HIV infection drastically in the coming years. The vast majority of the excess deaths due to AIDS projected to occur in the 1990s will be among those who are now in the incubation stage of infection. Furthermore, WHO estimates that annual spending on AIDS control and prevention programs would have to increase by more than a factor of five to reduce by half the number of new HIV infections by the year 2000 (World Health Organization, 1993).

The results of several scenarios developed using the Interagency Working Group on AIDS (IWGAIDS) model (Stanley et al., 1989; Seitz, 1991) were applied to 13 sub-Saharan African countries in which low-risk urban seroprevalence was estimated to exceed 5 percent in the early 1990s (Way and Stanecki, 1994). For each country, the spread of HIV infection was projected based on recent trends, and the impact of each country's epidemic was estimated using the model (see Way and Stanecki, 1994, Appendix A, for a full description of the methodology). In the discussion that follows, the projected demographic impact for those 13 countries is presented for the year 2000.

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 6-1). The magnitude of the impact varies because of both the severity of the projected epidemic and the underlying non-AIDS mortality levels.

As noted earlier, the HIV/AIDS epidemic in Africa is primarily heterosexual, with a consequently greater role for mother-to-child transmission. Although HIV transmission may occur in only one-quarter to one-half of births to HIV-infected women, the fact that most of the children thus infected die before age 5 implies a significant impact on the infant and child mortality rates. The impact is relatively larger on the child than on the infant mortality rate since many infected children survive beyond their first birthday, and since other causes of mortality under age 5 tend to be more severe under age 1 (Figure 6-2).

Life expectancy at birth, the single best summary measure of mortality, also shows a strong impact of the HIV/AIDS epidemic (Figure 6-3). Because AIDS deaths are concentrated among children and young adults, their effect is substantial, reducing life expectancy by over 20 years in several countries. The impact of AIDS on life expectancy at birth is not directly proportional to the severity of the

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

FIGURE 6-1 Crude Death Rate With and Without AIDS, for Selected Countries: 2000.

SOURCE: U.S. Bureau of the Census, International Programs Center, personal communication, 1995.

FIGURE 6-2 Child Mortality Rate With and Without AIDS, for Selected Countries: 2000.

SOURCE: U.S. Bureau of the Census, International Programs Center, personal communication, 1995.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

FIGURE 6-3 Life Expectancy at Birth With and Without AIDS, for Selected Countries: 2000.

SOURCE: U.S. Bureau of the Census, International Programs Center, personal communication, 1995.

HIV/AIDS epidemic, however, since the number of years of potential life lost for a death at a given age varies. For example, the death of a woman at age 30 in Zimbabwe has a greater impact on life expectancy than the death of a woman of the same age in Malawi since Zimbabwean women have a higher life expectancy at that age, and hence more potential years of life are lost as the result of one death.

Clearly, then, the impact of AIDS on a number of mortality measures in affected countries will be great. Infant/child mortality and life expectancy, which had experienced a 30- to 40-year period of improvement in many of these countries, are already showing the impact of AIDS and will suffer further setbacks in coming years. Development programs and child survival projects, which have used such measures as indicators of program impact, will be forced to attempt to factor out the effect of AIDS or develop alternative indicators.

But will AIDS decimate the sub-Saharan region? 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. Largely because of current high population growth rates resulting from high

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

fertility levels, no country in sub-Saharan Africa is projected to experience a population decline (negative population growth) as a result of AIDs. Several factors will contribute to this result. Because of the long incubation period of HIV infection, relatively high HIV seroprevalence is required to overcome the 3 to 4 percent growth rate currently found in most African countries. For example, a national adult seroprevalence of 40 percent or higher would typically be required (Stover, 1994).4

As discussed earlier, HIV seroprevalence approaching this level is currently found in some urban areas. Thus far, however, no country has experienced, or is even projected based on our analysis to come close to, such levels of infection at a national level. Available data suggest that there are differences in sexual behavior between urban and rural populations and that even within urban areas, large proportions of the population do not engage in behaviors that put them at risk of infection. These factors will tend, especially in the long run, to limit the spread of the HIV/AIDS epidemic. In addition, AIDS intervention programs are under way in most countries of the region. Although these programs are limited in scope and resources, some evidence of behavior change is becoming available. It is likely that additional change will result as the mortality effect of AIDS is felt by increasing numbers of households in a country.

Projections indicate that population growth rates will be sharply reduced by the impact of the HIV/AIDS epidemic, as one would surmise based on the above data on crude death rates. In many countries, population growth rates in the year 2000 will decline by more than one percentage point as compared with those expected in the absence of AIDS. Nonetheless, growth rates in the affected countries will typically be around 2 percent, as compared with non-AIDS projected growth rates of about 3 percent (Figure 6-4). The lowest projected growth rate among these AIDS-affected countries is in Zimbabwe (about 1.2 percent).

How much effect will AIDS have on the future size of populations? As shown in Figure 6-5, population size is clearly affected by AIDS, but the resulting deficit in population is not too great. In the aggregate, the projected total populations of the 13 countries in the year 2000 will be about 16.7 million lower as a result of AIDS as compared with the non-AIDS scenario (224.8 versus 241.4 million). This difference, however, is not due entirely to AIDS deaths. Some of the difference is due to the deficit in births to women who would have given birth had they not died from AIDS (either as infants/children or as adults). In longer-term projections, there is also a cumulative effect of the deficit due to the lack of births to those potential offspring.

An additional, potentially important impact of the HIV/AIDS epidemic may also be noted: its possible impact on family planning programs. Populations

4  

 In 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).

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

FIGURE 6-4 Population Growth Rates With and Without AIDS, for Selected Countries: 2000.

SOURCE: U.S. Bureau of the Census, International Programs Center, personal communication, 1995.

FIGURE 6-5 Total Population Size With and Without AIDS, for Selected Countries: 2000.

SOURCE: U.S. Bureau of the Census, International Programs Center, personal communication, 1995.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

experiencing elevated mortality as a result of AIDS may be reluctant to accept any services that may further reduce their completed family size (Wasserheit, 1989). There are as yet few formal data regarding this issue. However, in rural Uganda, community health workers have expressed some reluctance to distribute condoms, which were seen as further reducing birth rates in the face of population loss due to HIV (Joseph Konde-Lule, personal communication, 1995). In the same setting, an STD control project encountered concerns regarding STD medication because segments of the population were suspicious that the antibiotics were actually oral contraceptives being administered as part of an overall plan to reduce the local population through AIDS and family planning. These problems were successfully resolved through community education (Nelson K. Sewankambo, personal communication, 1994).

AIDS is not the only major health problem in sub-Saharan Africa, but in many countries throughout the region the impact of AIDS—at least until the year 2000 and perhaps well beyond—will increasingly be felt. Increases in infant and child mortality will be accompanied by increases in adult mortality, reducing life expectancy. 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. These additional deaths will put increasing strains on already overburdened health-care systems and on individual households trying to manage with limited economic resources. Care and support for orphans will be a growing concern, and traditional inheritance and other legal rights will be challenged. Although no country will experience an overall decline in population, the impact of AIDS—not only demographic, but also social and economic—will be enormous throughout the region.

