Speakers: Alan Whiteside, University of Natal and Tony Barnett, University of East Anglia.
Chair: Simon Maxwell
HIV/AIDS, poverty and development
1) Alan Whiteside started by stating his disappointment with the WDR in terms of HIV/AIDS. Very few of the WB's main strategies, centred around opportunity, empowerment and security, are attainable taking the effects of the epidemic into account. 'Can Africa Claim the 21st Century', another recent World Bank publication, proved equally disappointing in this respect. For Africa AIDS is the number one problem; unfortunately the World Bank has failed to recognise this. Not only are the development targets unattainable due to the AIDS epidemic (especially in parts of Africa), but indeed the very way in which development is practised will have to be rethought.
2) Quoting Tony Barnett, Whiteside described AIDS as a 'long wave disaster…that is a long time in the making and in which the major effects have already begun to occur long before the magnitude of the crisis is recognised and any response is possible' . In fact, the situation is worse than people realise; predictions about AIDS made a decade ago were far too positive.
3) The epidemic curve of HIV/AIDS can be divided into four:
i) the wave of HIV infection
ii) the wave of tuberculosis (most common opportunistic infection in Africa)
iii) the wave of AIDS illness and death
iv) the wave of impact (includes household poverty and orphaning)
Other epidemic curves are usually more predictable; illness leads to death and ultimately the epidemic curve goes down. With AIDS we simply do not know, all we can say for certain is that HIV will ultimately lead to AIDS and death - there is no recovery. What we do not know is what will happen to the epidemic curve in the aftermath of massive AIDS related deaths.
4) A recent survey from South Africa shows that 1 in 5 women attending ante-natal clinics are HIV positive. In Botswana, 37% of women attending ante-natal clinics are infected. We know that the rate of HIV infection will rise significantly in the future, and that most deaths occur in young adults. What will this mean for international development goals?
- In terms of reducing child mortality in Africa we can rather expect a significant increase; up to 30% of children born to HIV positive mothers will be infected and most die before the age of 5.
- In terms of life expectancy the epidemic has equally devastating effects: US estimates show that by 2010 life expectancy in Botswana will be reduced to 29 years.
5) The South African President has claimed that poverty causes AIDS. Does it? The simple answer is no. HIV causes AIDS. But what causes HIV? In Africa and Asia HIV is transmitted mainly through heterosexual intercourse, whereas in Eastern Europe the main source of transmission is needle sharing by intravenous drug users. In terms of sexual intercourse, the chances of transmission in a healthy person is not too great. However, factors such as the type of virus and the stage of infection do matter in terms of facilitating transmission as does the presence of other sexually transmitted diseases. Behavioural factors are of course crucial in this respect. In South Africa for example, people often have several partners at once in contrast to the assumed serial monogamy in the UK. However, sexual behaviour cannot be seen in isolation; migration, the status of women and their (lack of) access to economic resources, general health care etc. are all important factors. Thus, poverty in itself does not cause an AIDS epidemic but certainly contributes to it. However, more than poverty, inequality is a crucial factor (e.g. rich men buying sex from poor women). So yes- attacking poverty is important, but there are multiple factors that need to be addressed.
6) Tony Barnett took up Whiteside's last point, and claimed that the World Bank in fact does recognise a relationship between GNP per capita/income inequality and HIV infection. High HIV infection rates occur along with high income inequality, whereas countries with a high GNP per capita have lower rates of infection. This constitutes at least recognition that there is a relationship between poverty/inequality and HIV/AIDS. This is not a direct or simple relationship but it cannot be excluded from any consideration of poverty programmes or programmes that talk about 'trickle down'. There might not be time to let things 'trickle down'!
Although Africa is usually thought of in conjunction with AIDS, India in fact has the largest HIV positive population in any one country in the world. In China, rising income inequality along with high syphilis and gonorrhoea occurrences raises concerns regarding rapid increases in HIV infection rates. Unofficial estimates indicate that there may be as many as 10 million HIV positive people in China.
7) The youth/adult additional deaths caused by AIDS have huge implications for both health care and the division of labour and production. AIDS has already caused changes in population distribution in some African countries. Original findings from Barnett and Blaikie's research in Uganda in 1989 indicated changed population structure at the local level at that time. The main changes resulted in less good ratios between dependents and producers. A recent US Bureau of the Census model for Botswana in 2020 shows this Ugandan experience being repeated more than a decade later with a dramatically changed dependency ratio (age/gender distribution); this will have serious implications in terms of food availability, medical spending, care of orphans etc. A decline in life expectancy will affect employers and organisations and ultimately have a macro-level impact. On a household/community level, the effect will be seen most clearly in terms of farming systems and food production www.fao.org/sd/wpdirect/wpre0075.htm, and orphaning. Many orphans will lack basic care and grow up without being parented; some might experience orphaning not only once, but 2 or 3 times (i.e. when parents, then carers die). Care of elderly is also a major issue; who will provide crucial care if a large percentage of young adults are ill or die?
8) Barnett concluded by summing up the key areas in terms of the effect of AIDS:
- skills structure
- orphans and elderly (altered dependency ratio)
- inter- and -intra household dynamics and sharing
- trauma
- organisations (carry cost of medications and other employee related liabilities)
- employment
- subsistence agriculture
All of these are potentially impoverishing issues, and will have to be taken into account for any development intervention to be effective. Regrettably, the WDR has not taken these issues seriously.
9) In the discussion that followed it was pointed out that this was indeed welcome analysis: on the occupational side death (and following lack) of teachers have serious implications for education; many children may be forced into child labour; and how will businesses deal with the loss in social capital? A personal perspective on the link between poverty/inequality and risk of HIV infection was provided: In a compound in Botswana, a maid who was paid more than the usual salary still saw it necessary to earn money by 'having boyfriends' in order to send money back to her family. Only when this was discovered and the maid offered far better terms did the men stop coming. This illustrates the very real situation girls may find themselves in; their socio-economic situation may determine whether or not they are putting themselves (and others) at high risk of HIV infection. Tony Barnett commented that the knock-on effects of AIDS on teachers and other occupational groups are indeed incredibly important. In terms of child labour, an aspect often not discussed is military labour. The combination of civil unrest, arms and orphans is a very serious issue.
10)The chair asked whether there was a certain element of 'doom and gloom' in the analysis and the examples used in the presentation. Many countries in Africa do not have high rates of HIV, and some of the countries with previously high rates have seen a significant decline (e.g. Uganda and Thailand). Whiteside replied that the situation described will (if it isn't already) be reality for most of Africa, parts of Asia and Eastern Europe. According to UNAIDS, the lifetime risk of dying of AIDS for a 15 year old boy in Botswana is 85%; this is nothing but disturbing statistics. Many of the countries reporting low infection rates often do not have reliable data. And yes- there have been a few 'success-stories' however these are few and far between and the constant challenge is to stop the curve from rising. It was pointed out from the audience that that very incomplete data exist, especially in countries in unrest. Until now there has been no attempts to deal with HIV/AIDS in refugee camps. There might well be an element of 'doom and gloom' that we don't even acknowledge ourselves.
11) The role of businesses was then commented on: There is a need to encourage businesses to go beyond the business framework - businesses do not exist in a vacuum; they could be involved in both combating poverty and encouraging behavioural change. It was furthermore pointed out that the Caribbean is an area that has been largely neglected in terms of HIV/AIDS - despite an alarmingly high HIV infection rate. The worrying in this situation is that it is not taken onboard at local level nor by agencies such as the World Bank or the World Health Organisation.
12) Concluding, Whiteside and Barnett argued that the main message of AIDS and the effects we are seeing today is that we can not go on doing development in the same way. AIDS has shifted the parameters on which development is based, and this must be incorporated into the way we 'do' and talk about development. Although HIV prevention work is crucial in order to curb the spread of infection, we also need to look beyond infection to address, and deal with, the impact of the epidemic. AIDS poses the major development challenge today.
Thursday, December 17, 2009
ASSESSMENT OF THE SOCIO-ECONOMIC CAUSES AND CONSEQUENCES OF HIV/ AIDS
Objectives, Outputs and Processes
Increasing numbers of countries have undertaken or are proposing to undertake studies of the socioeconomic issues relating to the HIV epidemic. In some cases these studies are planned as part of the preparations relating to Strategic Planning for HIV and AIDS, and in other cases are seen as one of the important outputs of the Plan. The main objectives of such Studies are as follows: -
Advocacy: to increase understanding of the multiple ways in which the HIV epidemic affects human development as an essential input in the mobilisation of government and civil society in the national response to HIV and AIDS.
Economic and Social Analysis of the HIV epidemic: to present data/ information and analysis relevant for the design and implementation of a broad based multisectoral response to the HIV epidemic.
Given these as the two main objectives of such Studies the key outputs that can be expected are: -
· an increased understanding of the threat that the epidemic has for the sustained development of the country, both as a mechanism for raising awareness and as a means of increasing commitment to broad-based action, and,
· a clear specification of the practical activities that are feasible in the country, and which are needed if the socioeconomic aspects of the epidemic are to be addressed in a timely and effective manner.
The precise focus of such Studies needs to reflect the policy and programme needs of the country taking into consideration both the objectives and outputs identified above. Thus if the important issue that requires analysis is the impact of the epidemic on households then this should become the focus of the Study, and resources will not be misused in more general analysis and in less useful ways.
The processes followed in undertaking a Study must ensure that potential users of the data and information are involved throughout so as to ensure that it reflects policy and programme priorities. Furthermore, processes need to ensure national ownership, involve all important stakeholders in the design and implementation of the Study, and strengthen national research and other policy, programme and institutional capacity.
Below, we set out precisely what this entails.
Stage 1. Situation Analysis
Studies must involve an analysis and description of the socioeconomic conditions in the country as an essential step in identifying those factors which affect the susceptibility of the population to the HIV epidemic. Consideration will need to be given to the following: -
· identification of those behavioural and other factors which affect HIV transmission and the capacity to cope with a range of socioeconomic impacts of the epidemic
· the presentation and analysis of socio-economic data and information which increases understanding of the situation in the country at national and other levels, and which have policy and programme relevance both for understanding the conditions in which the epidemic is thriving and as a base for a broader-based policy and programme response.
Thus poverty is often seen as a factor which leads to behaviours which expose socially and economically excluded groups to risk of HIV infection, and which then reduces the capacity of such households to cope with the effects of HIV/AIDS [which are social, economic and psycho-social in their nature]. Exploring these relationships is crucial for ensuring that HIV and AIDS are integrated in poverty programmes.
An important output of will be a better founded understanding of the socioeconomic vulnerability of the population and of the country1s institutions, through a deeper understanding of the structure of the society and the economy. Thus the situation analysis will, for example:
· identify and explore the ways in which conditions of poverty and social exclusion, gender relationships, employment [especially of young persons], labour migration etc. affect the transmission of HIV, and thus have direct relevance for policies for HIV prevention, care and the mitigation of the socioeconomic impact of the epidemic,
in order to:
· strengthen understanding of the socio-economic factors which underlie the epidemic and which determine household, sectoral and national capacity to respond to the epidemic, as a foundation for a broader-based and more effective inter-sectoral national response.
It is also important to undertake an analysis of the existing epidemiological data on HIV and AIDS, so as to establish: -
· from the data/information what are the trends in HIV in the population, its spatial distribution, and its distribution by gender and age,
· the important relationships between epidemiological information and other data relating to education, occupation, rural/urban and other charactersistics of the population should be presented and analysed.
· a discussion of the present sources of data on HIV and on AIDS; the reliability of existing data and its coverage, and identification of any deficiencies with data for establishing more effective policies and programmes within the country.
· analysis of data/information that is set in the context of the HIV situation in the region and sub-region so that the epidemic can be seen within an appropriate context for a regional/sub-regional response ? including identifying relevant socioeconomic factors [such as labour migration and other factors affecting the movement of people].
This review of HIV surveillance and other data should generate a better understanding of trends in the epidemic in the country; a clearer perception of the factors that seem to be important in HIV transmission [including those which are social, cultural and economic in nature]; analysis of those factors which affect coping capacity in affected populations at household and sectoral level; provide a firm base for recommendations in the Study for improvements of the HIV surveillance data and system, and identify behavioural and other socio-economic data important for policy and programme development.
Stage 2. Assessing Socioeconomic Conditions
Identifying Causes and Estimating Impacts
This section of the Study needs to build on the Situation Analysis and other data/information drawn from regional and global sources. It should NOT simply address issues of actual and expected socioeconomic impact but also analyse those conditions which determine vulnerability and susceptability in the different sectors under discussion.
It is also important that each of the following sub-sections lead to practical recommendations of value to those developing the national response to the epidemic.
The Study may focus its analysis and description in respect of each or all of the 3 levels depending on policy and programme priorities as noted above.
A. Households
These are the primary socioeconomic unit in all societies with critical functions of an economic, social and cultural nature. They are important as productive units, especially in respect of farming and food production but also in the formal and informal productive sectors. They have crucial social and reproductive functions in terms of children and their socialisation [economic support, transference of productive skills and social patterning]. At the early stages of the HIV epidemic the effects are usually first felt and are observable at household level ? although many factors may intervene to hide these effects due to the shame, stigma and discrimination often associated with HIV and AIDS.
Issues that need to be addressed include the following: -
· an assessment of the factors affecting the capacity of households to survive in the face of the HIV epidemic,
· this assessment will build on data and information available on conditions relating to the susceptibility of households and their capacity to cope with the epidemic [poverty, proportion of female headed households, employment/unemployment conditions, health /education status of household members, housing conditions, etc.],
· the Study should build on what is known about these matters from elsewhere in the region, and globally, but the focus should be on what is being experienced now by households in the country, including access to public services and support from Government, NGOs and others [such as Churches],
· it should detail what are the needs of households for more extensive socio-economic support, drawing attention particularly to the effects on children and what is being done to address their specific needs,
· this section of the Study should clearly identify the problems being faced currently by affected households, the gaps in current policy and programme response, and what is needed in terms of extended social and economic support,
· where gaps exist in terms of current information and data the Study should recommend how these issues should be addressed, and by whom, so that a firm basis for policy is established,
· it is important that the special needs of children and young adults be identified by the Study and recommendations made for dealing with these ? including issues of access to key services such as health and education, housing and nutrition, and employment,
· constraints as well as needs have to be identified including matters relating to institutional capacity in public and private institutions ? taking into account that existing institutional arrangements for care and support will often be unable to cope with the new and expanded challenges and will need to be extensively reformed.
Undertaking studies of the effects of HIV and AIDS on households is extremely sensitive and all activities need to ensure that the researched community is fully involved at all stages in the design and implementation of the Study and in respect of follow-up activities. All activities need to ensure the confidentiality of respondents, and be undertaken in accordance with generally accepted ethical standards for such research.
B. Sectors
The Study should identify the ways in which the epidemic affects the capacity to maintain efficient forms of production and service provision in key economic and social sectors in the country. It is essential that the Study understand the structural foundations of the economy and the fact that its efficient operation depends on the functioning of its separate parts. In other words that the economy consists on an inter-dependent set of activities and has to be analysed and described in ways that recognise that the epidemic has systemic effects due to the losses of human and institutional capacity. An example is the impact of losses of transport capacity and higher costs in the transport sector for the marketability of rural products both in local and external markets.
· it is not the case that all productive sectors are equally affected by the losses of human and institutional capacity brought about by HIV and AIDS,
· it is essential that the Study identify what is currently happening in key sectors in the country, and building on other information in the region and globally to establish a set of qualitative and quantitative projections as to what may happen, and what may need to be done to reduce the actual or potential socio-economic impact.
Amongst the key sectors that will need to be analysed are the following:-
Transport and Communications
Tourism
Commercial Agriculture
Small-holder Agriculture [and related rural institutions and services]
Key economic sectors, such as Mining and Manufacturing
Finance ? Banking, Insurance, Development Banking
Health services ? public and private
Education
Military and other uniformed services [police and prisons]
Other key public and private services such as general public administration, water and the judicial system
The Study should therefore -
· establish what are the reasons for selecting sectors to be identified in terms of their essentiality for the continued functioning of the economy, and in the light of the predicted effects due to HIV and AIDS,
· make it clear why these sectors are vulnerable to losses of human and institutional capacity due to HIV and AIDS,
· identify what the potential effects may be in terms of higher costs and disruption of output,
· identify policy and programme options for mitigating current and future socio-economic impact,
· clearly identify the possible implications for the economy of the continued provision of key public and private services as noted above, together with recommendations as to what needs to be done to protect these services.
Important in this analysis is the identification of the impact of HIV and AIDS on public budgets and on public polices and programmes [including the establishment of effective HIV in the Workplace Programmes and review of training and other policies for public servants ? including review of the Government1s personnel policy framework so as to make this more relevant].
In all cases the Study should make recommendations as to what actions are needed to reduce future HIV infection amongst workers and managers; what needs to be done to mitigate current and expected socio-economic impact, and where responsibility lies for the development and implementation of appropriate policies and programmes.
C. Macroeconomic
Within the limitations of the HIV surveillance and other data available in the country the Study should attempt to set out the main channels through which the economy in the aggregate may be affected by the HIV epidemic. In addition it:
· should review data from other countries in the region who have attempted to estimate the macro impacts, and review other information on global estimates of the macro-economic impact on developing countries
· should summarise the main findings of such studies and the policy implications if any for the country
· should also indicate what data needs to be collected for rapid estimation of the macro impacts, bearing in mind that estimates of macro-economic effects are more useful as tools for advocacy than for the development of effective and practical responses to the epidemic
· should clearly indicate the limitations of existing macro studies of economic impact, and demonstrate if possible how such studies may be used in moving towards a deeper understanding of the HIV epidemic in the country.
Where data and other resources permit estimates of the macro-economic impact then these estimates can be made. Bearing in mind -
· the fact that projections of HIV are extremely unreliable in most countries, such that estimates more than 2 years into the future may have very high errors,
· that human capital approaches to estimating macro-economic effects contain serious analytical and other estimation problems, and
· that econometric estimates of economic impact require data and information not usually available to researchers in developing countries, and depend on often unjustified simplification of conditions in both product and factor markets.
It is important before setting out to make these predictions to realise their limitations, and to understand their role in the development of practical responses to the epidemic in the country.
Summary of Recommendations and Follow-up Processes
There are 2 basic conditions that need to be established and met by any studies that are undertaken. The study outputs must include the following:-
· the identification of, and policy and programnme recommendations relating to, all important socioeconomic aspects of the epidemic; concentrating on those recommendations that are most relevant for the operationalisation of the National Strategic Plan by the National AIDS Programme and other stakeholders.
· the establishment to the extent feasible of a set of recommendations for follow up by Government and others so as to ensure that the Study does indeed lead to a broader based and multisectoral response to the HIV epidemic. It should indicate what are the next steps in the policy process, and where responsibility lies for implementing the Study's main policy recommendations.
The operationalisation of the recommendations and any consequent decisions at national and other levels will be the litmus test of the value-added by the Study, given that the purpose of such studies is to strengthen the national response to HIV and AIDS within policy and programme frameworks which are multisectoral.
Increasing numbers of countries have undertaken or are proposing to undertake studies of the socioeconomic issues relating to the HIV epidemic. In some cases these studies are planned as part of the preparations relating to Strategic Planning for HIV and AIDS, and in other cases are seen as one of the important outputs of the Plan. The main objectives of such Studies are as follows: -
Advocacy: to increase understanding of the multiple ways in which the HIV epidemic affects human development as an essential input in the mobilisation of government and civil society in the national response to HIV and AIDS.
Economic and Social Analysis of the HIV epidemic: to present data/ information and analysis relevant for the design and implementation of a broad based multisectoral response to the HIV epidemic.
Given these as the two main objectives of such Studies the key outputs that can be expected are: -
· an increased understanding of the threat that the epidemic has for the sustained development of the country, both as a mechanism for raising awareness and as a means of increasing commitment to broad-based action, and,
· a clear specification of the practical activities that are feasible in the country, and which are needed if the socioeconomic aspects of the epidemic are to be addressed in a timely and effective manner.
The precise focus of such Studies needs to reflect the policy and programme needs of the country taking into consideration both the objectives and outputs identified above. Thus if the important issue that requires analysis is the impact of the epidemic on households then this should become the focus of the Study, and resources will not be misused in more general analysis and in less useful ways.
The processes followed in undertaking a Study must ensure that potential users of the data and information are involved throughout so as to ensure that it reflects policy and programme priorities. Furthermore, processes need to ensure national ownership, involve all important stakeholders in the design and implementation of the Study, and strengthen national research and other policy, programme and institutional capacity.
Below, we set out precisely what this entails.
Stage 1. Situation Analysis
Studies must involve an analysis and description of the socioeconomic conditions in the country as an essential step in identifying those factors which affect the susceptibility of the population to the HIV epidemic. Consideration will need to be given to the following: -
· identification of those behavioural and other factors which affect HIV transmission and the capacity to cope with a range of socioeconomic impacts of the epidemic
· the presentation and analysis of socio-economic data and information which increases understanding of the situation in the country at national and other levels, and which have policy and programme relevance both for understanding the conditions in which the epidemic is thriving and as a base for a broader-based policy and programme response.
Thus poverty is often seen as a factor which leads to behaviours which expose socially and economically excluded groups to risk of HIV infection, and which then reduces the capacity of such households to cope with the effects of HIV/AIDS [which are social, economic and psycho-social in their nature]. Exploring these relationships is crucial for ensuring that HIV and AIDS are integrated in poverty programmes.
An important output of will be a better founded understanding of the socioeconomic vulnerability of the population and of the country1s institutions, through a deeper understanding of the structure of the society and the economy. Thus the situation analysis will, for example:
· identify and explore the ways in which conditions of poverty and social exclusion, gender relationships, employment [especially of young persons], labour migration etc. affect the transmission of HIV, and thus have direct relevance for policies for HIV prevention, care and the mitigation of the socioeconomic impact of the epidemic,
in order to:
· strengthen understanding of the socio-economic factors which underlie the epidemic and which determine household, sectoral and national capacity to respond to the epidemic, as a foundation for a broader-based and more effective inter-sectoral national response.
It is also important to undertake an analysis of the existing epidemiological data on HIV and AIDS, so as to establish: -
· from the data/information what are the trends in HIV in the population, its spatial distribution, and its distribution by gender and age,
· the important relationships between epidemiological information and other data relating to education, occupation, rural/urban and other charactersistics of the population should be presented and analysed.
· a discussion of the present sources of data on HIV and on AIDS; the reliability of existing data and its coverage, and identification of any deficiencies with data for establishing more effective policies and programmes within the country.
· analysis of data/information that is set in the context of the HIV situation in the region and sub-region so that the epidemic can be seen within an appropriate context for a regional/sub-regional response ? including identifying relevant socioeconomic factors [such as labour migration and other factors affecting the movement of people].
This review of HIV surveillance and other data should generate a better understanding of trends in the epidemic in the country; a clearer perception of the factors that seem to be important in HIV transmission [including those which are social, cultural and economic in nature]; analysis of those factors which affect coping capacity in affected populations at household and sectoral level; provide a firm base for recommendations in the Study for improvements of the HIV surveillance data and system, and identify behavioural and other socio-economic data important for policy and programme development.
Stage 2. Assessing Socioeconomic Conditions
Identifying Causes and Estimating Impacts
This section of the Study needs to build on the Situation Analysis and other data/information drawn from regional and global sources. It should NOT simply address issues of actual and expected socioeconomic impact but also analyse those conditions which determine vulnerability and susceptability in the different sectors under discussion.
It is also important that each of the following sub-sections lead to practical recommendations of value to those developing the national response to the epidemic.
The Study may focus its analysis and description in respect of each or all of the 3 levels depending on policy and programme priorities as noted above.
A. Households
These are the primary socioeconomic unit in all societies with critical functions of an economic, social and cultural nature. They are important as productive units, especially in respect of farming and food production but also in the formal and informal productive sectors. They have crucial social and reproductive functions in terms of children and their socialisation [economic support, transference of productive skills and social patterning]. At the early stages of the HIV epidemic the effects are usually first felt and are observable at household level ? although many factors may intervene to hide these effects due to the shame, stigma and discrimination often associated with HIV and AIDS.
Issues that need to be addressed include the following: -
· an assessment of the factors affecting the capacity of households to survive in the face of the HIV epidemic,
· this assessment will build on data and information available on conditions relating to the susceptibility of households and their capacity to cope with the epidemic [poverty, proportion of female headed households, employment/unemployment conditions, health /education status of household members, housing conditions, etc.],
· the Study should build on what is known about these matters from elsewhere in the region, and globally, but the focus should be on what is being experienced now by households in the country, including access to public services and support from Government, NGOs and others [such as Churches],
· it should detail what are the needs of households for more extensive socio-economic support, drawing attention particularly to the effects on children and what is being done to address their specific needs,
· this section of the Study should clearly identify the problems being faced currently by affected households, the gaps in current policy and programme response, and what is needed in terms of extended social and economic support,
· where gaps exist in terms of current information and data the Study should recommend how these issues should be addressed, and by whom, so that a firm basis for policy is established,
· it is important that the special needs of children and young adults be identified by the Study and recommendations made for dealing with these ? including issues of access to key services such as health and education, housing and nutrition, and employment,
· constraints as well as needs have to be identified including matters relating to institutional capacity in public and private institutions ? taking into account that existing institutional arrangements for care and support will often be unable to cope with the new and expanded challenges and will need to be extensively reformed.
Undertaking studies of the effects of HIV and AIDS on households is extremely sensitive and all activities need to ensure that the researched community is fully involved at all stages in the design and implementation of the Study and in respect of follow-up activities. All activities need to ensure the confidentiality of respondents, and be undertaken in accordance with generally accepted ethical standards for such research.
B. Sectors
The Study should identify the ways in which the epidemic affects the capacity to maintain efficient forms of production and service provision in key economic and social sectors in the country. It is essential that the Study understand the structural foundations of the economy and the fact that its efficient operation depends on the functioning of its separate parts. In other words that the economy consists on an inter-dependent set of activities and has to be analysed and described in ways that recognise that the epidemic has systemic effects due to the losses of human and institutional capacity. An example is the impact of losses of transport capacity and higher costs in the transport sector for the marketability of rural products both in local and external markets.
· it is not the case that all productive sectors are equally affected by the losses of human and institutional capacity brought about by HIV and AIDS,
· it is essential that the Study identify what is currently happening in key sectors in the country, and building on other information in the region and globally to establish a set of qualitative and quantitative projections as to what may happen, and what may need to be done to reduce the actual or potential socio-economic impact.
Amongst the key sectors that will need to be analysed are the following:-
Transport and Communications
Tourism
Commercial Agriculture
Small-holder Agriculture [and related rural institutions and services]
Key economic sectors, such as Mining and Manufacturing
Finance ? Banking, Insurance, Development Banking
Health services ? public and private
Education
Military and other uniformed services [police and prisons]
Other key public and private services such as general public administration, water and the judicial system
The Study should therefore -
· establish what are the reasons for selecting sectors to be identified in terms of their essentiality for the continued functioning of the economy, and in the light of the predicted effects due to HIV and AIDS,
· make it clear why these sectors are vulnerable to losses of human and institutional capacity due to HIV and AIDS,
· identify what the potential effects may be in terms of higher costs and disruption of output,
· identify policy and programme options for mitigating current and future socio-economic impact,
· clearly identify the possible implications for the economy of the continued provision of key public and private services as noted above, together with recommendations as to what needs to be done to protect these services.
Important in this analysis is the identification of the impact of HIV and AIDS on public budgets and on public polices and programmes [including the establishment of effective HIV in the Workplace Programmes and review of training and other policies for public servants ? including review of the Government1s personnel policy framework so as to make this more relevant].
In all cases the Study should make recommendations as to what actions are needed to reduce future HIV infection amongst workers and managers; what needs to be done to mitigate current and expected socio-economic impact, and where responsibility lies for the development and implementation of appropriate policies and programmes.
C. Macroeconomic
Within the limitations of the HIV surveillance and other data available in the country the Study should attempt to set out the main channels through which the economy in the aggregate may be affected by the HIV epidemic. In addition it:
· should review data from other countries in the region who have attempted to estimate the macro impacts, and review other information on global estimates of the macro-economic impact on developing countries
· should summarise the main findings of such studies and the policy implications if any for the country
· should also indicate what data needs to be collected for rapid estimation of the macro impacts, bearing in mind that estimates of macro-economic effects are more useful as tools for advocacy than for the development of effective and practical responses to the epidemic
· should clearly indicate the limitations of existing macro studies of economic impact, and demonstrate if possible how such studies may be used in moving towards a deeper understanding of the HIV epidemic in the country.
Where data and other resources permit estimates of the macro-economic impact then these estimates can be made. Bearing in mind -
· the fact that projections of HIV are extremely unreliable in most countries, such that estimates more than 2 years into the future may have very high errors,
· that human capital approaches to estimating macro-economic effects contain serious analytical and other estimation problems, and
· that econometric estimates of economic impact require data and information not usually available to researchers in developing countries, and depend on often unjustified simplification of conditions in both product and factor markets.
It is important before setting out to make these predictions to realise their limitations, and to understand their role in the development of practical responses to the epidemic in the country.
Summary of Recommendations and Follow-up Processes
There are 2 basic conditions that need to be established and met by any studies that are undertaken. The study outputs must include the following:-
· the identification of, and policy and programnme recommendations relating to, all important socioeconomic aspects of the epidemic; concentrating on those recommendations that are most relevant for the operationalisation of the National Strategic Plan by the National AIDS Programme and other stakeholders.
· the establishment to the extent feasible of a set of recommendations for follow up by Government and others so as to ensure that the Study does indeed lead to a broader based and multisectoral response to the HIV epidemic. It should indicate what are the next steps in the policy process, and where responsibility lies for implementing the Study's main policy recommendations.
The operationalisation of the recommendations and any consequent decisions at national and other levels will be the litmus test of the value-added by the Study, given that the purpose of such studies is to strengthen the national response to HIV and AIDS within policy and programme frameworks which are multisectoral.
Africa: Next Wave of HIV/AIDS
This posting contains excerpts from a new report by the U.S. National Intelligence Council, identifying five countries including 40% of the world's population as the focus of the next wave of the HIV/AIDS pandemic. These countries include two African countries, Nigeria and Ethiopia, as well as Russia, India, and China. The full study is available at the NIC's web site at: http://www.odci.gov/nic
Note that the projections in the study are even higher than most others currently presented, and are acknowledged to have wide ranges of uncertainty. Note also that the study repeats the conventional assumption that almost all HIV in Africa results from heterosexual transmission. In contrast, a recent article in the Royal Society of Medicines' International Journal of STDs (Sexually Transmitted Diseases) and AIDS, excerpted in another posting today, contends that the proportion of transmission of the virus through unsafe medical care (injections,transfusions, and other procedures) is being grossly underestimated, and may even exceed the proportion transmitted by sexual intercourse.
The new NIC report was featured at a two-day meeting at the Center for Strategic and International Studies, including a luncheon keynote address by Stephen Lewis, special envoy of the UN Secretary-General on HIV/AIDS. See
http://www.csis.org/press/ma_2002_1003.htm Lewis' speech is available at: http://sustainable.allafrica.com/stories/200210040603.html
+++++++++++++++++end profile++++++++++++++++++++++++++++++
The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China
ICA 2002-04D September 2002
National Intelligence Council
The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China
Prepared under the auspices of David F. Gordon, formerly National Intelligence Officer for Economics and Global Issues.
Summary
The number of people with HIV/ AIDS will grow significantly by the end of the decade. The increase will be driven by the spread of the disease in five populous countries Nigeria, Ethiopia, Russia, India, and China where the number of infected people will grow from around 14 to 23 million currently to an estimated 50 to 75 million by 2010. This estimate eclipses the projected 30 to 35 million cases by the end of the decade in central and southern Africa, the current focal point of the pandemic.
* We project China will have 10 to 15 million HIV/ AIDS cases, and India is likely to have 20 to 25 million by 2010 the highest estimate for any country. By 2010, we project Nigeria will have 10 to 15 million cases, Ethiopia 7 to 10 million, and Russia 5 to 8 million.
HIV/AIDS is spreading at different rates in the five countries, with the epidemic the most advanced in Nigeria and Ethiopia. In all countries, however, risky sexual behaviors are driving infection rates upward at a precipitous rate.
* Adult prevalence rates - the total number of people infected as a percentage of the adult population - are substantially lower in Russia, India, and China, where the disease remains concentrated in high- risk groups, such as intravenous drug users in Russia and people selling blood plasma in China, where some villages have reported 60 percent infection rates.
* Nevertheless, the disease is spreading to wider circles through heterosexual transmission in India, the movement of infected migrant workers in China, and frequent prison amnesty releases of large numbers of infected prison inmates and rising prostitution in Russia.
It will be difficult for any of the five countries to check their epidemics by 2010 without dramatic shifts in priorities. The disease has built up significant momentum, health services are inadequate, and the cost of education and treatment programs will be overwhelming. Government leaders will have trouble maintaining a priority on HIV/ AIDS which has been key to stemming the disease in Uganda, Thailand, and Brazil because of other pressing issues and the lack of AIDS advocacy groups.
* The governments of Nigeria, India, and China are beginning to focus more attention on the HIV/ AIDS threat.
* Even if the five next-wave countries devote more resources to HIV/AIDS programs, implementation is likely to miss significant portions of the population, given weak or limited government institutions and uneven coordination between local and national levels.
* Nigeria and Ethiopia have very limited public services to mobilize. Russia is beset by other major public health problems. China has decentralized most responsibility for health and education issues to local governments that often are corrupt.
* India has taken some steps to improve its healthcare infrastructure to combat HIV/AIDS, but the government has few resources to treat existing infections and must cope with other major health problems such as tuberculosis (TB), which has become linked to the spread of HIV/AIDS.
The rise of HIV/AIDS in the next-wave countries is likely to have significant economic, social, political, and military implications. The impact will vary substantially among the five countries, however, because of differences among them in the development of the disease, likely government responses, available resources, and demographic profiles.
* Nigeria and Ethiopia will be the hardest hit, with the social and economic impact similar to that in the hardest hit countries in southern and central Africa decimating key government and business elites, undermining growth, and discouraging foreign investment. Both countries are key to regional stability, and the rise in HIV/AIDS will strain their governments.
* In Russia, the rise in HIV/AIDS will exacerbate the population decline and severe health problems already plaguing the country, creating even greater difficulty for Russia to rebound economically. These trends may spark tensions over spending priorities and sharpen military manpower shortages.
* HIV/AIDS will drive up social and healthcare costs in India and China, but the broader economic and political impact is likely to be readily absorbed by the huge populations of these countries. We do not believe the disease will pose a fundamental threat through 2010 to their status as major regional players, but it will add to the complex problems faced by their leaders. The more HIV/AIDS spreads among young, educated, urban populations, the greater the economic cost of the disease will be for these countries, given the impact on, and the need for, skilled labor.
The growing AIDS problem in the next- wave countries probably will spark calls for more financial and technical support from donor countries. It may lead to growing tensions over how to disburse international funds, such as the Global Fund for AIDS, TB and Malaria.