Relationship Between Seroprevalence and Mortality Rates

In examining the impact of AIDS on society, it is useful to review the arithmetic consequences for adult mortality of what is known or believed about the epidemiology of HIV in sub-Saharan Africa. As discussed in Chapter 3, rates of prevalence of HIV infection among low-risk adults in sub-Saharan Africa range from zero among large portions of the rural populations of many countries to as high as 30 to 40 percent among the urban populations of Zambia and Rwanda. However, without careful attention to the arithmetic of this slow plague, it is easy to overestimate the effect of even these very high infection rates on adult mortality.

Table 6-1 presents the calculations required to approximate the mortality impact of various levels of seroprevalence on a cohort of 1,000 African adults aged 15 to 50. Column 2 of the table gives the number of adults in the cohort who would be infected at each rate of infection in column 1. Columns 3 and 4 present

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

TABLE 6-1 Impact of Seroprevalence of HIV on the Annual Mortality Experience of 1,000 African Adults, Aged 15 to 50

Seroprevalence (%)

Number of HIV+

Annual Deaths from HIV with Median Incubation Period

Deaths Without HIV

Total Deaths per Year with Median Incubation Period

 

 

10

5

 

10

5

0

0

0

0

5

5

5

5

50

2.5

5

5

7.5

10

10

100

5

10

5

10

15

15

150

7.5

15

5

12.5

20

20

200

10

20

5

15

25

30

300

15

30

5

20

35

45

450

22.5

45

5

27.5

50

90

900

45

90

5

50

95

NOTE: Annual deaths are estimated by assuming that (1) all infected individuals die of HIV within 2 × M years after their infection and (2) deaths are distributed uniformly from the first year of infection to 2 × Mth year, where M is the assumed median incubation period. Thus, if M were 10, 5% of the infected would die each year, and if M were 5, 10% of the infected would die each year. Adding the baseline deaths to the HIV deaths assumes that those who die of HIV are different individuals from those who would have died in the baseline scenario. 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. Thus, with an HIV prevalence of 20 percent, HIV would cause the death of between 10 and 20 adults per year in this cohort. Column 5 presents the baseline mortality for African adults in the absence of HIV infection, which is assumed to be 5 per 1,000 in this age group. Columns 6 and 7 give the total deaths in the cohort obtained by adding the baseline deaths to the deaths caused by HIV under each of the two assumptions regarding the incubation period.

There is a good deal of uncertainty surrounding the length of time from HIV infection to AIDS-related symptomatic disease and from symptomatic disease to death for AIDS cases in sub-Saharan Africa. Some investigators have speculated that the latency period from HIV infection to an AIDS-defining opportunistic

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

infection may be shorter in sub-Saharan Africa than it is in North America or Europe because of high levels of other infections that may occur concurrently, such as malaria, trypanosomiasis, and filariasis, and are also known to have a major effect on the immune system (Quinn et al., 1987). Furthermore, the time between an AIDS-defining illness and death is substantially shorter in sub-Saharan Africa than in North America or Europe because most Africans do not have access to or cannot afford drugs that prevent or treat AIDS-related opportunistic infections or slow replication of the virus (Ryder and Mugerwa, 1994). Consequently, the length of time from HIV infection to death in sub-Saharan Africa is shorter than it is in North America or Europe, and death rates are higher at every level of prevalence (see Table 6-1). Recent results from a prospective cohort study in rural Uganda suggest that progression from HIV infection to death in sub-Saharan Africa is extremely rapid (Mulder et al., 1994a).

Columns 6 and 7 of Table 6-1 demonstrate that a 20 percent seroprevalence is likely to cause a 3- to 5-fold increase in prime-age adult mortality, from 5 to 15-25 per 1,000. Among groups where the seroprevalence rises to between 45 and 90 percent, mortality might rise by a factor of 10. However, it is important to realize that, even with a 5-year incubation period, a 90 percent seroprevalence would result in no more than 95 deaths per 1,000 per year. Note in particular that a seroprevalence of 90 percent does not produce a mortality rate of 90 percent (or 900 per 1,000) in that year.

Economic Impact

HIV/AIDS and Per Capita Income Growth

The arithmetic of Table 6-1 has implications for the magnitude of the impact of the epidemic on various aggregates of the population. Using a range of sophisticated demographic models, demographers predict that the disease will slow the rate of growth of the population in sub-Saharan Africa by approximately one percentage point (Bongaarts and Way, 1989; Bos and Bulatao, 1992; Stover, 1993; Way and Stanecki, 1993; Bongaarts, 1994). While a reduction of one percentage point in the rate of growth of an African population will not halt population growth in countries that are currently growing at 3 percent per year, a one-third decrease in the population growth rate is sizeable. If a family planning program were to reduce the population growth rate of an African country by this much, it would be declared a resounding success and would be presumed to yield many benefits for the country.

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

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

TABLE 6-2 Contrast Between the Impacts on National Economic Growth of Comparable Reductions in Population Growth Caused by a Family Planning Program and an HIV/AIDS Epidemic

Nature of Impact on Income Growth

Source of Reduction in Population Growth

Family Planning Program

HIV/AIDS Epidemic

Impact on growth of capital

A1. Fewer children will reduce schooling expenses. A portion of this reduction may be saved, financing physical investment, and a portion may be spent on lengthening the schooling of each child. Both of these results would increase the earnings of the next generation of workers.

B1. Increased expenditures on medical care may come partly from savings, slowing the accumulation of physical capital.; B2. The presence of an epidemic may induce households to increase their precautionary saving in anticipation of future health problems. This effect offsets, to an unknown degree, the additional costs incurred at the time of AIDS sickness and death.a

Impact on growth of labor

C1. The growth of the labor force slows.

D1. The growth of the labor force slows.

Impact on productivity of workers

E1. Reduced child care per adult worker may reduce absenteeism and increase productivity.; E2. Increased schooling per child may increase later productivity.

F1. When an HIV-infected worker converts to AIDS, productivity is reduced by sickness and absenteeism.; F2. Increased health-care expenses per worker increase employer costs without improving workers' net remuneration.; F3. The time of healthy workers is diverted to care for the sick family members.; F4. Increased worker attrition due to AIDS sickness and death increases employer costs per worker.; F5. To the extent that AIDS increases the morbidity and attrition of top-level managers and professionals, employers' costs rise more for the same number of deaths.; F6. Children may be withdrawn from school to help at home, decreasing their future productivity.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

Nature of Impact on Income Growth

Source of Reduction in Population Growth

Family Planning Program

HIV/AIDS Epidemic

Impact on the mix of workers

G1. More-educated parents are usually more likely to adopt family planning. Thus, unless a national program reaches out to the poor with particular vigor, it may reduce the growth rate of educated workers more than that of uneducated workers

H1. The impact on the mix of workers depends on the epidemiology of the epidemic. In many sub-Saharan African countries, education is a risk factor for men and for their wives, while poverty is a risk factor for single urban women.

Impact on the efficiency of the production process

I1. None.

J1. Loss of a top manager may induce chaos in the organization and destroy it.; J2. Lower life expectancy among the population may increase the rate at which even businessmen discount the future and therefore may reduce the enforceability of contracts and increase crime.

a Only if households fully anticipated future health costs from AIDS sickness and discounted those future costs at a relatively low discount rate would the precautionary saving of item B2 in this row offset the increased medical costs of item B1. This level of precautionary saving seems quite unlikely in poor sub-Saharan African societies.

growth caused by the epidemic could benefit the survivors? The differing consequences 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.

Table 6-2 shows several differences between the impact on national income growth of comparable reductions in population growth caused by a family planning program and an HIV/AIDS epidemic. This table is based on a simple model of economic growth, which assumes that the growth rate of national income depends on the growth of the factors of production of national output—capital and labor—and on changes in the efficiency with which these factors are used and combined.

Both family planning and an HIV/AIDS epidemic are likely to slow the growth of total national output simply because they both slow population growth. However, Table 6-2 makes clear that the HIV/AIDS epidemic is likely to slow output growth more than a similar decrease in population growth caused by family planning. The first row of the table contrasts the positive likely impact of

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

family planning and the negative likely impact of the HIV/AIDS epidemic on national savings rates. Although labor-force growth would be slowed in both scenarios, the third row of the table shows that the family planning slowdown would enhance labor productivity, while the HIV/AIDS epidemic will have six distinct negative effects on labor productivity, both now and in the future. By increasing employers' costs of labor relative to capital, the epidemic will bias employers toward labor-saving and away from labor-using technologies.

The fourth row of the table points out that family planning and HIV infection could both change the mix of workers in the same direction—toward a less-skilled work force. 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. Evidence from recent surveys of sexual behavior supports the hypothesis that men of higher status (specifically, men with higher educational attainment) have more casual sex partners per year (Caraël et al., 1994). The finding holds for men throughout the world, and for eight of the nine surveyed African countries (Caraël et al., 1994). Thus it is not surprising that where data on male HIV prevalence by socioeconomic status exist, they often show higher prevalence at higher income or education levels (see Ainsworth and Over, 1994b, for a recent review of the evidence on the current rate of HIV infection in sub-Saharan Africa by economic group). Since African populations are known to have improved greatly their understanding of the causes of AIDS since the risk behavior that resulted in the higher infection rates at higher social levels occurred, it is possible that this relationship has since been reversed. However, no data have yet been collected to demonstrate that more highly educated African men have responded to their improved knowledge of the causes of AIDS by (1) having fewer casual sex partners than less-educated men, (2) having safer sex more often than less-educated men, or (3) becoming infected at a lower rate than less-educated men. Moreover, even if such changes have occurred, the pattern of the epidemic for the next decade or two has been set by past risk behaviors and prevalence patterns. Those patterns make it likely that HIV will kill relatively

5  

 Of course, if the higher-income families reduce their children by a larger percentage than the poor, they will also save more educational expenses and will therefore have more resources available to be rechanneled into the education of the children they do have. This effect may partly offset the change in mix described in the text.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

more of the more highly educated workers, thus changing the mix of the work force toward the less educated. Note that higher prevalence and incidence of HIV infection among the more educated are entirely consistent with higher numbers of HIV-infected being uneducated. For predicting the impact of the epidemic on economic growth, the rates are more important than the absolute numbers.

Finally, the fifth row of Table 6-2 points to two more speculative impacts of the epidemic. First, the loss of a top manager could cause his or her firm to collapse. This outcome would occur in any situation where the skills embodied in the departing manager were so rare in the country that they could not be replaced in time to save the firm. 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. A few authors have attempted to quantify the effects of HIV on macroeconomic growth in sub-Saharan Africa by constructing simulation models of African economies and shocking them with HIV/AIDS epidemics that would reduce population and labor-force growth from about 3 to about 2 percent per year. Cuddington and Hancock (1994) and Cuddington (1993) have focused on the impacts of the epidemic on savings and on the reduced productivity of workers on the job. Over (1992) has modeled impacts on savings and the socioeconomic gradient of the infection, as the latter affects the mix of workers across and within the rural and urban sectors of the economy.

Cuddington and Hancock (1994) simulate the effect of AIDS in Malawi, assuming that population growth slows by 1.2 percentage points, treatment costs are financed entirely from savings, and workers with AIDS are half as productive as their healthy counterparts. The authors predict that gross domestic product growth rates would be between 0.2 and 0.3 percentage points lower in a medium scenario and between 1.2 and 1.5 percentage points lower in an extreme scenario. Under similar assumptions about treatment costs and productivity, but assuming a slightly smaller slowdown in population growth, Cuddington (1993) predicts that the epidemic would have a slightly smaller effect in Tanzania.

Over (1992) finds that the distribution of a one percentage point reduction in labor-force growth rate within a population will determine whether the epidemic reduces or increases the rate of growth of per capita income. Figure 6-6 presents the simulated impact of a one percentage point decrease in the growth rate of the population on the growth rate of per capita gross domestic product in 10 African countries (Over, 1992). Note that not only the magnitude but also the direction of the impact depend critically on which elements of the population are hardest hit. If the infection rate of the more highly educated is twice or four times as high as

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

FIGURE 6-6 Sensitivity of the Estimated Impact of an HIV Epidemic with Respect to the Socioeconomic Gradient of Infection. NOTE: Assumes that half of AIDS treatment costs are financed from savings. SOURCE: Over (1992).

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. In economies that are struggling to return to positive per capita growth rates after years of stagnation, this consequence represents a substantial additional handicap. On the other hand, if HIV infection follows the pattern of other endemic diseases in developing countries by infecting a higher proportion of the poor than of the nonpoor, the loss of these less productive workers will reduce growth in gross domestic product less than proportionately, leading to a net increase in the growth rate of per capita gross domestic product. This result, which is illustrated by the left-most bar in Figure 6-6, parallels exactly the effects of the twelfth-century European black plague: the death of approximately one-third of the population in approximately 3 years led to an increase in the ratio of land to labor, and thus increased the average productivity and wages of the remaining workers.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

Both of the models described above show that the impact of AIDS will depend importantly on the nature and degree of reduction in savings caused by the epidemic. Estimates of the impact of HIV infection on individual savings behavior will inform future macroeconomic models of the impact of the epidemic. However, greatly improved understanding of the microeconomic dynamic coping behavior of households will be required before such macroeconomic models can fully capture the complexities of the effects the epidemic will have on the economy.