The cost of antiretroviral drugs which can prolong the lives of infected people has plunged in recent years but still may be prohibitively high for populous, low- income countries. More importantly, the drug costs are only a portion of HIV/AIDS treatment costs. Drug- resistant strains are likely to spread because of the inconsistent use of antiretroviral therapies and the manufacture overseas of unregulated, substandard drugs. 5
* If an effective vaccine is developed in the coming years, Western governments and pharmaceutical companies will come under intense pressure to make it widely available.
* The next-wave countries are likely to seek greater US technical assistance in tracking and combating the disease.
...
We project that China probably will have 10 to 15 million HIV/AIDS cases by 2010. India is likely to have 20 to 25 million higher than projected for any other country. We estimate Nigeria probably will have 10 to15 million cases, Russia 5 to 8 million, and Ethiopia 7 to 10 million.
Country Profiles
Nigeria.
The HIV/AIDS epidemic in Nigeria is significantly ahead of that in India, China, and Russia - already advancing well beyond high- risk groups and into the general population. The official adult prevalence rate is almost 6 percent, but unofficial estimates range as high as 10 percent which represents 4 to 6 million people infected.
Heterosexual transmission of the HIV virus is the primary mode of spread in Nigeria, and infections appear to be as numerous in rural areas as in the cities. The reported rate of infection apparently varies significantly by region, with the lowest reported rate found generally in the predominantly Muslim northern parts of the country (see 9 figure 3). Infections are most numerous among men ages 20 through 24, but some experts caution that infection rates are rising quickly in young women.
Given the already advanced state of the disease and the government s limited capacity to respond, we expect HIV/AIDS to infect as many as 10 to 15 million people by 2010. This number would constitute roughly 18 to 26 percent of adults close to the current rates in some of the hardest hit countries in southern Africa.
Ethiopia.
Ethiopia's adult prevalence rate estimated at between 10 and 18 percent is the highest among the five countries, indicating that like Nigeria the disease has moved significantly into the general population. Government figures cite 2.7 million Ethiopians currently as HIV positive, although experts believe the actual number may be between 3 and 5 million. Adult prevalence is much higher in cities (13 to 20 percent) than in rural areas (5 percent) (see figure 4). The generally poor health of Ethiopians as a result of drought, 10 malnutrition, limited healthcare, and other infectious diseases has caused HIV to progress rapidly to AIDS. Heterosexual transmission is the primary mode of spread, and people with multiple partners especially those with sexually transmitted diseases (STDs) and prostitutes have significantly higher infection rates, ranging from 30 to 40 percent in STD- positive individuals to 50 to 70 percent in prostitutes.
Unlike conditions in other next- wave countries, war has significantly contributed to the spread of the disease in Ethiopia. Many soldiers contracted HIV/AIDS during the civil war in the 1980s by having contact with multiple sex partners. When the war ended in 1991, thousands of infected soldiers and prostitutes returned home, spreading HIV/AIDS in their villages and towns.
* Another surge of infections may be underway. Ethiopia has demobilized 150,000 soldiers over the last two years as the conflict with Eritrea has wound down. More troops will be sent home as the border dispute is settled.
* As soldiers demobilize, prostitutes who have even higher rates of infection disperse around the country as well.
Looking ahead, we expect 7 to 10 million Ethiopians probably will be infected by 2010 because of the high current rate of adult prevalence, widespread poverty, low educational levels, and the government's limited capacity to respond more actively.
...
HIV: The Science of the Disease
HIV-1 is a fatal infection acquired by contact with the blood or body fluids of an infected person. A transfusion with infected blood almost always results in spread of the virus, and children born to infected mothers have an up to 40 percent chance of contracting the virus prior to birth, during birth, or through breastfeeding. The transmission rate of the disease through sexual contact ranges from 1 to 3 percent. Reusing infected needles results in infections less than one percent of the time.
Sexually transmitted diseases or reproductive tract infections greatly increase the risk of contracting HIV, and uncircumcised men transmit HIV and other STDs to their partners more frequently than circumcised men.
As the disease progresses, a type of infection-fighting white blood cell the CD4 positive-t cell decreases, leading to an irreversible loss of immune function. This period is marked by many illnesses, or unusual opportunistic infections that healthy immune systems protect against.
HIV-positive persons are susceptible to opportunistic and infectious diseases, especially TB. Once they have contracted TB, the disease progresses to the highly infectious, active stage much more quickly and frequently than in HIV-negative persons and is often what kills them. ...
Prospects for Control
We assess that all five next-wave countries will have difficulty controlling their HIV epidemics in the short to medium-term. The disease has built up significant momentum especially in Nigeria and Ethiopia and the governments have been slow to respond. None of the five next-wave countries in this report is on a trajectory to replicate the success of such countries as Uganda, Thailand, and Brazil in stemming the spread of the disease. Several leaders of the nextwave countries are focusing more attention on the AIDS threat, but all face a host of competing demands. In addition, these countries have weak healthcare infrastructures and severe budget constraints, which will create difficulty in financing education and treatment programs for their large populations.
...
Nigeria's leadership has been the most active of the five countries in trying to raise AIDS awareness, for example, by hosting a regional AIDS conference in 2000 and publicly warning about the risk of extinction on the continent. Nonetheless, the Obasanjo administration is beset by such other pressing problems as an approaching election and rising ethnic and religious tensions. Moreover, Nigeria s government institutions have deteriorated so badly over the last decade that Obasanjo has few functioning public sector assets left to mobilize even if he chose to engage fully on the issue.
* Nigeria has taken some steps, however, to build domestic monitoring and diagnostic capabilities especially in Lagos and a major study on the economic effects of HIV/AIDS is underway. * The Nigerian military, concerned about the loss of key personnel from AIDS, now mandates training about the disease for soldiers.
* The Ethiopian Government does not appear focused on AIDS, despite occasional statements on the issue. The government has focused in recent years on the conflict with Eritrea. Healthcare workers privately have criticized efforts in recent years as half hearted, and UN officials have publicly warned Ethiopian leaders to take more measures to stem the epidemic.
...
Weak Healthcare Infrastructure
Although significant differences in capabilities exist among next- wave countries, all five have overburdened and under funded healthcare systems and limited abilities to provide integrated, nationwide programs to test people, track infections, and deliver treatment and education programs. Even within each of the five next- wave countries there are disparities in the ability of cities and regions to deal with the epidemic that are likely to grow in the coming years.
* Nigeria's public healthcare system, which has been deteriorating for years, is hard pressed to provide even the most basic public services. Many facilities lack electricity, water, and soap; even betterequipped hospitals are beset by strikes by medical staff.
* Ethiopia has never had a viable national healthcare system because of overwhelming poverty and years of war. The government is soliciting international assistance to build its capabilities, but progress on this front is likely to take years.
Implications
The rise of HIV/AIDS will have significant economic, social, political, and military implications in Nigeria, Ethiopia, Russia, India, and China, although the percentage of the adult population in each country that is infected is likely to remain below the hardest hit countries in southern and central Africa. The impact of the disease by the end of the decade will vary among the five countries, given differences in disease trajectories government responses, available resources, and demographic profiles.
Nigeria and Ethiopia: Hardest Hit
The social and economic impact of AIDS in Nigeria and Ethiopia probably will be similar to the hardest hit countries in Africa. The disease is likely to negatively impact almost all sectors of society by 2010. AIDS will take a heavy economic toll by robbing the countries of many key government and business elites and by discouraging foreign investment, although the oil sector is unlikely to be hurt significantly. 22
* The professional classes in Nigeria and Ethiopia like other African countries are more vulnerable in comparison to other next- wave countries because adult prevalence rates already are much higher and relatively fewer elites are concentrated in a smaller number of key positions.
* The drag of AIDS on economic growth will further reduce the ability of the government to handle the rising social and healthcare costs.
The further deterioration of already weak government institutions by the escalating HIV/AIDS crisis could leave Nigeria and Ethiopia seriously weakened states and is likely to reduce their ability to continue to play a regional leadership role.
* HIV/AIDS probably will complicate staffing in the military officer corps of the two countries as it has in other African states. Ethiopia is more likely to suffer military manpower shortages through the lower ranks, however, because it has a much larger army and smaller population than Nigeria, which plans to reduce the size of its force.
* Rising social tensions over AIDS and related economic problems could exacerbate regional and ethnic tensions within Nigeria and Ethiopia while leaving both governments less able to manage the problem.
Note that the projections in the study are even higher than most others currently presented, and are acknowledged to have wide ranges of uncertainty. Note also that the study repeats the conventional assumption that almost all HIV in Africa results from heterosexual transmission. In contrast, a recent article in the Royal Society of Medicines' International Journal of STDs (Sexually Transmitted Diseases) and AIDS, excerpted in another posting today, contends that the proportion of transmission of the virus through unsafe medical care (injections,transfusions, and other procedures) is being grossly underestimated, and may even exceed the proportion transmitted by sexual intercourse.
The new NIC report was featured at a two-day meeting at the Center for Strategic and International Studies, including a luncheon keynote address by Stephen Lewis, special envoy of the UN Secretary-General on HIV/AIDS. See
http://www.csis.org/press/ma_2002_1003.htm Lewis' speech is available at: http://sustainable.allafrica.com/stories/200210040603.html
+++++++++++++++++end profile++++++++++++++++++++++++++++++
The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China
ICA 2002-04D September 2002
National Intelligence Council
The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China
Prepared under the auspices of David F. Gordon, formerly National Intelligence Officer for Economics and Global Issues.
Summary
The number of people with HIV/ AIDS will grow significantly by the end of the decade. The increase will be driven by the spread of the disease in five populous countries Nigeria, Ethiopia, Russia, India, and China where the number of infected people will grow from around 14 to 23 million currently to an estimated 50 to 75 million by 2010. This estimate eclipses the projected 30 to 35 million cases by the end of the decade in central and southern Africa, the current focal point of the pandemic.
* We project China will have 10 to 15 million HIV/ AIDS cases, and India is likely to have 20 to 25 million by 2010 the highest estimate for any country. By 2010, we project Nigeria will have 10 to 15 million cases, Ethiopia 7 to 10 million, and Russia 5 to 8 million.
HIV/AIDS is spreading at different rates in the five countries, with the epidemic the most advanced in Nigeria and Ethiopia. In all countries, however, risky sexual behaviors are driving infection rates upward at a precipitous rate.
* Adult prevalence rates - the total number of people infected as a percentage of the adult population - are substantially lower in Russia, India, and China, where the disease remains concentrated in high- risk groups, such as intravenous drug users in Russia and people selling blood plasma in China, where some villages have reported 60 percent infection rates.
* Nevertheless, the disease is spreading to wider circles through heterosexual transmission in India, the movement of infected migrant workers in China, and frequent prison amnesty releases of large numbers of infected prison inmates and rising prostitution in Russia.
It will be difficult for any of the five countries to check their epidemics by 2010 without dramatic shifts in priorities. The disease has built up significant momentum, health services are inadequate, and the cost of education and treatment programs will be overwhelming. Government leaders will have trouble maintaining a priority on HIV/ AIDS which has been key to stemming the disease in Uganda, Thailand, and Brazil because of other pressing issues and the lack of AIDS advocacy groups.
* The governments of Nigeria, India, and China are beginning to focus more attention on the HIV/ AIDS threat.
* Even if the five next-wave countries devote more resources to HIV/AIDS programs, implementation is likely to miss significant portions of the population, given weak or limited government institutions and uneven coordination between local and national levels.
* Nigeria and Ethiopia have very limited public services to mobilize. Russia is beset by other major public health problems. China has decentralized most responsibility for health and education issues to local governments that often are corrupt.
* India has taken some steps to improve its healthcare infrastructure to combat HIV/AIDS, but the government has few resources to treat existing infections and must cope with other major health problems such as tuberculosis (TB), which has become linked to the spread of HIV/AIDS.
The rise of HIV/AIDS in the next-wave countries is likely to have significant economic, social, political, and military implications. The impact will vary substantially among the five countries, however, because of differences among them in the development of the disease, likely government responses, available resources, and demographic profiles.
* Nigeria and Ethiopia will be the hardest hit, with the social and economic impact similar to that in the hardest hit countries in southern and central Africa decimating key government and business elites, undermining growth, and discouraging foreign investment. Both countries are key to regional stability, and the rise in HIV/AIDS will strain their governments.
* In Russia, the rise in HIV/AIDS will exacerbate the population decline and severe health problems already plaguing the country, creating even greater difficulty for Russia to rebound economically. These trends may spark tensions over spending priorities and sharpen military manpower shortages.
* HIV/AIDS will drive up social and healthcare costs in India and China, but the broader economic and political impact is likely to be readily absorbed by the huge populations of these countries. We do not believe the disease will pose a fundamental threat through 2010 to their status as major regional players, but it will add to the complex problems faced by their leaders. The more HIV/AIDS spreads among young, educated, urban populations, the greater the economic cost of the disease will be for these countries, given the impact on, and the need for, skilled labor.
The growing AIDS problem in the next- wave countries probably will spark calls for more financial and technical support from donor countries. It may lead to growing tensions over how to disburse international funds, such as the Global Fund for AIDS, TB and Malaria.
The cost of antiretroviral drugs which can prolong the lives of infected people has plunged in recent years but still may be prohibitively high for populous, low- income countries. More importantly, the drug costs are only a portion of HIV/AIDS treatment costs. Drug- resistant strains are likely to spread because of the inconsistent use of antiretroviral therapies and the manufacture overseas of unregulated, substandard drugs. 5
* If an effective vaccine is developed in the coming years, Western governments and pharmaceutical companies will come under intense pressure to make it widely available.
* The next-wave countries are likely to seek greater US technical assistance in tracking and combating the disease.
...
We project that China probably will have 10 to 15 million HIV/AIDS cases by 2010. India is likely to have 20 to 25 million higher than projected for any other country. We estimate Nigeria probably will have 10 to15 million cases, Russia 5 to 8 million, and Ethiopia 7 to 10 million.
Country Profiles
Nigeria.
The HIV/AIDS epidemic in Nigeria is significantly ahead of that in India, China, and Russia - already advancing well beyond high- risk groups and into the general population. The official adult prevalence rate is almost 6 percent, but unofficial estimates range as high as 10 percent which represents 4 to 6 million people infected.
Heterosexual transmission of the HIV virus is the primary mode of spread in Nigeria, and infections appear to be as numerous in rural areas as in the cities. The reported rate of infection apparently varies significantly by region, with the lowest reported rate found generally in the predominantly Muslim northern parts of the country (see 9 figure 3). Infections are most numerous among men ages 20 through 24, but some experts caution that infection rates are rising quickly in young women.
Given the already advanced state of the disease and the government s limited capacity to respond, we expect HIV/AIDS to infect as many as 10 to 15 million people by 2010. This number would constitute roughly 18 to 26 percent of adults close to the current rates in some of the hardest hit countries in southern Africa.
Ethiopia.
Ethiopia's adult prevalence rate estimated at between 10 and 18 percent is the highest among the five countries, indicating that like Nigeria the disease has moved significantly into the general population. Government figures cite 2.7 million Ethiopians currently as HIV positive, although experts believe the actual number may be between 3 and 5 million. Adult prevalence is much higher in cities (13 to 20 percent) than in rural areas (5 percent) (see figure 4). The generally poor health of Ethiopians as a result of drought, 10 malnutrition, limited healthcare, and other infectious diseases has caused HIV to progress rapidly to AIDS. Heterosexual transmission is the primary mode of spread, and people with multiple partners especially those with sexually transmitted diseases (STDs) and prostitutes have significantly higher infection rates, ranging from 30 to 40 percent in STD- positive individuals to 50 to 70 percent in prostitutes.
Unlike conditions in other next- wave countries, war has significantly contributed to the spread of the disease in Ethiopia. Many soldiers contracted HIV/AIDS during the civil war in the 1980s by having contact with multiple sex partners. When the war ended in 1991, thousands of infected soldiers and prostitutes returned home, spreading HIV/AIDS in their villages and towns.
* Another surge of infections may be underway. Ethiopia has demobilized 150,000 soldiers over the last two years as the conflict with Eritrea has wound down. More troops will be sent home as the border dispute is settled.
* As soldiers demobilize, prostitutes who have even higher rates of infection disperse around the country as well.
Looking ahead, we expect 7 to 10 million Ethiopians probably will be infected by 2010 because of the high current rate of adult prevalence, widespread poverty, low educational levels, and the government's limited capacity to respond more actively.
...
HIV: The Science of the Disease
HIV-1 is a fatal infection acquired by contact with the blood or body fluids of an infected person. A transfusion with infected blood almost always results in spread of the virus, and children born to infected mothers have an up to 40 percent chance of contracting the virus prior to birth, during birth, or through breastfeeding. The transmission rate of the disease through sexual contact ranges from 1 to 3 percent. Reusing infected needles results in infections less than one percent of the time.
Sexually transmitted diseases or reproductive tract infections greatly increase the risk of contracting HIV, and uncircumcised men transmit HIV and other STDs to their partners more frequently than circumcised men.
As the disease progresses, a type of infection-fighting white blood cell the CD4 positive-t cell decreases, leading to an irreversible loss of immune function. This period is marked by many illnesses, or unusual opportunistic infections that healthy immune systems protect against.
HIV-positive persons are susceptible to opportunistic and infectious diseases, especially TB. Once they have contracted TB, the disease progresses to the highly infectious, active stage much more quickly and frequently than in HIV-negative persons and is often what kills them. ...
Prospects for Control
We assess that all five next-wave countries will have difficulty controlling their HIV epidemics in the short to medium-term. The disease has built up significant momentum especially in Nigeria and Ethiopia and the governments have been slow to respond. None of the five next-wave countries in this report is on a trajectory to replicate the success of such countries as Uganda, Thailand, and Brazil in stemming the spread of the disease. Several leaders of the nextwave countries are focusing more attention on the AIDS threat, but all face a host of competing demands. In addition, these countries have weak healthcare infrastructures and severe budget constraints, which will create difficulty in financing education and treatment programs for their large populations.
...
Nigeria's leadership has been the most active of the five countries in trying to raise AIDS awareness, for example, by hosting a regional AIDS conference in 2000 and publicly warning about the risk of extinction on the continent. Nonetheless, the Obasanjo administration is beset by such other pressing problems as an approaching election and rising ethnic and religious tensions. Moreover, Nigeria s government institutions have deteriorated so badly over the last decade that Obasanjo has few functioning public sector assets left to mobilize even if he chose to engage fully on the issue.
* Nigeria has taken some steps, however, to build domestic monitoring and diagnostic capabilities especially in Lagos and a major study on the economic effects of HIV/AIDS is underway. * The Nigerian military, concerned about the loss of key personnel from AIDS, now mandates training about the disease for soldiers.
* The Ethiopian Government does not appear focused on AIDS, despite occasional statements on the issue. The government has focused in recent years on the conflict with Eritrea. Healthcare workers privately have criticized efforts in recent years as half hearted, and UN officials have publicly warned Ethiopian leaders to take more measures to stem the epidemic.
...
Weak Healthcare Infrastructure
Although significant differences in capabilities exist among next- wave countries, all five have overburdened and under funded healthcare systems and limited abilities to provide integrated, nationwide programs to test people, track infections, and deliver treatment and education programs. Even within each of the five next- wave countries there are disparities in the ability of cities and regions to deal with the epidemic that are likely to grow in the coming years.
* Nigeria's public healthcare system, which has been deteriorating for years, is hard pressed to provide even the most basic public services. Many facilities lack electricity, water, and soap; even betterequipped hospitals are beset by strikes by medical staff.
* Ethiopia has never had a viable national healthcare system because of overwhelming poverty and years of war. The government is soliciting international assistance to build its capabilities, but progress on this front is likely to take years.
Implications
The rise of HIV/AIDS will have significant economic, social, political, and military implications in Nigeria, Ethiopia, Russia, India, and China, although the percentage of the adult population in each country that is infected is likely to remain below the hardest hit countries in southern and central Africa. The impact of the disease by the end of the decade will vary among the five countries, given differences in disease trajectories government responses, available resources, and demographic profiles.
Nigeria and Ethiopia: Hardest Hit
The social and economic impact of AIDS in Nigeria and Ethiopia probably will be similar to the hardest hit countries in Africa. The disease is likely to negatively impact almost all sectors of society by 2010. AIDS will take a heavy economic toll by robbing the countries of many key government and business elites and by discouraging foreign investment, although the oil sector is unlikely to be hurt significantly. 22
* The professional classes in Nigeria and Ethiopia like other African countries are more vulnerable in comparison to other next- wave countries because adult prevalence rates already are much higher and relatively fewer elites are concentrated in a smaller number of key positions.
* The drag of AIDS on economic growth will further reduce the ability of the government to handle the rising social and healthcare costs.
The further deterioration of already weak government institutions by the escalating HIV/AIDS crisis could leave Nigeria and Ethiopia seriously weakened states and is likely to reduce their ability to continue to play a regional leadership role.
* HIV/AIDS probably will complicate staffing in the military officer corps of the two countries as it has in other African states. Ethiopia is more likely to suffer military manpower shortages through the lower ranks, however, because it has a much larger army and smaller population than Nigeria, which plans to reduce the size of its force.
* Rising social tensions over AIDS and related economic problems could exacerbate regional and ethnic tensions within Nigeria and Ethiopia while leaving both governments less able to manage the problem.
Conclusions and Recommendations
In the preceding chapters, the impact and consequences of the HIV/AIDS epidemic on small farmers in Eastern Africa, as well as on the estate sector in Zambia and to an extent in Tanzania, have been considered. It was found that some factors appear to be true for all the systems studied, notably that HIV/AIDS furthers the process of impoverishment. Linked to this is the impact which the epidemic has on labour availability. This impact can have grave consequences for farming systems, which are heavily reliant on human labour power, either seasonal or perennial. AIDS-related sickness and death reduce the number of hands available to do both household and farm work having profound effects on the domestic farm labour economy. This results in productivity declines with cash incomes likely to fall.
Obviously the extent to which the farming system is affected depends very much on the particular circumstances which pertain for each situation. Moreover, since farming systems are not static, and at the same time epidemic impact is not constant, with rapid increases in morbidity and mortality being most pronounced in the earlier stages of the epidemic, the consequences vary not only from one context to another, and from also one stage of the epidemic to another.
In Uganda, three different stages of the epidemic as it affects three different farming systems were observed (and supported by population data collected in the course of the study). These were pre-impact, early impact and full impact. Examples of each stage were seen in Rakai, North Mubende and South Iganga respectively. Broadly speaking, it seems that in Uganda, affected households follow a path of regressive decline in terms of the content of their production. This is most marked in the case of Gwanda, where, using comparative material from 1989 (Barnett and Blaikie, 1992), it was observed that there has been a marked shift to more basic and less varied food and other crop production. This change was more pronounced among the poorer households. The focus of these adjustments is in the domestic-farm labour economy, and has serious implications for the lives of women and children. In Uganda, the areas which are more vulnerable to the epidemic are often those which have farming systems which are particularly susceptible to labour loss.
In Zambia, as far as can be ascertained on very limited disease incidence data, the farming systems which are most vulnerable to labour loss are not those which are most vulnerable to the epidemic. epidemic. At the same time, while it may be generally true that the most labour-vulnerable farming systems in Zambia are not immediately susceptible to the epidemic, this should not be taken as grounds for complacency in a country with high levels of seroprevalence and a tradition of large-scale internal and international labour migration. The case studies from Teta and
Chipese indicate that in these communities, the epidemic is already affecting quite large numbers of households. The effects of this differ between patrilineal and matrilineal peoples, the latter, as has been noted above, being much more immediately vulnerable to the effects of labour loss.
In Tanzania where oxen are quite widely used and where there are complex exchanges of labour for use of oxen, one adverse effect of HIV/AIDS may be to increase the depth of socio-economic differentiation between ox-owning and non-ox-owning households. However, a very positive aspect of this is that, in Tanzania, insofar as oxen increase productivity and thus earnings, rural youths appear less likely to leave farming in search of incomes and excitement elsewhere. This is in contrast to the situation in Uganda and is important in relation both to the spread of the epidemic and to labour availability as epidemic-related shortages may be less likely to be exacerbated by labour migration than for example in Uganda.
An important observation, in the light of the differences in the findings, is that it is important to have seroprevalence information from as many sites as possible given that rural data are vital for a deeper understanding of the problem and that currently their availability is very limited.
The recommendations will not exclusively concentrate on the agricultural sector, they also will include nutritional and health aspects, as the impact of HIV/AIDS has multi-sectoral dimensions and has to be tackled multi-sectoral.
6.2 The impact of HIV/AIDS on programmes and projects
Rising mortality and morbidity as a result of AIDS are likely to have an impact on project performance since health is a precondition for development. One of the most serious threats to any project is absenteeism on the part of both beneficiaries and project staff, which can be caused by mortality and morbidity, attendance to funerals and various other exigencies of daily life. Absenteeism from project activities may set back the progress of projects in countries severely affected by the disease. Discrimination at the workplace of HIV-positive staff may further interfere with the work performance of all staff.
The impact of AIDS can manifest itself in various ways. It may result in labour shortages forcing farm households to shift from cash to subsistence crops when food security is being threatened. Cash crops which require a long investment period may not be suitable for families afflicted by AIDS that are in need of quick returns to cover immediate medical, funeral or orphan-related expenses.
Livestock activities might be jeopardized by family members selling off their animals to finance medical care for AIDS patients. In addition, if the person in charge of the livestock dies, family members are often unable to manage the livestock due to the loss of skills and relevant experience.
The viability of agricultural credit schemes may be at risk as a result of HIV/AIDS for three reasons: a) increased mortality may raise the number of defaults; b) AIDS-affected families may be forced to liquidate their assets in order to repay the credit or else have their assets seized, thereby ending up worse off than before they incurred the credit; and c) AlDS-afflicted families may have to spend part or all of the credit to finance medical care for family members suffering from AIDS, rather than use the funds for investment.
Agricultural research priorities might shift in view of AIDS to focus on the special needs of farm household with fewer working adults. Projects supporting agricultural extension services need to ensure that forms of labour-substitution, technical advice and credit services are made available to AIDS-affected farm families. Such projects should review the impact of HIV/AIDS both in terms of increased mortality among agricultural extension staff, but also in terms of the reduction of the work time as a result of the increase in funeral attendance.
In countries or regions where AIDS is claiming the lives of skilled labour and the labour market is limited in this labour segment, consideration of the impact of AIDS may be critical to the success and sustainability of investment projects. Recruitment, personnel replacement, training strategies and employment benefits (medical, pension funds, etc) may have to be revised accordingly.
For any training activity, HIV/AIDS may have to be taken into account both in terms of replacement/re-training provisions and strategies, but also in terms of revising training curricula.
6.3 General recommendations at the planning and policy level
Given that a principal finding of this study is that the impact of HIV/AIDS is uneven between and within countries, it follows that policy responses must be developed in relation to the situation as it is observed in particular regions, districts and communities and thus that local involvement in policy and project development is essential.
Even in countries like Tanzania with high national rates of seroprevalence and cumulative AIDS cases, it is quite difficult to observe the impact of the epidemic in most rural communities. This is because the epidemic manifests quite marked regional and local variations and the impact may vary quite dramatically over small distances. This has implications for the method to be used in any future work on this problem and points once again to the necessity for community involvement in diagnosis and programming if resources are to be used most effectively.
In communities where the impact is just being felt it may be necessary to think in terms of rapid response so as to ensure that
- labour-economising strategies are immediately developed for the specific needs of this type of community through the extension services, research stations and NGOs. This will require considerable inter-agency coordination;
- extension messages contain explicit HIV/AIDS components which should include both general HIV/AIDS advice and education and also sensitization to the known impacts of HIV/AIDS on rural livelihoods and production.
However, in communities such as South Iganga in Uganda the main response should contain medium-term efforts to develop labour economising strategies which are suitable for the local production system plus the inclusion of HIV/AIDS education in the extension service message.
Although these specific points derive from the situation in Uganda, they may be applied to all three countries. Thus, a zoning approach may be adopted using the vulnerability mapping data (see below) from this report or from other sources in other countries. Such an approach would classify areas of each country by a particular type of programme which is relevant.
6.4 Determining epidemic impact on labour availability
The Uganda material, in particular, demonstrates very clearly the difficulty and importance of distinguishing epidemic impact on labour availability from other background effects such as local labour market operation. This observation should be brought to the attention of anybody dealing with responses at the local and district level. At the same time, the most important programme and policy responses will be those which enable people to cope with the results of labour loss.
A major result of HIV/AIDS impact is increased pressure on the household labour economy. The most important programme and policy responses will be those which enable people to cope with the results of labour loss. Recommendations include working with local people, to develop responses which facilitate labour economising responses in:
- production - for example by exploring novel inter-crops or the introduction of new varieties or technologies;
- marketing - for example by assisting women's mobility both spatial and social; and
- caring, for example by the development of and assistance to support groups among members of affected households.
This study reveals that members of communities which have been longer exposed to HIV/AIDS may be more open to innovations than they previously were. People are forced to react to the crisis which is caused by AIDS.
6.5 The use of vulnerability mapping
Earlier work in Uganda used available data to map the relative vulnerability to labour loss of different farming systems. This method has been shown to be as expected a broad but imprecise indicator in the case of Uganda. In the present study, a similar exercise was completed for Zambia, thus providing the basis for broad vulnerability mapping in that country. There were insufficient data to develop the basis for a vulnerability map of Tanzania, although existing reports may provide some guide to this problem and further analysis may be possible.
In general however, it is recommended that an HIV/AIDS farming system/rural livelihood vulnerability mapping system be developed for a country. This would serve three purposes. Firstly, it would enable broad identification of risk by administrative area, agro-ecological zone, farming systems and livelihood strategy. Secondly, it would provide a framework for the development of area-specific policies and thirdly it would facilitate the monitoring of impact and policy outcomes.
The process of vulnerability mapping as a means of understanding how farming and rural livelihood systems are affected by labour loss may also give rise to the development of an early warning system. This would consist of a hierarchy of information - broad classification as has been achieved in Uganda and Zambia, more detailed information from district-level agricultural and other administrative sources, and finally, limited examination of the nature of the impact in specific communities using RRA/PRA methods. The usefulness of such an approach was in part demonstrated in the case work for Tanzania, where, with the exception of Kagera region, the rural impact is so far slight but seroprevalence rates indicate that it will increase in the medium-term. Development of an early warning system should facilitate focused responses when the epidemic impact becomes manifest.
Once a hierarchy has been established three levels of responses could be used.
Level 1: The creation of a broad map of rural vulnerability to the impact of HIV/AIDS. Experience suggests that the information for this first stage of vulnerability mapping description and ranking of farming and rural livelihood systems in terms of their sensitivity to labour loss -may be obtained from country resources in departments of agriculture and from research stations as well as from other sources. This is then combined with seroprevalence and cumulative AIDS case data obtained from National AIDS Control Programme sentinel surveillance surveys.
Level 2: Limited verification of the broad vulnerability mapping through small-scale studies (e.g. RRA/PRA) in order to indicate whether the broad mapping is providing useful guidance, undertaking a detailed description of the situations in specific areas and identifying the types of local coping response and demands for assistance.
Level 3: Development of assistance programmes for areas which exhibit different levels of vulnerability and are at different stages of the epidemic impact.
Moreover, if this approach is to be successful, it will be desirable to develop adequate HIV/AIDS impact training programmes at all levels. These would include:
- general training in HIV/AIDS impact issues for politicians and departmental heads;
- specific training in HIV/AIDS impact issues for middle level administrators in all departments engaged with rural and agricultural development; and
- community-based participatory analysis of the situation and needs in specific communities.
6.6 The targeting of assistance
The main burden of the impact at the household level falls on the labour economy of the household. This has considerable implications for the targeting of assistance on women, children and in some cases widowers who are raising children. It is difficult to see how to target these groups, thus there are few response strategies which can be targeted specifically towards the HIV/AIDS-affected and or afflicted. The issue is poverty and the response has to be to deal with a likely increase in poverty rather than to assume that a high level of targeting is possible. Policy responses should integrate all aspects of poverty relief, the domestic and farm labour, the educational needs of orphans and other young people, food security and income generation.
Using existing coping strategies
Communities and households have developed their own coping mechanism. The reorganisation of cropping schedules, selection of cultivars, rearrangement of domestic/farm labour interfaces are all examples. Some of the accumulated experience of coping should be documented and members of "experienced" communities should be encouraged to share their experience with communities at the beginning of the coping process or which have not yet been affected. This sharing could be achieved both via the extension services, but also through the facilitation of direct contacts between members of different communities.
Cost recovery
Cost recovery of both school and medical costs have become more widespread in recent years as part of liberalisation programmes. These place additional burdens on all households and in particular on affected and afflicted households. Relief in these two areas could make an important contribution to both current and future welfare of rural households.
6.7 Donor funding and the role of NGOs
In Uganda where the long-term effects of an HIV/AIDS epidemic are observable, NGOs have been very active. The difficulty is in knowing how sustainable are their efforts. Accordingly, this is a question which donors should address very clearly when making funding decisions.
Funding decisions should also take into account two other considerations. Firstly, the social and economic impact of HIV/AIDS is, apart from its specifically medical aspects, to increase poverty. This means that specific HIV/AIDS targeting and project design is difficult in a context of general poverty. Policy responses should integrate all aspects of poverty relief, the domestic-farm labour interface, educational needs of orphans and other young people, food security and income generation.
Secondly, whether in some communities (for example Gwanda) efforts to find and fund sustainable projects may be in vain and the need for medium-term relief should be considered. There is a conventional belief that development projects and programmes are preferable to relief projects and programmes. The main rationale for this view is usually that the former are sustainable and longterm, the latter are emergency measures, short-term and unsustainable. While it is certainly the case that in general long-term sustainability should be a policy goal, there is a danger that the provision of long-term development projects and programmes, may be used as a way of avoiding the cost of long-term relief. However, long-term, sustainable development projects require certain macro-economic conditions and a degree of realism if they are to be truly sustainable and appropriate.
6.8 Taking HIV/AIDS into consideration in project design
In countries with pandemic proportions of HIV/AIDS its impact should be taken into account in all steps of a project cycle such as project identification and design, project appraisal, project implementation and monitoring & evaluation.
In the project identification phase, it is important to find out, to what extent HIV/AIDS is prevalent in a project area. Statistical data provide a first indication, but as experience shows, they often differ significantly from the real situation. Therefore the potential impact of AIDS should be included in Participatory Rural Appraisal and Rapid Rural Appraisal exercises. The identification of target groups should be taken serious to ensure that AIDS affected families are not excluded and that their special needs are addressed.
The implications of AIDS need to be considered in cost-benefit analyses on which labour shortages, reduced agricultural yields, absenteeism, etc have their effect. For the project implementation phase the reduced labour availability of both project staff and beneficiaries to participate in project activities should be reflected in the workplan.
The impact of the epidemic on projects needs to be closely monitored in order to make timely adjustments. Due to the special nature of HIV/AIDS the impact is expected to become more serious over the next years. Project strategies and interventions should be revised accordingly.