Effect of the Epidemic on Sectors of Economic Activity

Illness and death from AIDS will affect productivity, turnover, training costs, and resource allocation. Productivity is liable to suffer from absenteeism of both sick and healthy workers. Sick workers will miss work because of illness; healthy workers are liable to miss work as they care for the dying or attend funerals, the latter being a custom which in Africa often involves extensive travel and can take many days.

Policy makers sometimes inquire whether a few sectors of the economy are likely to be particularly vulnerable to the HIV/AIDS epidemic and therefore might benefit from sector-specific mitigation policies. In this regard, it is necessary to distinguish between the health sector and all other sectors of the economy.

The Health Sector There is little disagreement that the health sector faces a potential crisis. In the presence of a major HIV/AIDS epidemic, the health sector will experience a large rise in demand, which will continue to increase in the coming years, as well as decreased supply through increased worker absenteeism and attrition.

AIDS will certainly result in a rise in the demand for health care, although the magnitude of this increase is impossible to predict. Cost assessments of the impact of the disease on the demand for health care are complicated. First, AIDS increases the prevalence of opportunistic infections that are already widespread in the region, such as tuberculosis, pneumonia, and malaria, and it is difficult to recognize whether these diseases are symptoms of AIDS (Ainsworth and Over, 1994a). Second, there is a huge difference between the type of care that would be provided ideally and the type of care that is realistic in sub-Saharan Africa, where drugs for controlling opportunistic infections and skilled nursing staff are in such short supply. 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. In addition to increasing health-care costs on both a personal and a national level,

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

services provided to persons with AIDS will further limit the availability of professional-service time, hospital space, and medications for other patients, some of whom will have curable maladies. In general, however, despite the obvious seriousness of the epidemic for the health sector in Africa, just how the epidemic will ultimately affect the supply, demand, and quality of health care on the continent is still unknown.

The public sector provides a substantial portion of all health care in Africa, and public health-care facilities can neither fairly raise prices in the short run nor realistically increase capacity in the longer run. The public health system may instead be forced to resort to rationing its hospital beds and to placing increasingly stringent service requirements on its publicly employed physicians in order to keep them from leaving to work in private clinics. Neither of these solutions is desirable. Whether the epidemic results in higher prices, as in a private system, or rationed beds, as in most public ones, the result will be to crowd out some patients suffering from curable ailments who have neither the money to pay for private care nor the connections to obtain care in the rationed public system.

The health-care sector will also be confronted with the increased mortality of health-care professionals due to HIV/AIDS. A recent study conducted in Zambia indicated that female nurses at two hospitals have experienced a 13-fold increase in mortality since 1980 (Buvé et al., 1994). Mann et al. (1986) found a seroprevalence of 6.4 percent among 2,384 hospital workers in Mama Yemo Hospital in Kinshasa, Zaire, although they found no difference in seroprevalence between nurses providing care to people with AIDS and other nurses. To the degree that health workers themselves succumb to AIDS, their greater scarcity will further increase the price of, or reduce access to, care for the poor.

The medical costs of treating a person with AIDS are considerable. Excluding associated costs such as transportation, medical care can cost hundreds or even thousands of dollars per case (Ainsworth and Over, 1994b; Shepard, 1991; World Bank, 1992a). Efforts at extrapolation are in their infancy and continue to rely on guesswork for major variables. The more affected nations—Zimbabwe, Kenya, Malawi, Tanzania, and Rwanda—may have spent between 23 and 66 percent of their 1990 public-health-care budgets on AIDS-related treatment alone (Ainsworth and Over, 1994b). The factors identified as determining the level of spending include the severity of the epidemic, the strength of the economy, and the availability of medical care. AIDS commandeered far less of the total health spending of these nations in 1990: between 3 and 30 percent (Ainsworth and Over, 1994b). In Zambia, average costs of visits for people with AIDS in 1993 ranged from US $17 for care in a rural health clinic to US $66 for care at a district hospital (Foster, 1993). 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

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

decreasing supply resulting from the HIV/AIDS epidemic must be studied as the disease progresses.

Other Sectors For most other economic sectors, both demand and supply are expected to decrease as a result of the epidemic; furthermore, the slow nature of the epidemic will allow time for those sectors to adjust. 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. For example, three of the sub-Saharan African countries hardest hit by the epidemic—Kenya, Tanzania, and Côte d'Ivoire—depend on agricultural products for over 70 percent of their exports; in four of the other most severely affected countries—Burundi, Malawi, Rwanda, and Uganda—that figure is over 90 percent (World Bank, 1992b). The effects of HIV/AIDS on the agricultural sector are therefore likely to reverberate throughout the national economy of these countries. As the epidemic progresses, agriculture, like most economic sectors in Africa, will be forced to adjust in some way to both the decrease in adult labor and the decrease in national demand.

Although there has been a great deal of conjecture about the impact of AIDS on the agricultural sector, the analyses to date have generally focused on the impact of an adult death on a given agricultural household; they ignore the possibility that a neighboring household that has not suffered an adult death can use the land that the affected household may not be able to use. In rural areas, where the vast majority of the labor force is engaged in subsistence farming and where migration to the city has already reduced the number of people of prime working age, the additional burden of AIDS-related morbidity and mortality may be significant. To the extent that agricultural labor is already fully employed, AIDS can be expected to result in declining agricultural production relative to predictions without AIDS. Yet analyses of the epidemic's impact on agriculture have also paid scant attention to the reduction in demand for food crops, especially from the urban sector. Insofar as AIDS-related deaths decrease national demand for agricultural products relative to a no-AIDS scenario—as indeed they must—the effects of a decrease in production may be mitigated. Data are not yet available to clarify the net result, although the loss of the main food-producing age group suggests that there will be a food deficit in the affected areas.

The ultimate impact of AIDS on production and exports will depend most heavily on how households respond to the crisis. Households continue to constitute the major agricultural production units in sub-Saharan Africa; their decision making about crop selection and labor inputs will shape the availability and prices of both domestic foodstuffs and exports. Some subsistence crops, such as maize, sweet potatoes, and cassava, are substantially less labor-intensive than

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

export crops such as cotton or tobacco (Norse, 1991; Gillespie, 1989). Consequently, the epidemic may result in an increase in the production of subsistence crops relative to export crops as the agricultural labor crisis deepens. Research on the economic impact of AIDS in the agricultural sector is still to 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. Africans suffer from many tropical and infectious diseases, and identifying the distinct impact of any one presents enormous difficulties in research design.

Attempts to measure the effects of AIDS on agricultural production have found little conclusive evidence thus far. Barnett and Blaikie (1992) observe that the abundant rainfall and types of crops grown in the Rakai and Masaka districts of Uganda allowed even these heavily affected areas to adjust to the loss of adult labor to AIDS. Gillespie (1989) estimates the impact of AIDS on each of the five agricultural areas of Rwanda. He proposes that the impact of the epidemic on agriculture will depend on how labor is employed: the seasonality of labor demands, the degree of age and sex specialization, the independence of labor inputs, the economies of scale in labor, and the feasibility of employing laborsaving technology. More empirical research is needed to test his hypothesis.