In view of the above observations, the need for inter-agency and inter-sectoral cooperation in strategy and project formulation is of great importance. This is of some significance for the role which all United Nations agencies will play in the years ahead (and not only in Africa) and may well prove to be a test of the effectiveness of some of those agencies. It also raises the important issue of the relation between United Nations agencies and NGOs, both local and international.
6.9 Specific recommendations at the micro level
6.9.1 Crop production activities
6.9.2 Livestock and small-stock raising
6.9.3 Income-generating activities
6.9.4 Health
6.9.5 Nutrition
In broad terms, for individual farming systems, the following basic types of activities are required:
- improving returns to labour;
- extending the planting period (minimum tillage, early maturing varieties, crops and methods for later planting);
- crop diversification and reducing external input requirements;
- improved livestock management techniques;
- small credit schemes.
6.9.1 Crop production activities
Specific activities or improvements aimed at improving yields, producing more relish crops and helping farmers to adapt to labour shortages might include for crop production, the following:
- advice on possible labour economising methods for cultivating staples in order to delay the effects of labour shortage, for example, how to deal with the weevil problem in bananas;
- advice on how yields of secondary staples, for example cassava and yams, now displacing bananas, may be increased without needing extra labour;
- advice on better storage of secondary staples resulting in an effective increase in production
- access to improved varieties of relish crops, specifically groundnuts, beans, cowpeas and bambara nuts;
- exploring other mixtures and intercrop possibilities;
- use of labour-saving implements e.g. reduced tillage implements for oxen such as rippers and ridgers;
- using minimum tillage and ground cover crops to reduce weeding for hand hoe cultivators;
- consideration of the weed control problem - is there a role for herbicides in some circumstances? Are there alternative mulching methods which do not require large amounts of labour?
- improvements in the marketing of relish crops
- access to small loans for other crops and staples (especially targeting women, see also below);
- promotion of research into indigenous relish crops, processing methods and seed storage;
- improving crop management for intercropping;
- tractor hire; or promotion of draught power; and
- promotion of alternative soil fertility strategies (as opposed to reliance on fertilisers) through the use of organic fertiliser, intercrops and crop rotation.
6.9.2 Livestock and small-stock raising
Specific activities or improvements aimed at livestock production are the following:
- promotion of breeds requiring limited attention;
- advice on feed and health care techniques for cattle, sheep, goats, pigs and poultry;
- in societies where cultural tradition permits, pig keeping may be encouraged as a labour economising replacement for cattle, having advantages both as a source of cash and protein which may be particularly beneficial for female- headed households;
- poultry keeping may be encouraged especially for orphans to raise some cash;
- promotion of non-traditional livestock activities, e.g. bee keeping (apiary);
- finally inheritance customs which may prevent widows from inheriting livestock should be discouraged.
6.9.3 Income-generating activities
Where appropriate, small especially home-based low labour income generating opportunities and petty trading activities may be considered. However, these may well mean that provision needs to be made to ensure access to credit by small farmers, either as individuals or groups. Such activities include sewing, tailoring, bee keeping, pig keeping and the production of handicrafts.
However, it is worth noting that local initiatives and ideas are only feasible in circumstances where there are markets for products. Accordingly, encouragement of any kind of income-generating activity should only be considered on the basis of the right conditions being present. These may include access to the inputs needed for the activity, storage and transport facilities if necessary and reasonable likelihood of the marketability of the product.
6.9.4 Health
The large numbers of AlDS-afflicted and affected families in areas of high seroprevalence means that the care of AIDS patients is an important, time-consuming and expensive part of the daily lives of such households. Many of those interviewed in the course of the field studies whose families had been affected by AIDS said that they preferred to have patients die at home.
In Zambia, for example, home-based care programmes will be essential in most rural areas, especially since several of the local hospitals examined, already had constant occupancy rates of over 100 percent. Thus it will not be possible to care for the bulk of HIV/AIDS patients in hospitals, and neither is it particularly desirable, as they are then separated from their kin.
Women in particular reported that they prefer those who are sick to be at home, as it disrupts their production activities less and removes the cost of transport to the hospital. However, caring for patients at home also involves material costs, notably for food and bedding. With regard to food, it was observed that patients often did not like and would not eat vegetables and thus became very hungry. They wanted meat, fish, and eggs. With respect to bedding, blankets are expensive and if they become soiled and torn are costly to replace.
Measures should therefore be taken regarding the home care of HIV/AIDS patients so as to:
- provide for the training of family members in the basic skills of handling and taking care of patients to avoid the risk of infection; and
- provide resources so that households can afford both food and medication, treatment and bedding for the sick.
In all farming systems, regardless of the stage of epidemic impact, AIDS prevention measures, most notably through health education' urgently need to be introduced (or strengthened as the case may be). Such measures include:
- promotion of social activities since many, particularly marginalized rural areas, offer virtually nothing in terms of activities apart from beer drinking and sex;
- door-to-door awareness-raising campaigns are preferable to rallies as a means of disseminating information;
- health education/AIDS teaching should be integrated into work with agricultural extension groups;
- schools should be supported to provide health and AIDS education. This is particularly relevant in areas where the HIV/AIDS epidemic is regarded as a kind of witchcraft or is generally considered to be a taboo subject. In a number of villages in Zambia, for example, people were more reluctant to discuss at any length symptoms of the living, however, knowing that to say someone has AIDS is to condemn that person. There was no occasion when someone said categorically that a living person had AIDS, but there were occasions when it was stated that someone had died of AIDS. One difficulty in dealing with AIDS in Zambia, in urban as well as rural areas, is that often it will be associated with witchcraft. This lack of understanding of what AIDS is simply hinders campaigns to arrest and mitigate its impact;
- support should be given to awareness-raising concerning the use of condoms. The wider distribution of condoms is also required e.g. from stores, depots, grocery stores etc.;
- pregnancies amongst HIV couples should be discouraged; and
- cultural tradition like sexual cleansing in Zambia, should be discouraged or at least men should be encouraged to use condoms.
6.9.5 Nutrition
Findings from the research in most of the farming systems studied cited the declining nutritional status among households affected and or afflicted by HIV/AIDS. Thus efforts should be made to improve the diets of households burdened by having to care for patients or having a high dependency ratio, because of children (and mothers) who have been relocated through divorce and death.
Greater encouragement should be given to:
- the production and use of groundnuts, soyabeans (soya flour) and mashed cowpeas;
- creating awareness of the need for a balanced diet (and therefore for diversified production);
- mothers continuing breastfeeding even when pregnant again;
- improving food preparation (many foods are frequently over cooked);
- involving men in nutrition programmes; and
- promoting child spacing programmes (i.e. to allow sufficient time for a baby to be adequately weaned and to grow before the next child is born).
6.10 Recommendations for specific target groups
Orphans
As noted in previous chapters, a direct effect of the HIV/AIDS epidemic has been to increase the number of orphaned children.
Accordingly, support to orphans and institutions or organizations concerned with the welfare of such children should be assisted or where necessary established. This includes assistance in the payment of school fees, skills training, etc..
Pastoralists
In Tanzania efforts to complete a study of pastoralists were unsuccessful. Little is known about the effect of the epidemic on such livelihood systems (see Chapter 3), these groups are often marginalised, and such a study should be given priority in future work on HIV/AIDS impact.
Women
In many instances women form the backbone of the farming systems. At the same time, their responsibility for the collection as well as the production of food, and their household duties render them particularly vulnerable to the effects of HIV/AIDS morbidity and mortality. Measures which might assist women and especially those who are or become (e.g. by reason of sickness or divorce) heads of households include the following:
- regarding both land and inheritance laws, such legislation should be reviewed so as to clearly stipulate land ownership rights for women. And although laws may not discriminate against women with regard to land rights, traditional or customary laws often do. In this regard, state laws should prevail over customary or religious laws;
- assistance and advice is generally required in the transport, storage (e.g. through the provision of milling facilities for grains in order to produce flour) and in the marketing of products;
- access by women to draught power, farm implements and other inputs;
- provision of adequate extension services especially to women in remote areas;
- encouragement of group formation among widows who currently and in the future will carry much of the burden of coping;
- encouragement of the use of bicycles by women to ease the burden and time required in undertaking a number of farm and household tasks especially for the collection of firewood, water and in the transport and marketing of produce.
6.11 Recommendations relevant to the Estate Sector
6.11.1 HIV/AIDS education and prevention
6.11.2 Improvement of the socio-economic environment
6.11.3 Recruitment policies
6.11.4 Training and staff development
6.11.5 Employment benefits
So far, the impact of HIV/AIDS on the estate examined in this study, the Nakambala Sugar Estate (NSE) has been noticeable and worrying, but not devastating. In general, there are two main responses for HIV/AIDS: HIV prevention and mitigation. In an environment with limited financial resources, these have to be cost-effective.
In the NSE example, medical staff had strongly expressed the need for HIV testing facilities in order to make better diagnosis and hence provide more appropriate treatment. The testing should obviously not be compulsory but be available for individuals wishing to know their status. In addition, the development of HIV infection could be monitored. However, it is absolutely necessary that results be kept confidential.
HIV testing should also be accompanied by counselling and a home-based care system. In the study of NSE, respondents frequently said that they could not endure an HIV positive result. Therefore, psychological support is essential. The opinion of women in the NSE townships, for example, was split between AIDS patients being cared for at home or in the hospitals. Some women expressed the fear that they do not know how to care for patient and therefore think that the care in hospitals is better. Others believe that the conditions in the hospitals are not favourable and prefer to look after patients themselves? especially if they are taught how to treat the patients. The establishment of a home based care system would be one way to mitigate the effect of HIV/AIDS on companies.
6.11.1 HIV/AIDS education and prevention
Companies should become more active in HIV prevention and education to limit the spread of HIV among the workforce. The present HIV education activities are not sufficient to reach all employees. The expense of such a programme is minimal compared with the cost of replacing someone who dies of the illness. In an awareness campaign, other STDs should also be included. High risk groups, such as cane cutters in the NSE example, should receive special attention. As alcohol abuse is often associated with unreasonable risky sexual behaviour, an HIV prevention programme could be combined with an anti-alcohol campaign.
6.11.2 Improvement of the socio-economic environment
Companies should contribute towards creating a socio-economic environment, which makes the spread of HIV more difficult. One way is to empower women by improving their economic status. In companies such as NSE, there are often plenty of positions, which could be occupied by women, ranging from the unskilled to the professional level.
6.11.3 Recruitment policies
Pre-employment testing is not recommended and would be discriminatory. In countries, such as Zambia, where there is a narrow skill base for professionals and high rates of infection, exclusion of HIV positive persons would be a self-defeating policy. An HIV positive person can be productive and beneficial for the company for a considerable number of years. Even if an employee is HIV negative at the time of starting work, there is no guarantee that the employee will not be infected afterwards. The situation is different with applicants who are already sick and stretch the company's budget on medical costs and other benefits right from the beginning of their assignment. Therefore a mandatory chest examination as part of routine medical evaluation for permanent employment is recommended as is the practice in other parts of the world.
6.11.4 Training and staff development
It is debatable whether employees should be screened prior to training, as training is an investment in persons, which will only be paid back over time. If the employee falls sick soon after completing the training, the investment will have been lost. This investment is also lost if the employees leave the company for other reasons. But such cases tend to be in the minority. Where there is a proven positive result, owing to the nature of the HIV/AIDS, it is not known whether the employee is able to work for the next 6 months or the next 10 years. Therefore a company could still realize a return on its investment because afflicted individuals may still have a fairly long work life. The longer the training takes, the less return could be expected. A cost-benefit analysis could compare the costs of the training with the likely return form the individual; such an analysis would also have to take into account the probability of death and disability occurring from other diseases or circumstances (Pangs, l 992).
6.11.5 Employment benefits
Most of the costs which arise due to HIV/AIDS may be attributed to employment benefits. These costs are inevitable and the company has to live with them. But as it is expected that these costs will rise in the near future consideration should be given to whether any financial limit might be set. If this is the case? these limits should be negotiated with trade unions.
Obviously the extent to which the farming system is affected depends very much on the particular circumstances which pertain for each situation. Moreover, since farming systems are not static, and at the same time epidemic impact is not constant, with rapid increases in morbidity and mortality being most pronounced in the earlier stages of the epidemic, the consequences vary not only from one context to another, and from also one stage of the epidemic to another.
In Uganda, three different stages of the epidemic as it affects three different farming systems were observed (and supported by population data collected in the course of the study). These were pre-impact, early impact and full impact. Examples of each stage were seen in Rakai, North Mubende and South Iganga respectively. Broadly speaking, it seems that in Uganda, affected households follow a path of regressive decline in terms of the content of their production. This is most marked in the case of Gwanda, where, using comparative material from 1989 (Barnett and Blaikie, 1992), it was observed that there has been a marked shift to more basic and less varied food and other crop production. This change was more pronounced among the poorer households. The focus of these adjustments is in the domestic-farm labour economy, and has serious implications for the lives of women and children. In Uganda, the areas which are more vulnerable to the epidemic are often those which have farming systems which are particularly susceptible to labour loss.
In Zambia, as far as can be ascertained on very limited disease incidence data, the farming systems which are most vulnerable to labour loss are not those which are most vulnerable to the epidemic. epidemic. At the same time, while it may be generally true that the most labour-vulnerable farming systems in Zambia are not immediately susceptible to the epidemic, this should not be taken as grounds for complacency in a country with high levels of seroprevalence and a tradition of large-scale internal and international labour migration. The case studies from Teta and
Chipese indicate that in these communities, the epidemic is already affecting quite large numbers of households. The effects of this differ between patrilineal and matrilineal peoples, the latter, as has been noted above, being much more immediately vulnerable to the effects of labour loss.
In Tanzania where oxen are quite widely used and where there are complex exchanges of labour for use of oxen, one adverse effect of HIV/AIDS may be to increase the depth of socio-economic differentiation between ox-owning and non-ox-owning households. However, a very positive aspect of this is that, in Tanzania, insofar as oxen increase productivity and thus earnings, rural youths appear less likely to leave farming in search of incomes and excitement elsewhere. This is in contrast to the situation in Uganda and is important in relation both to the spread of the epidemic and to labour availability as epidemic-related shortages may be less likely to be exacerbated by labour migration than for example in Uganda.
An important observation, in the light of the differences in the findings, is that it is important to have seroprevalence information from as many sites as possible given that rural data are vital for a deeper understanding of the problem and that currently their availability is very limited.
The recommendations will not exclusively concentrate on the agricultural sector, they also will include nutritional and health aspects, as the impact of HIV/AIDS has multi-sectoral dimensions and has to be tackled multi-sectoral.
6.2 The impact of HIV/AIDS on programmes and projects
Rising mortality and morbidity as a result of AIDS are likely to have an impact on project performance since health is a precondition for development. One of the most serious threats to any project is absenteeism on the part of both beneficiaries and project staff, which can be caused by mortality and morbidity, attendance to funerals and various other exigencies of daily life. Absenteeism from project activities may set back the progress of projects in countries severely affected by the disease. Discrimination at the workplace of HIV-positive staff may further interfere with the work performance of all staff.
The impact of AIDS can manifest itself in various ways. It may result in labour shortages forcing farm households to shift from cash to subsistence crops when food security is being threatened. Cash crops which require a long investment period may not be suitable for families afflicted by AIDS that are in need of quick returns to cover immediate medical, funeral or orphan-related expenses.
Livestock activities might be jeopardized by family members selling off their animals to finance medical care for AIDS patients. In addition, if the person in charge of the livestock dies, family members are often unable to manage the livestock due to the loss of skills and relevant experience.
The viability of agricultural credit schemes may be at risk as a result of HIV/AIDS for three reasons: a) increased mortality may raise the number of defaults; b) AIDS-affected families may be forced to liquidate their assets in order to repay the credit or else have their assets seized, thereby ending up worse off than before they incurred the credit; and c) AlDS-afflicted families may have to spend part or all of the credit to finance medical care for family members suffering from AIDS, rather than use the funds for investment.
Agricultural research priorities might shift in view of AIDS to focus on the special needs of farm household with fewer working adults. Projects supporting agricultural extension services need to ensure that forms of labour-substitution, technical advice and credit services are made available to AIDS-affected farm families. Such projects should review the impact of HIV/AIDS both in terms of increased mortality among agricultural extension staff, but also in terms of the reduction of the work time as a result of the increase in funeral attendance.
In countries or regions where AIDS is claiming the lives of skilled labour and the labour market is limited in this labour segment, consideration of the impact of AIDS may be critical to the success and sustainability of investment projects. Recruitment, personnel replacement, training strategies and employment benefits (medical, pension funds, etc) may have to be revised accordingly.
For any training activity, HIV/AIDS may have to be taken into account both in terms of replacement/re-training provisions and strategies, but also in terms of revising training curricula.
6.3 General recommendations at the planning and policy level
Given that a principal finding of this study is that the impact of HIV/AIDS is uneven between and within countries, it follows that policy responses must be developed in relation to the situation as it is observed in particular regions, districts and communities and thus that local involvement in policy and project development is essential.
Even in countries like Tanzania with high national rates of seroprevalence and cumulative AIDS cases, it is quite difficult to observe the impact of the epidemic in most rural communities. This is because the epidemic manifests quite marked regional and local variations and the impact may vary quite dramatically over small distances. This has implications for the method to be used in any future work on this problem and points once again to the necessity for community involvement in diagnosis and programming if resources are to be used most effectively.
In communities where the impact is just being felt it may be necessary to think in terms of rapid response so as to ensure that
- labour-economising strategies are immediately developed for the specific needs of this type of community through the extension services, research stations and NGOs. This will require considerable inter-agency coordination;
- extension messages contain explicit HIV/AIDS components which should include both general HIV/AIDS advice and education and also sensitization to the known impacts of HIV/AIDS on rural livelihoods and production.
However, in communities such as South Iganga in Uganda the main response should contain medium-term efforts to develop labour economising strategies which are suitable for the local production system plus the inclusion of HIV/AIDS education in the extension service message.
Although these specific points derive from the situation in Uganda, they may be applied to all three countries. Thus, a zoning approach may be adopted using the vulnerability mapping data (see below) from this report or from other sources in other countries. Such an approach would classify areas of each country by a particular type of programme which is relevant.
6.4 Determining epidemic impact on labour availability
The Uganda material, in particular, demonstrates very clearly the difficulty and importance of distinguishing epidemic impact on labour availability from other background effects such as local labour market operation. This observation should be brought to the attention of anybody dealing with responses at the local and district level. At the same time, the most important programme and policy responses will be those which enable people to cope with the results of labour loss.
A major result of HIV/AIDS impact is increased pressure on the household labour economy. The most important programme and policy responses will be those which enable people to cope with the results of labour loss. Recommendations include working with local people, to develop responses which facilitate labour economising responses in:
- production - for example by exploring novel inter-crops or the introduction of new varieties or technologies;
- marketing - for example by assisting women's mobility both spatial and social; and
- caring, for example by the development of and assistance to support groups among members of affected households.
This study reveals that members of communities which have been longer exposed to HIV/AIDS may be more open to innovations than they previously were. People are forced to react to the crisis which is caused by AIDS.
6.5 The use of vulnerability mapping
Earlier work in Uganda used available data to map the relative vulnerability to labour loss of different farming systems. This method has been shown to be as expected a broad but imprecise indicator in the case of Uganda. In the present study, a similar exercise was completed for Zambia, thus providing the basis for broad vulnerability mapping in that country. There were insufficient data to develop the basis for a vulnerability map of Tanzania, although existing reports may provide some guide to this problem and further analysis may be possible.
In general however, it is recommended that an HIV/AIDS farming system/rural livelihood vulnerability mapping system be developed for a country. This would serve three purposes. Firstly, it would enable broad identification of risk by administrative area, agro-ecological zone, farming systems and livelihood strategy. Secondly, it would provide a framework for the development of area-specific policies and thirdly it would facilitate the monitoring of impact and policy outcomes.
The process of vulnerability mapping as a means of understanding how farming and rural livelihood systems are affected by labour loss may also give rise to the development of an early warning system. This would consist of a hierarchy of information - broad classification as has been achieved in Uganda and Zambia, more detailed information from district-level agricultural and other administrative sources, and finally, limited examination of the nature of the impact in specific communities using RRA/PRA methods. The usefulness of such an approach was in part demonstrated in the case work for Tanzania, where, with the exception of Kagera region, the rural impact is so far slight but seroprevalence rates indicate that it will increase in the medium-term. Development of an early warning system should facilitate focused responses when the epidemic impact becomes manifest.
Once a hierarchy has been established three levels of responses could be used.
Level 1: The creation of a broad map of rural vulnerability to the impact of HIV/AIDS. Experience suggests that the information for this first stage of vulnerability mapping description and ranking of farming and rural livelihood systems in terms of their sensitivity to labour loss -may be obtained from country resources in departments of agriculture and from research stations as well as from other sources. This is then combined with seroprevalence and cumulative AIDS case data obtained from National AIDS Control Programme sentinel surveillance surveys.
Level 2: Limited verification of the broad vulnerability mapping through small-scale studies (e.g. RRA/PRA) in order to indicate whether the broad mapping is providing useful guidance, undertaking a detailed description of the situations in specific areas and identifying the types of local coping response and demands for assistance.
Level 3: Development of assistance programmes for areas which exhibit different levels of vulnerability and are at different stages of the epidemic impact.
Moreover, if this approach is to be successful, it will be desirable to develop adequate HIV/AIDS impact training programmes at all levels. These would include:
- general training in HIV/AIDS impact issues for politicians and departmental heads;
- specific training in HIV/AIDS impact issues for middle level administrators in all departments engaged with rural and agricultural development; and
- community-based participatory analysis of the situation and needs in specific communities.
6.6 The targeting of assistance
The main burden of the impact at the household level falls on the labour economy of the household. This has considerable implications for the targeting of assistance on women, children and in some cases widowers who are raising children. It is difficult to see how to target these groups, thus there are few response strategies which can be targeted specifically towards the HIV/AIDS-affected and or afflicted. The issue is poverty and the response has to be to deal with a likely increase in poverty rather than to assume that a high level of targeting is possible. Policy responses should integrate all aspects of poverty relief, the domestic and farm labour, the educational needs of orphans and other young people, food security and income generation.
Using existing coping strategies
Communities and households have developed their own coping mechanism. The reorganisation of cropping schedules, selection of cultivars, rearrangement of domestic/farm labour interfaces are all examples. Some of the accumulated experience of coping should be documented and members of "experienced" communities should be encouraged to share their experience with communities at the beginning of the coping process or which have not yet been affected. This sharing could be achieved both via the extension services, but also through the facilitation of direct contacts between members of different communities.
Cost recovery
Cost recovery of both school and medical costs have become more widespread in recent years as part of liberalisation programmes. These place additional burdens on all households and in particular on affected and afflicted households. Relief in these two areas could make an important contribution to both current and future welfare of rural households.
6.7 Donor funding and the role of NGOs
In Uganda where the long-term effects of an HIV/AIDS epidemic are observable, NGOs have been very active. The difficulty is in knowing how sustainable are their efforts. Accordingly, this is a question which donors should address very clearly when making funding decisions.
Funding decisions should also take into account two other considerations. Firstly, the social and economic impact of HIV/AIDS is, apart from its specifically medical aspects, to increase poverty. This means that specific HIV/AIDS targeting and project design is difficult in a context of general poverty. Policy responses should integrate all aspects of poverty relief, the domestic-farm labour interface, educational needs of orphans and other young people, food security and income generation.
Secondly, whether in some communities (for example Gwanda) efforts to find and fund sustainable projects may be in vain and the need for medium-term relief should be considered. There is a conventional belief that development projects and programmes are preferable to relief projects and programmes. The main rationale for this view is usually that the former are sustainable and longterm, the latter are emergency measures, short-term and unsustainable. While it is certainly the case that in general long-term sustainability should be a policy goal, there is a danger that the provision of long-term development projects and programmes, may be used as a way of avoiding the cost of long-term relief. However, long-term, sustainable development projects require certain macro-economic conditions and a degree of realism if they are to be truly sustainable and appropriate.
6.8 Taking HIV/AIDS into consideration in project design
In countries with pandemic proportions of HIV/AIDS its impact should be taken into account in all steps of a project cycle such as project identification and design, project appraisal, project implementation and monitoring & evaluation.
In the project identification phase, it is important to find out, to what extent HIV/AIDS is prevalent in a project area. Statistical data provide a first indication, but as experience shows, they often differ significantly from the real situation. Therefore the potential impact of AIDS should be included in Participatory Rural Appraisal and Rapid Rural Appraisal exercises. The identification of target groups should be taken serious to ensure that AIDS affected families are not excluded and that their special needs are addressed.
The implications of AIDS need to be considered in cost-benefit analyses on which labour shortages, reduced agricultural yields, absenteeism, etc have their effect. For the project implementation phase the reduced labour availability of both project staff and beneficiaries to participate in project activities should be reflected in the workplan.
The impact of the epidemic on projects needs to be closely monitored in order to make timely adjustments. Due to the special nature of HIV/AIDS the impact is expected to become more serious over the next years. Project strategies and interventions should be revised accordingly.
In view of the above observations, the need for inter-agency and inter-sectoral cooperation in strategy and project formulation is of great importance. This is of some significance for the role which all United Nations agencies will play in the years ahead (and not only in Africa) and may well prove to be a test of the effectiveness of some of those agencies. It also raises the important issue of the relation between United Nations agencies and NGOs, both local and international.
6.9 Specific recommendations at the micro level
6.9.1 Crop production activities
6.9.2 Livestock and small-stock raising
6.9.3 Income-generating activities
6.9.4 Health
6.9.5 Nutrition
In broad terms, for individual farming systems, the following basic types of activities are required:
- improving returns to labour;
- extending the planting period (minimum tillage, early maturing varieties, crops and methods for later planting);
- crop diversification and reducing external input requirements;
- improved livestock management techniques;
- small credit schemes.
6.9.1 Crop production activities
Specific activities or improvements aimed at improving yields, producing more relish crops and helping farmers to adapt to labour shortages might include for crop production, the following:
- advice on possible labour economising methods for cultivating staples in order to delay the effects of labour shortage, for example, how to deal with the weevil problem in bananas;
- advice on how yields of secondary staples, for example cassava and yams, now displacing bananas, may be increased without needing extra labour;
- advice on better storage of secondary staples resulting in an effective increase in production
- access to improved varieties of relish crops, specifically groundnuts, beans, cowpeas and bambara nuts;
- exploring other mixtures and intercrop possibilities;
- use of labour-saving implements e.g. reduced tillage implements for oxen such as rippers and ridgers;
- using minimum tillage and ground cover crops to reduce weeding for hand hoe cultivators;
- consideration of the weed control problem - is there a role for herbicides in some circumstances? Are there alternative mulching methods which do not require large amounts of labour?
- improvements in the marketing of relish crops
- access to small loans for other crops and staples (especially targeting women, see also below);
- promotion of research into indigenous relish crops, processing methods and seed storage;
- improving crop management for intercropping;
- tractor hire; or promotion of draught power; and
- promotion of alternative soil fertility strategies (as opposed to reliance on fertilisers) through the use of organic fertiliser, intercrops and crop rotation.
6.9.2 Livestock and small-stock raising
Specific activities or improvements aimed at livestock production are the following:
- promotion of breeds requiring limited attention;
- advice on feed and health care techniques for cattle, sheep, goats, pigs and poultry;
- in societies where cultural tradition permits, pig keeping may be encouraged as a labour economising replacement for cattle, having advantages both as a source of cash and protein which may be particularly beneficial for female- headed households;
- poultry keeping may be encouraged especially for orphans to raise some cash;
- promotion of non-traditional livestock activities, e.g. bee keeping (apiary);
- finally inheritance customs which may prevent widows from inheriting livestock should be discouraged.
6.9.3 Income-generating activities
Where appropriate, small especially home-based low labour income generating opportunities and petty trading activities may be considered. However, these may well mean that provision needs to be made to ensure access to credit by small farmers, either as individuals or groups. Such activities include sewing, tailoring, bee keeping, pig keeping and the production of handicrafts.
However, it is worth noting that local initiatives and ideas are only feasible in circumstances where there are markets for products. Accordingly, encouragement of any kind of income-generating activity should only be considered on the basis of the right conditions being present. These may include access to the inputs needed for the activity, storage and transport facilities if necessary and reasonable likelihood of the marketability of the product.
6.9.4 Health
The large numbers of AlDS-afflicted and affected families in areas of high seroprevalence means that the care of AIDS patients is an important, time-consuming and expensive part of the daily lives of such households. Many of those interviewed in the course of the field studies whose families had been affected by AIDS said that they preferred to have patients die at home.
In Zambia, for example, home-based care programmes will be essential in most rural areas, especially since several of the local hospitals examined, already had constant occupancy rates of over 100 percent. Thus it will not be possible to care for the bulk of HIV/AIDS patients in hospitals, and neither is it particularly desirable, as they are then separated from their kin.
Women in particular reported that they prefer those who are sick to be at home, as it disrupts their production activities less and removes the cost of transport to the hospital. However, caring for patients at home also involves material costs, notably for food and bedding. With regard to food, it was observed that patients often did not like and would not eat vegetables and thus became very hungry. They wanted meat, fish, and eggs. With respect to bedding, blankets are expensive and if they become soiled and torn are costly to replace.
Measures should therefore be taken regarding the home care of HIV/AIDS patients so as to:
- provide for the training of family members in the basic skills of handling and taking care of patients to avoid the risk of infection; and
- provide resources so that households can afford both food and medication, treatment and bedding for the sick.
In all farming systems, regardless of the stage of epidemic impact, AIDS prevention measures, most notably through health education' urgently need to be introduced (or strengthened as the case may be). Such measures include:
- promotion of social activities since many, particularly marginalized rural areas, offer virtually nothing in terms of activities apart from beer drinking and sex;
- door-to-door awareness-raising campaigns are preferable to rallies as a means of disseminating information;
- health education/AIDS teaching should be integrated into work with agricultural extension groups;
- schools should be supported to provide health and AIDS education. This is particularly relevant in areas where the HIV/AIDS epidemic is regarded as a kind of witchcraft or is generally considered to be a taboo subject. In a number of villages in Zambia, for example, people were more reluctant to discuss at any length symptoms of the living, however, knowing that to say someone has AIDS is to condemn that person. There was no occasion when someone said categorically that a living person had AIDS, but there were occasions when it was stated that someone had died of AIDS. One difficulty in dealing with AIDS in Zambia, in urban as well as rural areas, is that often it will be associated with witchcraft. This lack of understanding of what AIDS is simply hinders campaigns to arrest and mitigate its impact;
- support should be given to awareness-raising concerning the use of condoms. The wider distribution of condoms is also required e.g. from stores, depots, grocery stores etc.;
- pregnancies amongst HIV couples should be discouraged; and
- cultural tradition like sexual cleansing in Zambia, should be discouraged or at least men should be encouraged to use condoms.
6.9.5 Nutrition
Findings from the research in most of the farming systems studied cited the declining nutritional status among households affected and or afflicted by HIV/AIDS. Thus efforts should be made to improve the diets of households burdened by having to care for patients or having a high dependency ratio, because of children (and mothers) who have been relocated through divorce and death.
Greater encouragement should be given to:
- the production and use of groundnuts, soyabeans (soya flour) and mashed cowpeas;
- creating awareness of the need for a balanced diet (and therefore for diversified production);
- mothers continuing breastfeeding even when pregnant again;
- improving food preparation (many foods are frequently over cooked);
- involving men in nutrition programmes; and
- promoting child spacing programmes (i.e. to allow sufficient time for a baby to be adequately weaned and to grow before the next child is born).
6.10 Recommendations for specific target groups
Orphans
As noted in previous chapters, a direct effect of the HIV/AIDS epidemic has been to increase the number of orphaned children.
Accordingly, support to orphans and institutions or organizations concerned with the welfare of such children should be assisted or where necessary established. This includes assistance in the payment of school fees, skills training, etc..
Pastoralists
In Tanzania efforts to complete a study of pastoralists were unsuccessful. Little is known about the effect of the epidemic on such livelihood systems (see Chapter 3), these groups are often marginalised, and such a study should be given priority in future work on HIV/AIDS impact.
Women
In many instances women form the backbone of the farming systems. At the same time, their responsibility for the collection as well as the production of food, and their household duties render them particularly vulnerable to the effects of HIV/AIDS morbidity and mortality. Measures which might assist women and especially those who are or become (e.g. by reason of sickness or divorce) heads of households include the following:
- regarding both land and inheritance laws, such legislation should be reviewed so as to clearly stipulate land ownership rights for women. And although laws may not discriminate against women with regard to land rights, traditional or customary laws often do. In this regard, state laws should prevail over customary or religious laws;
- assistance and advice is generally required in the transport, storage (e.g. through the provision of milling facilities for grains in order to produce flour) and in the marketing of products;
- access by women to draught power, farm implements and other inputs;
- provision of adequate extension services especially to women in remote areas;
- encouragement of group formation among widows who currently and in the future will carry much of the burden of coping;
- encouragement of the use of bicycles by women to ease the burden and time required in undertaking a number of farm and household tasks especially for the collection of firewood, water and in the transport and marketing of produce.
6.11 Recommendations relevant to the Estate Sector
6.11.1 HIV/AIDS education and prevention
6.11.2 Improvement of the socio-economic environment
6.11.3 Recruitment policies
6.11.4 Training and staff development
6.11.5 Employment benefits
So far, the impact of HIV/AIDS on the estate examined in this study, the Nakambala Sugar Estate (NSE) has been noticeable and worrying, but not devastating. In general, there are two main responses for HIV/AIDS: HIV prevention and mitigation. In an environment with limited financial resources, these have to be cost-effective.
In the NSE example, medical staff had strongly expressed the need for HIV testing facilities in order to make better diagnosis and hence provide more appropriate treatment. The testing should obviously not be compulsory but be available for individuals wishing to know their status. In addition, the development of HIV infection could be monitored. However, it is absolutely necessary that results be kept confidential.
HIV testing should also be accompanied by counselling and a home-based care system. In the study of NSE, respondents frequently said that they could not endure an HIV positive result. Therefore, psychological support is essential. The opinion of women in the NSE townships, for example, was split between AIDS patients being cared for at home or in the hospitals. Some women expressed the fear that they do not know how to care for patient and therefore think that the care in hospitals is better. Others believe that the conditions in the hospitals are not favourable and prefer to look after patients themselves? especially if they are taught how to treat the patients. The establishment of a home based care system would be one way to mitigate the effect of HIV/AIDS on companies.
6.11.1 HIV/AIDS education and prevention
Companies should become more active in HIV prevention and education to limit the spread of HIV among the workforce. The present HIV education activities are not sufficient to reach all employees. The expense of such a programme is minimal compared with the cost of replacing someone who dies of the illness. In an awareness campaign, other STDs should also be included. High risk groups, such as cane cutters in the NSE example, should receive special attention. As alcohol abuse is often associated with unreasonable risky sexual behaviour, an HIV prevention programme could be combined with an anti-alcohol campaign.
6.11.2 Improvement of the socio-economic environment
Companies should contribute towards creating a socio-economic environment, which makes the spread of HIV more difficult. One way is to empower women by improving their economic status. In companies such as NSE, there are often plenty of positions, which could be occupied by women, ranging from the unskilled to the professional level.