A rapid assessment of the effects of HIV/AIDS on farming systems and rural livelihoods in Uganda, Tanzania, and Zambia was recently prepared by the Food and Agriculture Organization (FAO) (Barnett, 1994). Despite the high national seroprevalence and cumulative number of AIDS cases in all three countries, the research team had difficulty documenting the impact of the epidemic. In Zambia, they collected some evidence that the epidemic is affecting individual households in certain areas. It is also having an impact on the supply of skilled and educated workers in the estate sector, but this labor shortage does not have serious financial implications. Only in one part of Uganda—Gwanda—was the research team able to find significant impacts. Based on a study of only 14 households, of which 12 were either affected or afflicted by AIDS, the team hypothesized that in AIDS-affected agricultural areas, farmers will shift to more basic and less varied food and other crop production. It is unclear, however, how the larger economy is coping. Indeed, the study reports that in Kasensero, located a few kilometers from Gwanda, it is very difficult to acquire employment because there is a surplus of labor. Despite numerous deaths from AIDS in this fishing village, there is no shortage of fishermen; any fishermen who die are replaced quickly by new ones.

The Education Sector The education sector is likely to be affected by HIV/AIDS. Both the numbers of children enrolled in school and the numbers of teachers available to teach them are likely to decline as the epidemic proceeds. The paucity of careful studies of the education sector makes it difficult to assess

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

the degree to which these declines will compensate and what other effects they will have on social organization.

On the demand side, the epidemic will reduce the number of children enrolled in school. As children become ill, cohort size can be expected to drop; as children are needed to care for ill family members, they may be withdrawn; as resource-strapped families can no longer pay school fees or buy uniforms, children can be anticipated to stay home. Similarly, households headed by the more educated, who have higher HIV infection rates, may view education as a risky investment and thus choose to keep their children home (Ainsworth and Over, 1994a). As school cohorts decline in size, total costs associated with education may also decline, although costs per student may reasonably be assumed to increase.

At the same time, the supply of teachers may decline. Insofar as teachers are infected and develop AIDS, there will be a reduction in supply; replacing them will be both difficult and costly. For example, the World Bank estimates that by 2020, Tanzania will have lost some 27,000 teachers to the disease, and training of their replacements will cost US $37.8 million (World Bank, 1992a). At the same time, the total population paying for education will increase more slowly than in a no-AIDS scenario.

Whether supply side and demand side factors will balance to maintain somewhat steady expenditures per capita for education is unclear. One recent study in Tanzania indicates that the net impact of AIDS on schooling expenditures per capita may be slight (World Bank, 1992a), 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. Of course, it must be emphasized that the ultimate measure of the impact of the epidemic is not the effect on firms. If firms go out of business, but their employees are able to find alternative employment, and their owners are able to sell the firm's assets and reinvest those assets equally profitably elsewhere, then the impact of the firm closures will be very small. Conversely, if firms are able to adjust with impunity, but their adjustment is at the expense of individual workers and members of their households, then the damage caused by the epidemic may be great. For these reasons, the definitive measure of the impact of the epidemic is its effect on the well-being of households and individuals.

Nevertheless, firms are important because they provide employment and facilitate the production and distribution of goods and services. Thus their well-being does, in fact, have an impact on the well-being of individuals. Skeptics point to two reasons for doubting that AIDS is, or will soon be, a serious impediment

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

to private-sector growth in Africa. First, even in the most severely affected economies, attrition resulting from illness and death due to AIDS may not be a large proportion of the total attrition in firms. Consequently, the additional cost of recruiting replacements for sick or dead workers will be small in the context of the recruitment that is necessary anyway. Second, even if attrition from AIDS is large relative to that from other causes, the total impact on the firm will depend on how difficult it is to replace the lost workers. Given the fact that most African economies are operating with labor surpluses, skeptics suggest that hiring a replacement worker with similar or superior productivity may be as easy as stepping to the front gate of the firm and taking the first person in line. To make a convincing case for a large impact of AIDS on individual firms, one would have to refute both of these hypotheses.

Here again, few published studies are available to address these questions. A study of the Zambian Sugar Company explicitly sought impacts of the virus on the company and found none (Ministry of Health [Zambia], 1994). A study of 21 companies in Lusaka, Zambia, found that mortality of workers increased significantly between 1987 and 1991, but the percentage of deaths or of total worker turnover attributable to AIDS was unspecified (Baggaley et al., 1994).

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) project of the World Bank, a team of economists selected a random sample of approximately 200 registered manufacturing firms in each of seven countries to learn how firms respond to changing market conditions, especially with respect to the outward-or inward-oriented policies of their respective governments. In the most recent round of the survey, the investigators added one page of questions designed explicitly to learn more about the two questions posed above. Results from only three of the seven countries were available at the time this report was prepared (World Bank Regional Program on Enterprise Development, personal communication, 1995).

Table 6-3 presents basic information regarding firm size and attrition in the three countries for which the relevant labor-force data are currently available from the RPED database. The countries differ dramatically in average size of firms, ranging from 300 workers in Zimbabwe to 50 in Ghana. Total attrition as a percentage of total workers also varies across the countries, with attrition as a percentage of total workers per annum estimated at 9.1 and 11.6 percent for Zimbabwean and Ghanaian firms, respectively. The higher attrition in the Ghanaian firms is clearly not related to the severity of the epidemic, since the latest data suggest a much less severe epidemic in Ghana than in the other two countries.

The explanation for this seeming paradox is that attrition obeys roughly the same statistical law in all three countries: small firms have high and unpredictable attrition rates. Regardless of the country, the larger the firm, the more

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

TABLE 6-3 Data on Worker Attrition in Zimbabwe, Kenya, and Ghana, 1994: Total and by Sickness or Death

Country

Percent Urban HIV+ (Low-Risk)

Total in Sample

Attrition Due to All Causes

Attrition Due to Sickness or Death

Firms

Workers

Number

Percentage of All Workers

Total

Percentage of All Workers

Zimbabwe

18.0

199

59,210

5,366

9.1

695

1.2

Kenya

15.0

214

17,126

1,325

7.7

151

0.9

Ghana

2.2

188

9,607

1,110

11.6

30

0.3

Total

 

601

85,943

7,801

9.1

876

1.0

 

SOURCES: Seroprevalence data from U.S. Bureau of the Census (1994). Other data from the Africa Region Private Enterprise Development Project (World Bank Regional Program on Enterprise Development, personal communication, 1995).

closely its annual attrition rate approximates 6 percent of its work force. Hence the explanation for the higher attrition rate in Ghana despite that country's lower HIV prevalence rate is simply that the average size of its firms is much smaller than in Zimbabwe and somewhat smaller than in Kenya.

Assuming that the HIV infection rates given in the first column of Table 6-3 apply to the work forces of the firms in those countries, we can apply Table 6-1 to estimate the attrition that would be expected as a result of HIV in each country. In Kenya and Zimbabwe, respectively, seroprevalence of 15 and 18 percent means that 1.2 and 2.3 percent of workers should be forced to leave the work force each year because of AIDS. On the other hand, Ghana's 2.2 percent seroprevalence suggests that fewer than 0.6 percent of workers should be forced to leave because of AIDS. The last column of Table 6-3 demonstrates that the ranking of attrition rates from sickness and death across the three countries does match their ranking by seroprevalence. However, the attrition rates due to sickness and death are systematically lower than would be expected based on the arithmetic in Table 6-1.

Thus, limited data suggest that there is a statistically measurable increment to the worker attrition rate associated with HIV infection. Furthermore, the differences among the three countries are statistically significant at the 99.9 percent confidence level. However, the magnitude of the effect is extremely small, perhaps only half of what one would expect based on national seroprevalence. Of course, the main effects may be yet to emerge as more HIV-positive people develop full-blown AIDS. Another possible explanation is that premature

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

departures from a firm are hidden under another category, such as ''fired" or "quit," when in fact the departure was due to AIDS. If people systematically return to their families in rural areas to receive care, this scenario is quite likely. In the countries in this sample, attrition due to illness and death ranged from 3 percent of all attrition in Ghana to 13 percent of all attrition in Zimbabwe. Any attrition is costly to a firm, but it seems unlikely that an increment of even 15 percentage points in the attrition rate would be enough to impede seriously a firm's growth. 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. However, on the questionnaires for Zimbabwe, Kenya, and Ghana, an additional page of questions was added to gather more complete data on the first nine deaths in each firm. While compliance was not always perfect, of the 592 workers who had left because of death, some detailed information is available on 258 (44 percent). 6

Table 6-4 presents information on the difficulty of replacing workers by four skill categories. Among the 229 workers for whom data on skill category and the result of the replacement process were available, only 8 were professionals, while the other 221 were grouped into the descending categories of "skilled," "operator," and "unskilled." Focusing on these last three groups, we note that the proportion of deceased workers for whom a replacement had been found as of the time of the interview decreased with increasing skill level, from only 59 percent for skilled workers and 56 percent for operators to 72 percent for unskilled. Conversely, the proportion of openings that the employer was still trying to fill declined from 12.1 percent for skilled workers to 2.4 percent for the unskilled. We must also note that the response "do not plan to replace" was more frequent than the response "still looking" for every skill category, sometimes by an order of magnitude. Whether these responses represent downsizing, a change of job description, an extended and expensive search, or a misunderstanding of the questionnaire is impossible to interpret. Yet the data tend to indicate support for the hypothesis that the labor market is tighter at the top of the skill spectrum than at the bottom.

The last column of Table 6-4 gives, for those positions for which a replacement was found, the number of weeks the employer reported searching until finding the replacement. Here again, though the sample size is small, there is evidence that more search was required at higher than at lower skill levels. There are a number of reasons to expect firms to spend longer searching for higher-skilled

6  

 Ghana provided information on 95 percent of its deaths, Kenya on 86 percent, and Zimbabwe on 35 percent. Zimbabwe's lower completion rate was due partly to the fact that some large firms had experienced more than nine deaths. Since the questionnaire had space for only nine questions, the form was not physically able to handle the other deaths.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

TABLE 6-4 Relationship of Skill Level to the Ease and Speed of Replacement of a Deceased Worker

Skill Category

Number of Observations

Found a Replacement

Still Looking

Decided Not to Replace Employee

Average Weeks to Find a Replacement for Those Found

Professional

8

1

(12.5%)

1

(12.5%)

6

(75%)

n.a.

Skilled

58

34

(58.6%)

7

(12.1%)

17

(29.3%)

3.1

Operator

78

44

(56.4%)

4

(5.1%)

30

(38.5%)

3.0

Unskilled

85

61

(71.8%)

2

(2.4%)

22

(26%)

1.7

Total

229

140

(61%)

14

(6.1%)

75

(33%)

 

n.a. = not available

SOURCE: Africa Region Private Enterprise Development Project (World Bank Regional Program on Enterprise Development, personal communication, 1995).

than for lower-skilled workers, such as the desire for better matching of skills with job requirements among more important workers. Yet, firms in the sample are apparently not typically required to engage in an extended search for even a skilled worker. Of the 34 positions vacated by the deaths of skilled workers and later filled, 8 were filled within one week, and another 15 required only a second week of search. Based on these data, it is difficult to argue that the deaths of skilled workers will greatly impede the operations of sub-Saharan African firms.

It has often been conjectured that the loss of a small number of elite individuals in the economy can disproportionately disrupt economic and social activity. If the maturing cadre of younger leaders is too small or too inexperienced to fill adequately the roles of its deceased seniors, economic growth suffers. Table 6-3 presents data on worker attrition, but unfortunately these data do not permit a breakdown of attrition rates by skill category of worker. 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 1,000). However, the results

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

of the RPED survey reported in Table 6-4 demonstrate the difficulty of measuring the mortality rate among professionals through sample survey techniques: even in a survey of 600 firms, the total number of top-level professionals is so small that very few deaths are reported. 7

Summary

The impact of HIV/AIDS on life in sub-Saharan Africa is fragmented. For individual people living with infection and all the social ramifications it brings, the disease is devastating. On the other hand, the epidemic may not have the drastic effect on economies that was first imagined. Unifying these disparate interpretations of the impact of AIDS is difficult. Clearly, preventing and assuaging human suffering is important. Yet not all people with AIDS are poor, and not all of the poor have AIDS, so there are numerous other ways to allocate scarce resources. With resources so precious, other poverty-alleviation intervention efforts compete with AIDS mitigation for attention. How can mitigation of HIV/AIDS be responsibly integrated into the general health-improvement/poverty-reduction package? We now turn to a discussion of mitigation programs, both actual and potential.

ATTEMPTS TO MITIGATE THE IMPACT OF HIV/AIDS

Many donors believe that government or donor intervention is unlikely to have much effect on the severity of the epidemic's impact, and that resources would be better spent on interventions designed to prevent the spread of HIV. 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. Many of these groups are performing important and worthwhile work. Yet the question raised earlier of best use of resources returns: How can the negative impact of AIDS on sub-Saharan Africa best be assuaged?

7  

 Suppose that each of the 601 firms in the sample had only one professional-or managerial-level employee, who was the head of the firm. Then the 8 deaths reported in Table 5-4 would constitute an adult mortality rate of 13 per 1,000, which would be consistent with a seroprevalence of between 5 and 10 percent. If the average were two professionals/managers per firm, the mortality rate would be only 7 per 1,000, a rate insufficiently high to show the effect of an HIV/AIDS epidemic. Of course, firms whose head had died in the last year would be under-represented in the sample if such firms were more likely than others to disintegrate.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

Mitigation interventions can be classified along three dimensions: by the level of social organization of the intended beneficiary, by the type of social or governmental organization rendering support, and by the type of support rendered. This section examines the distinctions that can be drawn along each of these dimensions in turn and identifies associated issues.