6.11.3 Recruitment policies
Pre-employment testing is not recommended and would be discriminatory. In countries, such as Zambia, where there is a narrow skill base for professionals and high rates of infection, exclusion of HIV positive persons would be a self-defeating policy. An HIV positive person can be productive and beneficial for the company for a considerable number of years. Even if an employee is HIV negative at the time of starting work, there is no guarantee that the employee will not be infected afterwards. The situation is different with applicants who are already sick and stretch the company's budget on medical costs and other benefits right from the beginning of their assignment. Therefore a mandatory chest examination as part of routine medical evaluation for permanent employment is recommended as is the practice in other parts of the world.
6.11.4 Training and staff development
It is debatable whether employees should be screened prior to training, as training is an investment in persons, which will only be paid back over time. If the employee falls sick soon after completing the training, the investment will have been lost. This investment is also lost if the employees leave the company for other reasons. But such cases tend to be in the minority. Where there is a proven positive result, owing to the nature of the HIV/AIDS, it is not known whether the employee is able to work for the next 6 months or the next 10 years. Therefore a company could still realize a return on its investment because afflicted individuals may still have a fairly long work life. The longer the training takes, the less return could be expected. A cost-benefit analysis could compare the costs of the training with the likely return form the individual; such an analysis would also have to take into account the probability of death and disability occurring from other diseases or circumstances (Pangs, l 992).
6.11.5 Employment benefits
Most of the costs which arise due to HIV/AIDS may be attributed to employment benefits. These costs are inevitable and the company has to live with them. But as it is expected that these costs will rise in the near future consideration should be given to whether any financial limit might be set. If this is the case? these limits should be negotiated with trade unions.
Projections of the economic impact for the near future
The projection in Table 9 is based on an assumed increase of AIDS deaths and sickness of 70 percent. The expenses due to the epidemic will not proportionally rise in all affected departments.
Table 9: Cost increase due to HIV/AIDS from 1992-93 to 1995-96
Description Costs 92-93 Increase Costs 95-96
(US $) (%) (US $)
Lost workforce 148920 70 253164
Extension of expatriates 60000 100 120000
Medical Department 70124 70 119210
Funerals 24314 70 41333
Pensions for death +early retirement 75184 0 75184
Repatriation 59448 70 101061
Training 35208 100 70416
Total 473198 780368
Source: Haslwimmer. 1994
The projected costs caused by HIV/AIDS could rise until 1995-96 to 3.1 percent of the total costs. But two variables could influence these costs more dramatically than is indicated in Table 9. These development of the Zambian and Southern African labour market and production losses.
At the lower end of the skills spectrum in Zambia, labour is abundant. HIV/AIDS will not reduce this labour force to such an extent that labourers at this level become scarce. On the skilled and professional level, the market is much thinner and is influenced by various factors. It is only since 1991 that the Zambian Sugar Company has offered competitive salaries compared with other employers in Zambia. In the past the company had found it difficult to attract highly qualified people, in particular engineers, who preferred to work in the Copperbelt. The Estate's rural setting also appears to be a disincentive in terms of attracting qualified people and attractive housing facilities are also lacking at NSE. Moreover, because Zambia's neighbours, particularly South Africa offer better salaries, many highly qualified Zambians prefer to work abroad. AIDS will contribute to the tightness of the labour market, especially as the disease has claimed a number of people among the ranks of professionals.
It is also possible that professional salaries will increase. This also means that, for example, an extra 20 percent increase for the salaries of professionals could to be included in the cost estimates for 199596.
5.9 The impact of HIV/AIDS on the Kaleya Smallholder Company in Zambia
Kaleya Smallholders Company Limited is a smallholder settlement scheme established to develop 1 885 ha of sugar cane in the district of Mazabuka in Zambia. Two-thirds of the area is settled by 300 smallholders and one-third remains a nucleus estate. The target annual cane production is 200 000 tonnes - 15 % of the national output.
Currently 1 782 ha have been planted and 140 smallholders settled. The company supplies the smallholders with training and extension services, agricultural inputs and mechanical services, arranges cane harvesting and haulage and distributes irrigation water. The smallholders are responsible for 4 ha of sugar cane, with family members caring for the infield irrigation, weed control, fertilizer application and removal of diseased cane stalks. The cost of all direct service is charged to the smallholders. Kaleya pays the growers for standing cane, with the price related to Nakambala's production costs.
The cane is sold by Kaleya to the Zambia Sugar Company which processes the sugar cane. The terms of the sale are determined by a cane purchase agreement negotiated between Zambia Sugar Company and three outgrowers (Kaleya, and two private farms). Currently the Kaleya is controlled by the founder shareholders - the Commonwealth Development Corporation, Zambia Sugar Company, the Development Bank of Zambia and Barclays Bank of Zambia. Ultimately it is intended that all of the ordinary share capital of Kaleya will be purchased by the smallholders who will become the owners.
It appears that the smallholders are equally or worse affected by HIV/AIDS than the population of Mazabuka. The smallholders come from different parts of Zambia, many having previously lived on the Copperbelt, which is characterised by very high rates of seroprevalence. Being a smallholder in Kaleya is an attractive occupation which provides a relatively high income (in comparison to most of the rural population). Polygamy is widespread among the cane growers and marriages are reputedly very unstable. At the time of this study, 14 out of the 140 smallholders and their families were suspected of having died of AIDS.
Box 12: Case study 6
Eleanor is a 24-yeas old widow. She has three young children of her own and one son of her late husband. She and her husband came to Kaleya some years ago.
Her husband died in July 1993 aged 36, most probably from AIDS. While her husband was ill with AIDS Eleanor nursed him. As a result she did not have time to produce enough maize for her family's consumption. Added to this the yield of sugar cane was low last season, which Eleanor believes is due to the age of the cane and not because of a labour constraint. Next season her yield is likely to be even lower. Eleanor employed part-time workers to undertake irrigation works on her plot but because she does not know enough about irrigation in sugar cane, she could not control the work properly. Although she had asked the local extension service for advice, at the time of the interview nobody had been to visit her.
Eleanor believes, that she and her late husband's sixteen year-old son could manage the farm in the future. However, although she and the son are the official holders of the settlement, her in-laws have been pressing to gain control of the farm. Now she is afraid that she is bewitched.
The smallholders rely mostly on family members for their production activities, but they also hire labour. Labour, which is provided by family members, who fall sick and finally die of AIDS, cannot be as easily replaced as on an estate. As observed frequently in many of the small farming systems described earlier, care for patients at home, attendance at funerals and the loss of management skills, all contribute to the labour constraints of an AIDS-affected household. But all households are not equally vulnerable.
For example, one farmer who was interviewed, and is probably suffering from AIDS, has several grown-up children, who now do all the work in the fields. The death of the father would not necessarily have an effect on sugar cane production, because there is still enough labour force and the father's knowledge has already been passed on to his children. However, the death of the most experienced person in a household, especially in the production of sugar cane, can have serious consequences, especially where the remaining family members do not have the necessary farm management skills, as in the example below of case study 7.
Box 13: Case study 7
Justin is 22 years old and has three brothers aged 24, 20 and 16, and two younger sisters are at school in the Copperbelt. In 1986 his parents came from the Copperbelt as smallholders to Kaleya.
In 1989 Justin's father died of AIDS. Two brothers were forced to leave school to work on the family farm. With their help and the employment of part-time labourers sugar cane production could be maintained under the management of the mother. In 1990 Justin's mother also fell sick and returned to the Copperbelt with her youngest child. In 1991 both his mother and the child died and all the children left Kaleya for one month to attend the funeral in the copperbelt. During that time the neighbours assisted in caring for the farm, but they were unable to carry out the farm work as effectively as Justin's family. As a consequence, yields declined by 40 percent in 1991 and the household's income suffered accordingly.
Since then production has begun to increase once more but has not yet reached its previous level. It appears that once sugar cane yields drop significantly, it is very difficult to reach previous levels. In 1993 the household was are also able to produce enough bags of maize for themselves to eat.
The most vulnerable households are those with a high dependency ratio, since widows will frequently loose many of their possession when, by traditional custom, the husband's relatives arrive soon after the death to claim all the household possessions.
5.10 The impact of HIV/AIDS on the Tukuyu Tea Estates in Tanzania
The Tukuyu Tea Estates are located near the Ushirika minor settlement in Tanzania. Covering an area of 1 530 ha they consist of seven estates with two factories among them. The estates have a permanent staff of 1 200 and employ an additional 2 000 labourers during the peak tea picking season. Most of these casual labourers come from neighbouring villages.
Although there have only been two confirmed cases of AIDS to date, the general situation of the Tukuyu Estates renders them potentially vulnerable. HIV/AIDS can affect this estate as in the cases of those described above in Zambia since they depend on the availability of trained manpower. It takes a long time and significant resources to train an expert. Thus experienced workers are difficult to replace.
Since the Tukuyu Estates are located on the highway to Malawi and close to two settlements and the town of Tukuyu, there is a lot of contact with urban and more densely populated areas, one of which, Ushirika is considered to be a high-risk area. Whether by chance, or partially as a result of the preventive measures taken by Tukuyu Tea Estates to date, AIDS has had a minimal impact on the company.
The preventive measures that may be in part responsible include the supply of condoms to male workers (although such supplies are irregular) and the establishment of an AIDS education programme using television and videos. At the same time the company offers its employees free lunches, medical care and clinic facilities. Child nutritional status is reported to be good.
Table 9: Cost increase due to HIV/AIDS from 1992-93 to 1995-96
Description Costs 92-93 Increase Costs 95-96
(US $) (%) (US $)
Lost workforce 148920 70 253164
Extension of expatriates 60000 100 120000
Medical Department 70124 70 119210
Funerals 24314 70 41333
Pensions for death +early retirement 75184 0 75184
Repatriation 59448 70 101061
Training 35208 100 70416
Total 473198 780368
Source: Haslwimmer. 1994
The projected costs caused by HIV/AIDS could rise until 1995-96 to 3.1 percent of the total costs. But two variables could influence these costs more dramatically than is indicated in Table 9. These development of the Zambian and Southern African labour market and production losses.
At the lower end of the skills spectrum in Zambia, labour is abundant. HIV/AIDS will not reduce this labour force to such an extent that labourers at this level become scarce. On the skilled and professional level, the market is much thinner and is influenced by various factors. It is only since 1991 that the Zambian Sugar Company has offered competitive salaries compared with other employers in Zambia. In the past the company had found it difficult to attract highly qualified people, in particular engineers, who preferred to work in the Copperbelt. The Estate's rural setting also appears to be a disincentive in terms of attracting qualified people and attractive housing facilities are also lacking at NSE. Moreover, because Zambia's neighbours, particularly South Africa offer better salaries, many highly qualified Zambians prefer to work abroad. AIDS will contribute to the tightness of the labour market, especially as the disease has claimed a number of people among the ranks of professionals.
It is also possible that professional salaries will increase. This also means that, for example, an extra 20 percent increase for the salaries of professionals could to be included in the cost estimates for 199596.
5.9 The impact of HIV/AIDS on the Kaleya Smallholder Company in Zambia
Kaleya Smallholders Company Limited is a smallholder settlement scheme established to develop 1 885 ha of sugar cane in the district of Mazabuka in Zambia. Two-thirds of the area is settled by 300 smallholders and one-third remains a nucleus estate. The target annual cane production is 200 000 tonnes - 15 % of the national output.
Currently 1 782 ha have been planted and 140 smallholders settled. The company supplies the smallholders with training and extension services, agricultural inputs and mechanical services, arranges cane harvesting and haulage and distributes irrigation water. The smallholders are responsible for 4 ha of sugar cane, with family members caring for the infield irrigation, weed control, fertilizer application and removal of diseased cane stalks. The cost of all direct service is charged to the smallholders. Kaleya pays the growers for standing cane, with the price related to Nakambala's production costs.
The cane is sold by Kaleya to the Zambia Sugar Company which processes the sugar cane. The terms of the sale are determined by a cane purchase agreement negotiated between Zambia Sugar Company and three outgrowers (Kaleya, and two private farms). Currently the Kaleya is controlled by the founder shareholders - the Commonwealth Development Corporation, Zambia Sugar Company, the Development Bank of Zambia and Barclays Bank of Zambia. Ultimately it is intended that all of the ordinary share capital of Kaleya will be purchased by the smallholders who will become the owners.
It appears that the smallholders are equally or worse affected by HIV/AIDS than the population of Mazabuka. The smallholders come from different parts of Zambia, many having previously lived on the Copperbelt, which is characterised by very high rates of seroprevalence. Being a smallholder in Kaleya is an attractive occupation which provides a relatively high income (in comparison to most of the rural population). Polygamy is widespread among the cane growers and marriages are reputedly very unstable. At the time of this study, 14 out of the 140 smallholders and their families were suspected of having died of AIDS.
Box 12: Case study 6
Eleanor is a 24-yeas old widow. She has three young children of her own and one son of her late husband. She and her husband came to Kaleya some years ago.
Her husband died in July 1993 aged 36, most probably from AIDS. While her husband was ill with AIDS Eleanor nursed him. As a result she did not have time to produce enough maize for her family's consumption. Added to this the yield of sugar cane was low last season, which Eleanor believes is due to the age of the cane and not because of a labour constraint. Next season her yield is likely to be even lower. Eleanor employed part-time workers to undertake irrigation works on her plot but because she does not know enough about irrigation in sugar cane, she could not control the work properly. Although she had asked the local extension service for advice, at the time of the interview nobody had been to visit her.
Eleanor believes, that she and her late husband's sixteen year-old son could manage the farm in the future. However, although she and the son are the official holders of the settlement, her in-laws have been pressing to gain control of the farm. Now she is afraid that she is bewitched.
The smallholders rely mostly on family members for their production activities, but they also hire labour. Labour, which is provided by family members, who fall sick and finally die of AIDS, cannot be as easily replaced as on an estate. As observed frequently in many of the small farming systems described earlier, care for patients at home, attendance at funerals and the loss of management skills, all contribute to the labour constraints of an AIDS-affected household. But all households are not equally vulnerable.
For example, one farmer who was interviewed, and is probably suffering from AIDS, has several grown-up children, who now do all the work in the fields. The death of the father would not necessarily have an effect on sugar cane production, because there is still enough labour force and the father's knowledge has already been passed on to his children. However, the death of the most experienced person in a household, especially in the production of sugar cane, can have serious consequences, especially where the remaining family members do not have the necessary farm management skills, as in the example below of case study 7.
Box 13: Case study 7
Justin is 22 years old and has three brothers aged 24, 20 and 16, and two younger sisters are at school in the Copperbelt. In 1986 his parents came from the Copperbelt as smallholders to Kaleya.
In 1989 Justin's father died of AIDS. Two brothers were forced to leave school to work on the family farm. With their help and the employment of part-time labourers sugar cane production could be maintained under the management of the mother. In 1990 Justin's mother also fell sick and returned to the Copperbelt with her youngest child. In 1991 both his mother and the child died and all the children left Kaleya for one month to attend the funeral in the copperbelt. During that time the neighbours assisted in caring for the farm, but they were unable to carry out the farm work as effectively as Justin's family. As a consequence, yields declined by 40 percent in 1991 and the household's income suffered accordingly.
Since then production has begun to increase once more but has not yet reached its previous level. It appears that once sugar cane yields drop significantly, it is very difficult to reach previous levels. In 1993 the household was are also able to produce enough bags of maize for themselves to eat.
The most vulnerable households are those with a high dependency ratio, since widows will frequently loose many of their possession when, by traditional custom, the husband's relatives arrive soon after the death to claim all the household possessions.
5.10 The impact of HIV/AIDS on the Tukuyu Tea Estates in Tanzania
The Tukuyu Tea Estates are located near the Ushirika minor settlement in Tanzania. Covering an area of 1 530 ha they consist of seven estates with two factories among them. The estates have a permanent staff of 1 200 and employ an additional 2 000 labourers during the peak tea picking season. Most of these casual labourers come from neighbouring villages.
Although there have only been two confirmed cases of AIDS to date, the general situation of the Tukuyu Estates renders them potentially vulnerable. HIV/AIDS can affect this estate as in the cases of those described above in Zambia since they depend on the availability of trained manpower. It takes a long time and significant resources to train an expert. Thus experienced workers are difficult to replace.
Since the Tukuyu Estates are located on the highway to Malawi and close to two settlements and the town of Tukuyu, there is a lot of contact with urban and more densely populated areas, one of which, Ushirika is considered to be a high-risk area. Whether by chance, or partially as a result of the preventive measures taken by Tukuyu Tea Estates to date, AIDS has had a minimal impact on the company.
The preventive measures that may be in part responsible include the supply of condoms to male workers (although such supplies are irregular) and the establishment of an AIDS education programme using television and videos. At the same time the company offers its employees free lunches, medical care and clinic facilities. Child nutritional status is reported to be good.
The estate sector
In order to consider the ways in which HIV/AIDS affects not only the small farm sector but also the commercial sector, studies were carried out on several estates in Zambia and in Tanzania. In particular, a detailed analysis was made of the Nakambala Sugar Estate (NSE) in Zambia. This forms the basis of the present chapter.
The aims of the study of NSE were to determine the present position on the estate vis a vis HIV and to make projections for the future; to assess the knowledge and attitude towards HIV/AIDS among NSE employees as well as the social implications of the disease; and to consider the present economic impact in terms of costs caused by HIV/AIDS in affected departments and make projections for the near future.