Intended Beneficiary

Assistance can be provided directly to a person with HIV or AIDS, to the individual's entire household, to a village or community affected by AIDS, to a geographic region containing many villages, to a firm (whether it be in the formal or informal sector), to a government entity (such as a university or ministry), to a specific economic sector or industry (such as the trucking industry), or perhaps to an entire national economy.

Since the provision of any kind of assistance to everyone affected in a country would be prohibitively expensive, a key issue is how the recipients of assistance are selected. The assisting entity might choose beneficiaries informally and subjectively, or it might use a formal set of targeting criteria to determine eligibility. An alternative would be to provide a form of assistance that would have little or no value to people outside the class of desired beneficiaries. An example of such a "self-targeting" assistance program would be home care for people with AIDS, which would be neither needed nor desired by a household without a person having the disease.

The application of formal criteria for eligibility consumes resources that could otherwise finance more of whatever type of assistance is being rendered. Therefore, assistance agencies face the problem of designing criteria that will discriminate successfully between intended recipients and others on a relatively easy and inexpensive basis. 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. Any of these providers can operate with or without the support of bilateral or multilateral donors.

In view of the potential for opportunism discussed above, a critical issue in the implementation of targeted assistance programs is the ease with which providers of assistance can gather information on the characteristics of potential recipients. Generally speaking, providers of assistance that are located close to the potential recipients will have access to better information about recipients than will a more distant provider. For example, family members and neighbors

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

are in a better position to judge the need of an individual or household for assistance than is a local nongovernmental organization, which in turn would have an advantage in this regard over a national government agency or a bilateral donor.

Types of Mitigation Help Being Provided

In evaluating the costs and effects of proposed programs, total program costs must be categorized as fixed or variable. Then, for each type of program, it is necessary to propose an indicator or output measure that can serve as the denominator in computing both types of costs. The institutional framework or context and its effect on costs, particularly on fixed costs, must be carefully specified as well.

The fundamental evaluation issue is how to compare the outputs of the different interventions. This comparison is relatively easy in the area of prevention because one can compare, at least theoretically, all the different possible interventions with respect to the number of (primary and secondary) cases of HIV each prevents per dollar. Not only is it difficult to compare the benefit of assisting an orphan to attend school with the benefit of averting a case of HIV infection, but it is even difficult to compare the benefits of two mitigation interventions. For example, how does one compare a program that assists a dying person with AIDS and another that helps the surviving household members? A related issue is how to weigh assistance to improve a household's well-being immediately after an AIDS death (for example, by providing food) against assistance that improves the future well-being of the surviving children (for example, by helping them to stay in school). One impact of the epidemic is an increase in the cost of insurance, both formal and informal. Thus, a potential type of assistance would be to subsidize insurance premiums. In the formal sector, this subsidy would help people prepare for the possibility that a family member would get sick, while also increasing the national saving rate. The comparable intervention in rural areas without formal insurance might be to subsidize rural credit programs that would help people self-insure ex ante through precautionary savings or cope ex post with the shock of a death in the household.

While informal information about AIDS support projects is widespread, databanks of "who does what" are rare and incomplete. Relatively little information is available about mitigation efforts, and certainly nothing is available about their effectiveness.

There is an urgent need for hard data on the cost-effectiveness of alternative mechanisms for assisting severely affected households. 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

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

that many of the best-developed of these organizations do not exist primarily to respond to the epidemic. This suggestive information calls for a deeper investigation of the characteristics of the broad range of for-profit and nonprofit nongovernmental institutions involved, regardless of their previous connection to the epidemic, and of the links between these characteristics and the institution's capacity to implement various kinds of prevention and mitigation programs. 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.

KEY RECOMMENDATION 4. Research on mitigating the impact of the disease should focus on the needs of people with HIV/AIDS.

A great deal more is known about designing and implementing HIV-prevention programs than is known about providing care to the millions of people in sub-Saharan Africa already infected with the virus. Simple, cost-effective solutions to daily living problems faced by persons with AIDS, such as palliative care, part-time home care, and group counseling, may make larger, more expensive interventions unwarranted.

Recommendation 6-1. Research efforts to evaluate the impact of HIV/AIDS on individuals, households, firms, economic sectors, and nations are badly needed.

Research on impact should incorporate both qualitative and quantitative approaches to data collection and should evaluate both short-and long-term effects. Of particular interest is research that would permit an understanding of the impact of HIV/AIDS on poverty and on individual decision making. Research is needed to ascertain whether decreased life expectancy reduces willingness to save or invest in financial and real assets, in human capital, and in the relationships necessary to maintain social interactions. In the long term, the impact of HIV/AIDS on sub-Saharan Africa will depend on the strength and malleability of social and economic networks in accommodating the changes that are occurring.

Recommendation 6-2. Since the attempt to assist directly every affected household would be financially nonsustainable, research is needed on

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

criteria for determining which households and communities should be targeted for assistance and which institutions should deliver that assistance.

The epidemic has already affected millions of households in sub-Saharan Africa and will continue to do so for at least the next 20 years. Efforts to mitigate the effects of the disease have been uncoordinated and poorly targeted, and their ability to provide solutions for those infected and their families remains to be proven.

Recommendation 6-3. 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. Research is needed on the determinants of the effectiveness of nongovernmental organizations, including those not devoted primarily to AIDS prevention and mitigation, in a variety of AIDS prevention and mitigation activities. Care is needed in defining the technical assistance needs and the absorptive capacities of nongovernmental organizations, to enhance their roles in research and prevention and to avoid overload and inefficient use of scarce resources.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

ANNEX 6-1: A BRIEF SURVEY OF NONGOVERNMENTAL ORGANIZATIONS IMPLEMENTING MITIGATION PROGRAMS IN SUB-SAHARAN AFRICA

In an attempt to alleviate partially the dearth of information on mitigation activities, the panel recruited consultants in each of six sub-Saharan countries to administer a standard questionnaire to a selected sample of nongovernmental organizations (NGOs) in each country. The first and second columns of Table 6A-1 list the countries that participated in the survey and the number of questionnaires received from each.

There was no attempt to define a formal sampling frame for each country, but the consultants were asked to sample a broad range of NGOs, not restricting themselves to those that were established explicitly in response to the HIV/AIDS epidemic. Because the consultants were themselves associated with the struggle against the epidemic in several countries, this strategy was successful only in Tanzania and Zambia, where few of the NGOs sampled are explicitly related to the epidemic (see column 3 of Table 6A-1). Ironically, in Cameroon, where the epidemic and the struggle against it are less advanced, all the examples in our sample of NGOs mention AIDS prevention among their objectives or goals. Column 4 of Table 6A-1 shows that among the NGOs that mention AIDS in describing themselves, approximately half also mentioned mitigation of the epidemic's impact.

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

Country

Number of Questionnaires Received

Percent Naming as Goal or Objective

Prevention

Mitigation

Cameroon

25

100

32

Côte d'Ivoire

5

80

60

Kenya

5

80

40

Tanzania

22

45

27

Zambia

13

8

8

Zimbabwe

5

100

80

Total

75

65

32

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

TABLE 6A-2 Comparison of AIDS and Other Nongovernmental Organizations (NGO): Scale of Operations

Characteristic of NGO

General NGO

AIDS NGO

Total

Average year of origination

1973; (26)

1986; (49)

1982; (75)

Total workers (volunteer & salaried)

97; (26)

68; (49)

78; (75)

Percentage of workers who are volunteers

32; (26)

76; (49)

61; (75)

Monthly expenditure (in 1995 US dollars)

12,749; (14)

1,097; (28)

4,981; (42)

Total number of individual beneficiaries in last 3 months

3,661; (23)

37,094; (45)

25,786; (68)

Total number of household beneficiaries in last 3 months

55,057; (23)

28; (45)

18,640; (68)

Total number of community beneficiaries in last 3 months

26,538; (23)

2,739; (45)

10,788; (68)

NOTE: The number of responses to each question is given in parentheses.

Table 6A-2 presents the responses to several of the questions in the survey, classified by whether or not the NGO mentioned AIDS among its goals or objectives. Since most of the NGOs outside Tanzania and Zambia are connected to AIDS, the differences between the two groups might also be due to differences between NGOs operating in Tanzania and Zambia and those in other countries.

As might be expected, the NGOs established for purposes other than AIDS are on average about 13 years older than those whose objectives or goals mention the epidemic. Perhaps because these general-purpose NGOs are older, they seem to be better established by any of the other measures in Table 6A-2. 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. The non-AIDS NGOs count more households, communities, and firms as beneficiaries. The AIDS NGOs exceed the other NGOs on only one dimension—the average number of individual beneficiaries—and this difference disappears if we drop one outlier that claims to serve 1.5 million individual beneficiaries throughout Cameroon.

Similarly, we can separately examine the 48 AIDS-related NGOs to discover that those which mention mitigation of the impact of the epidemic are about the

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

FIGURE 6A-1 Types of Mitigation Interventions Provided (total of all countries).

same age as those which do not. 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. The question of intervention type is pertinent to the question of effectiveness, as discussed earlier in this chapter. Although the sample is small and not random, this graph demonstrates the diversity of projects loosely termed "mitigation." Surprisingly, economic assistance, whether in cash or in kind, constitutes only 26 percent of the mitigation effort. If self-help projects are added, the cumulative total is still only 34 percent. Counseling, which has both a supportive and preventative role, is the primary service provided by NGOs for people with HIV/AIDS in Africa; 50 percent of the program components described by the NGOs fit into this category.

Figure 6A-2 shows how many program components per NGO are dedicated

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

FIGURE 6A-2 Primary Beneficiary of Mitigation Efforts.

to providing services to each of three beneficiary groups: individuals with AIDS, their families, and the community as a whole. Each of the three groups is beneficiary of about one-third of the program components, but the families of people with AIDS are the intended beneficiaries of slightly more components than either the people with AIDS themselves or the community at large.

Table 6A-3 compares the sources of funding for AIDS and non-AIDS NGOs. Although AIDS NGOs are smaller and have smaller budgets than other NGOs, Table 6A-3 reveals that they take less advantage of every source of financing than do the other NGOs. 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. The mitigation NGOs are also slightly less

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

TABLE 6A-3 Comparison of AIDS and Other Nongovernmental Organizations (NGO): Funding Sources

 

Percent Receiving Funds by Type of NGO

 

 

Sources of Funding

General NGO

AIDS NGO

Multipliera (t-statistic)

Fees charged beneficiaries

23

13

2.43

(1.6)

Member dues

77

71

0.19

(-2.5)

Government grants

42

2

3.25

(2.2)

Local groups

54

29

8.85

(3.9)

International religious organizations

27

20

1.15

(.27)

International nonreligious NGOs

81

33

2.64

(1.5)

International bilateral donors

54

31

3.71

(2.5)

Other

58

57

1.26

(.59)

N

26

49

 

 

a Multipliers are the antilogs of the coefficients on the dummy variables for the indicated funding source in a regression explaining the logarithm of the monthly dollar budget. The R-squared is .83 on 41 observations, and the antilog of the estimated constant term is US $191, with a t-statistic of 8.3.

likely to fix membership dues, perhaps because many of the individuals they serve are destitute as a result of the epidemic.

The last column of Table 6A-3 explores the question of whether some of the funding sources are statistically more associated than others with (the logarithm of) the monthly dollar budget of the type of organization. The regression fits extremely well, with coefficients that are highly statistically significant on several funding categories. 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. The source of funds with the second-largest estimated impact on monthly expenditures is the bilateral agency representing a developed country, which is estimated to increase monthly expenditures by 271 percent. Local

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×

TABLE 6A-4 Operation of Social and Economic Programs by Nongovernmental Organization Goals

 

Type of Program

Goal of NGO

Mitigation

Other

Total

Prevention

99

(58%)

72

(42%)

171

(100%)

Other

57

(50%)

57

(50%)

114

(100%)

Total

156

(55%)

129

(45%)

285

(100%)

government resources come next, with an estimated increase of 225 percent, while reliance on membership dues is apparently associated with a net decrease in total expenditures of 81 percent. A possible interpretation of this last finding is that members are quite parsimonious with organization resources when those resources come from their own pockets, but less so when the resources are raised outside.

The 75 individual NGOs in the sample operate a total of 288 separate programs or program components. Using the organization's description of the activities associated with each program, it is possible to score each component with a zero or a 1 on mitigation, depending on whether it includes any social or economic support activities. Such programs can provide substantial assistance to AIDS-affected households, regardless of whether the program was originally intended to address the impact of AIDS.

Table 6A-4 shows the percentage of programs capable of helping households and other social units cope with the impact of AIDS by type of NGO. Of the 171 programs operated by AIDS-related NGOs, 58 percent have a social or economic objective and thus can help individuals, households, or other social units cope with the impact. 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. In fact, if the greater experience and resources of the non-AIDS NGOs in this sample can be generalized to other settings, a mitigation program may have more chance of success if it is implemented by a non-AIDS NGO.

Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
×
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Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
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Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
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Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
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Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
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Suggested Citation:"6 MITIGATING THE IMPACT OF THE EPIDEMIC." National Research Council. 1996. Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: The National Academies Press. doi: 10.17226/5177.
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Next: 7 BUILDING CAPACITY FOR AIDS-RELATED RESEARCH »
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