5.1 About the Nakambala Sugar Estate
The Zambia Sugar Company is the sole producer of sugar in the country. The head office is in Lusaka while all the sugar cane is grown at NSE. The Estate is situated near Mazabuka, in Southern
Province where good soil and climatic conditions exist for growing sugar-cane under irrigated conditions. Rains falling between mid November and March result in an effective cultivation season between April and October. The Estate has experienced several periods of expansion and now has a nominal capacity of 140 000 tonnes of sugar per year with some 10 000 hectares under cane cultivation. In addition, 1785 hectares of sugar cane is provided by the Kaleya Smallholders Scheme, where 140 smallholders manage 560 ha and the remainder is run as an estate. Two neighbouring farmers own 450 ha of sugar cane which they deliver to Nakambala for processing.
Employment structure on the Nakambala Estate
Some 22 000 people live at Nakambala Estate (Census 1993). It is estimated that a further 10 000 people, who live outside Nakambala, derive their livelihoods from the sugar estate.
The Nakambala Sugar Estate provides permanent employment to 3 250 people. Seasonal employees bring the total to 8 100 during certain periods of peak operation. Fourteen expatriates also work at NSE mainly in senior management positions.
The labour force is strongly male-dominated; women are overrepresented among the seasonal workers and underrepresented among the unionised employees. Altogether women make up about 12 percent of the workforce, and are mostly in low paid positions.
At present the company is not able to provide housing for all employees. but the aim is eventually to house all permanent employees. There are five townships on the estate and a senior staff housing area. Nakambala provides utilities and community services such as water, refuse collection, electricity and community halls. There are fifteen churches dotted around the estate. The estate employs two doctors and operates one main clinic and several subsidiary ones in the townships. The clinics are inevitably one of the most heavily used facilities provided on the Estate, frequently seeing 300 patients per day.
HIV/AIDS care and education at Nakambala Estate
Medical staff at the estate currently carry out HIV/AIDS education at the clinics and also conduct seminars on AIDS for a limited number of more senior employees. Condoms are distributed free of charge at the clinic on demand. Two officers with clinical experience in the running of the Chest and Skin/STD clinics had also lately recruited. Pre-employment testing is not practiced by Zambia Sugar Company. HIV/AIDS is treated as any other life threatening illness. Employees continue to work as long as they are able to do so. After retirement on medical grounds or death they or their families receive the same benefits as any other employee.
5.2 Socio-economic conditions
Women are in an especially vulnerable position to contract the AIDS virus. At Nakambala as in the rest of Zambia, women have an inferior economic and social status to men. The majority are economically dependent on men. Some women at NSE have the possibility to cultivate vegetable gardens and thus earn a small cash income, but others in other townships have limited possibilities to generate income. Economic dependence may also determine with whom a woman has sex. The women at NSE reported that the first reason to have sex with a "boyfriend" is money. Single women are especially at risk, but married women often have to use sexual relations to supplement their incomes because men at NSE do not always share their earnings with their families. This limits the ability which women have to control their sexuality and to protect themselves. In interviews women said that they cannot determine the terms under which they have sex, including whether a condom is used and whether their partner is sexually faithful. While infidelity is by no means exclusive to men, it is more acceptable for a man to have more than one regular partner. Therefore it happens that women who are infected are monogamous and have contracted HIV from their nonmonogamous partners
Migration is a factor which may often be associated with the spread of HIV. Although Nakambala Sugar Estate is a rural area, a lot of migration and movement takes place. People looking for work, such as cane cutters, are recruited seasonally from other parts of Zambia and many truck drivers pass Nakambala daily on their way along major communications routes. In any case, the tradition of labour migration which has become a pronounced feature of Zambian life in the last seventy years, with long separations and frequent breakdown in family patterns, contributed to a rise in prostitution and the incidence of STDs long before HIV appeared. Migrants who contract HIV may infect their spouses when returning home.
5.3 The incidence of HIV/AIDS on NSE
The Zambia Sugar Company has not yet developed a policy towards HIV/AIDS, but the management is very concerned about the development of the disease. However in view of the fact that the epidemic has spread rapidly in Zambia in the last decade, what was originally a more urban disease has now reached rural areas.
According to the medical records for 1991 and 1992, 75 percent of deaths in 1991 were attributed to HIV/AIDS as well as 70 percent of the medical retirements. In the medical report 1992/93 the causes of death are classified as tuberculosis/AIDS, gastroenteritis, pneumonia, malaria, malnutrition and others. In this classification only 45 % of deaths are attributed officially to TB/AIDS, but in reality it is suspected that many AIDS cases are hidden in other categories, such as "gastroenteritis" and "others". Therefore it is assumed that also in 1992193 probably as many as seventy-five percent of deaths were HIV/AIDS related.
As elsewhere, so also the Estate Sector, and as noted in Chapter 3, HIV/AIDS incidence has been age selective. Sixty-two percent of the deaths among company employees were in the age group 21 40 years in 1992-93. No employees died above the age of 50. This lends weight to the hypothesis that AIDS takes its toll from the younger age groups. The overall mortality rate among all company employees was 9 per I 000.
It was also observed that there was a marked decrease in AIDS-xrelated deaths between 1991 and 1992-93. While this may simply be attributable to the fact that the small numbers in total could be within the range of reporting and sample variation, another explanation is also possible. In Zambia the epidemic was initially more prevalent among the educated, well-off and mobile in urban areas. Most of these people are now relatively knowledgeable about the disease, thus they may well have adapted their behaviour accordingly. The basic knowledge about HIV/AIDS has only recently and or partially trickled down to the less educated or illiterate in remote areas. Most of those who die today were infected before 1987. It is possible that this particular group has already reached a peak of AIDS cases. In future, the death rate among staff may stagnate or decrease while the rate may increase among unionised and seasonal employees. But this is only a hypothesis which has not yet been confirmed by any research in Zambia. What is known is, that the gap between company professionals and the poor with regard to seroprevalence is narrowing fast.
In 1992-93 the mortality rate among staff and unionised company employees was 14.9 per 1 000 much higher than the rate among seasonal workers which stood at 3.9 per 1 000. The usual yearly rate of adult mortality in sub-Saharan Africa is about 5 per 1000. This does not necessarily mean that seasonal workers are less affected by HIV. One of the reasons for the difference between the groups could be that the seasonal workers are characterized by a high turnover rate and that they are hired every year anew. It is less likely that a very sick person will apply given that most of the seasonal jobs are physically very demanding. The company does not monitor the deaths of seasonal workers who have stopped working for the company, therefore many cases of AIDS in this occupational group will go undetected.
From January 1993 until September 1993, 16 employees were given early retirement on medical grounds due to HIV-related symptoms. Projections for the future indicate that the number of AIDS deaths and medical releases due to HIV/AIDS could increase by 70 percent from 1992-93 to 1995-96'. Even after 1996, the number of people with AIDS will certainly increase, but the longer these data are projected into the future, the more imprecise any forecasts become. The annual adult mortality rate due to the epidemic could rise to 28.2 per 1 000 for permanent staff members.
5.4 HIV/AIDS-related morbidity and absenteeism at NSE
Morbidity due to AIDS has a strong impact on a company like the Zambia Sugar Company. Once an individual develops AIDS, the average survival time appears to be between six months and two years. In cases of prolonged illness, the salaries of the permanent employees are paid for the obligatory three months, after which a further three months are paid at a reduced level. As shown in Table 5, the person-hours lost due to tuberculosis/AIDS account for 50 percent of cases. If gastroenteritis is added to this total, because it is often associated with HIV, the figure rises to 60 percent. Experience at NSE indicates that AIDS patients are variously in and out of their work places for one year. When they return to work they often cannot perform their duties as well as before. On average a person with tuberculosis is absent from work for 60 days a year.
Table 5: Person-hours lost due to major illnesses in 1990, 1991 and 1992 at NSE
Disease Year
1990 1991 1992
Malaria 36,024 25,268 20,060
Accidents & Injuries 28,232 17,224 12,346
Gastroenteritis 12,576 10,792 12,176
TB/AIDS 102,591 71,507 61,713
TOTAL 179,423 124,691 107,295
Total all diseases 266,752 162,584 122,567
Source: Medical Department, Zambia Sugar Company
Since 1990 there has been a continuing decline in the incidence of major illnesses affecting the employees on the estate. There could be different reasons for this decline. One, the health status of the employees may have improved due to better medical care and an improved sanitary infrastructure. Two, it is also possible that the criteria used for including employees on the sick-list have become stricter. Any absence from work is recorded officially under the following categories: paid leave, unpaid leave, sickness and absenteeism. Healthy employees are absent from their workplace for various reasons, which could be HIV-related such as caring for sick relatives. Furthermore, employees can leave the workplace for some hours at the discretion of their supervisor for special occasions such as funerals, medical reasons and other urgent matters. Thus, different types of absence can be influenced by HIV/AIDS but the quantity is difficult to estimate.
The overall rate of work due to illness was about two percent. This is a very low figure and even lower than in industrialized countries. By contrast, among nurses in a University Teaching Hospital in Lusaka, the rate of sickness is usually assumed at 8 percent, while the absenteeism rate is 16 percent. In England, the sickness-absence rate was 4.7 percent in 1989-90 (Foster, 1993). As stated above, 50 to 60 percent of recorded sickness cases can be attributed to HIV/AIDS.
In studying the records for NSE, it appears that as recorded by the company, funerals have become a major reason for employee absences from work. There is a strong social obligation to attend the funerals of near and distant relatives, friends and neighbours. Compassionate leave has been abolished for unionised employees in order to harmonize the working conditions with staff and unionised labourers. Thus employees must use their annual leave if they have to attend a funeral, which takes place some distance away. There its anecdotal evidence that some employees spend all their annual leave attending funerals and even have to take additional unpaid leave to meet their social obligations in this respect. In the case of the death of a company employee, at least 80 colleagues attend the burial and some are occupied with the preparations for several days.
The increasing incidence of Tuberculosis
Tuberculosis is increasing at NSE and Pulmonary Tuberculosis is part of the clinical case definition of AIDS. Tuberculosis is especially serious for the company because patients are absent from work for a minimum of 60 days. In 1991, for example, 73 cases of tuberculosis were registered as compared with 106 cases in 1992 and 141 in 1993. It should be noted, however, that this rise can also be partly attributed to better diagnostic facilities. By far the largest number of cases were reported in the age group 25-34, some 52 percent of cases, and compared to 27.8 percent and 11.3 percent for the age groups 35-44 and 45-54, respectively. The clinical staff do not know who among these patients is HIV-positive, because they do not have any HIV testing facilities. Patients presenting HIV-associated chest problems end up receiving treatment for suspected tuberculosis when they fail to respond to the usual antibiotics. This means that half of the patients are not treated appropriately due to the lack of testing facilities. However, currently available national data suggest that between 70 and 80 percent of tuberculosis patients are HIV positive. Although drugs against tuberculosis are distributed without cost at the NSE clinic, treatment for one patient costs US$ 175. Therefore the medical staff strongly expressed the need for HIV test kits.
Malnutrition
Malnutrition continued to be a problem; from July 1992 to March 1993, 19 children died of malnutrition at NSE. After pneumonia, it was the second highest cause of death among children. Malnutrition is considered more of a social than a medical problem. Social workers support women with malnourished children with High-Energy-Protein (HEPS) food. Presently they care for 68 severe and 194 non- severe malnourished children.
The social workers observe that a lot of malnourished children do not respond to HEPS, even after 4 weeks. Considering the high incidence of HIV at NSE it can be assumed that a number of these children are children of HIV positive mothers and themselves positive. Despite the efforts to combat malnutrition, these cases are likely to increase in the near future due to the epidemic.
5.5 The spread of HIV/AIDS infection at NSE
Polygamy is quite widespread in Zambia and is practiced by people living and working on Nakambala Estate. In addition, in a number of interviews, respondents reported high frequencies of change of sexual partners and multiple sexual partners. According to the Medical Department, the level of sexually transmitted diseases (STD) is high among the population of NSE. STDs are associated with the same behaviour that exposes individuals to potential HIV infection and greatly facilitates both the acquisition and transmission of the AIDS virus.
Some culturally enjoined sexual practices, in particular the tradition of "sexual cleansing" associated with the levirate may further contribute to the spread of HIV at NSE. But these traditions are starting to change. Group discussions with women in the townships showed that a lot of women would not agree any more to be sexually cleansed after the death of their husbands because of the existence of AIDS. Accordingly, other methods of cleansing, which do not involve sexual intercourse, are becoming more common.
5.6 Knowledge of HIV/AIDS at NSE
The level of knowledge among the population at NSE varies considerably. Everybody, who was interviewed at Nakambala had heard about HIV/AIDS, although people are differently informed. Generally men know more than women, because they have better access to information. One woman from a township asked: "Everybody speaks about AIDS, but what is it?". Women have heard about condoms, but some have never seen one. A survey which was conducted by the Medical Department at NSE on the subject of health issues showed the incomplete knowledge which respondents have about HIV/AIDS. Two hundred and sixty employees of different departments filled out questionnaires. Nearly all knew about HIV and that it is sexually transmitted. But 42 percent did not know that HIV also can be contracted through blood transfusion. The higher the level of education the greater was the understanding of the disease and the way it is transmitted.
Another finding of the survey was that willingness to use condoms is low. It should be a matter of concern that only 32 percent of the employees stated that they have ever used condoms, especially given that a lot of men are reputed to have extramarital affairs.
Witchcraft is still very strong in Zambia and is often given as the cause for sickness and death instead of AIDS. People indicated in interviews that they have a contradictory attitude towards witchcraft and AIDS. Some reported that they can identify a person with AIDS, but if a member of their own family or they themselves are concerned, they say it is witchcraft. AIDS cases which are attributed to witchcraft have already caused problems at NSE. The AIDS afflicted, or the relatives of people who have died of AIDS have reputedly accused colleagues of bewitching them for various reasons. This is a harmful phenomenon in any work environment, but it is even more so in one where places of work and residence are the same.
5.7 The social impact of HIV/AIDS at NSE
Although the company has to deal with the serious impact of the epidemic, HIV/AIDS-affected households carry the major burden.
These households have to care for the sick and face increasing medical expenses. They lose the income and entitlement to housing after six months after the employee's death. Seasonal labourers are in an even more vulnerable position than permanent employees, because they do not receive the full range of benefits. Although the estate is not concerned, because HIV-affected families leave the estate, the number of orphans in the villages around Nakambala is growing, with all the additional pressures that this places on relatives and the community at large.
5.8 The economic impact of HIV/AIDS.
5.8.1 Production loss
5.8.2 Costs caused by HIV/AIDS
5.8.3 Summary of the costs
5.8.4 Projections of the economic impact for the near future
The economic impact of HIV/AIDS is basically felt as a result of two factors; in the loss of production and by increasing costs.
5.8.1 Production loss
The production of sugar cane and sugar has increased continuously since the creation of NSE. In 1992/93, the sale of sugar reached its peak since the founding of NSE. It can be concluded that AIDS has not so far had a serious impact on production. The question arises however, how high can the number of AIDS cases rise without affecting production? What is the threshold?
In order to answer these questions, it is necessary to identify the most important and therefore vulnerable phase of the labour process of cane cultivating, harvesting, processing and selling, plus the support services to ensure smooth integration of these processes. According to senior management, the post of a farm officer is quite crucial for the development of the cane. Each farm officer is in charge of 200 ha of cane. Production levels depend very much on timely farming operations. Although some of the farm officers had developed AIDS in recent years, their absence was compensated for, and thus no serious impact on the cane yield occurred.
Table 6: Cost statement for the Nakambala Estate 1992-93
Description Labour Materials Total
(US $) % total (US $) % total
Agricultural costs 3143465 33.5 6229841 66.5 9373306
Cane purchase 0 0 6350007 100.0 6350007
Factory cost 932378 20.4 3636946 79.6 4569324
Business Dept. 151985 38.7 238262 61.3 390346
Purchase &Supplies 137556 50.4 134554 49.6 272110
Personnel Dept. 2111724 77.6 608481 22.4 2720206
Medical & Public Health 138091 49.5 140970 50.5 279061
Estate Services 321334 46.6 365642 53.4 686876
Total Dept. Costs 6936532 28.1 17704603 71.9 24641136
Depreciation 0 0 1252787 100.0 1252787
Insurance 0 0 364981 100.0 364981
Forward Crop
Adjustment 0 0 (3736835) 100.0 (3736835)
Total Op. Costs 6936532 30.8 15585537 69.2 22522069
Refinery Cost 40370 40.8 57649 59.2 98018
Packing Cost 469107 20.3 1.840682 79.7 2309789
Total Nakambala
Cost 7446008 29.8 17483867 70.2 24929875
Source: Business Department, Zambia Sugar Company
Overtime working is common at NSE to compensate for absences from the workplace. In some sections of the factory, overtime is not exceptional. Indeed employee complaints suggested that it appears to be all too common. According to interviews with management, the quality of work suffers under these circumstances. Unfortunately, it is not possible to quantify this possibly important factor.
5.8.2 Costs caused by HIV/AIDS
Material costs make up the major part of the costs while those caused by HIV/AIDS are mostly labour-related.
- Absenteeism and sickness
About 50 percent of the absenteeism at the company is due to sickness of which 2 percent can be attributed to HIV/AIDS. It is also assumed that one percent of the labour force is lost by leaving the workplace for some hours a day to attend burials, to go to the clinic and to attend to various other exigencies of daily life.
- Additional employment of expatriates
Zambia Sugar Company trains and promotes highly qualified Zambians to gradually replace expatriates. However, this process is now in danger due to the epidemic. In 1992-93, for example, one senior Zambian manager was supposed to substitute an expatriate. This person died of AIDS and the contract of the expatriate engineer had to be extended because there was no other Zambian who could have filled this position quickly. This is costing the company about US$ 60,000 per year.
- Medical care
It is difficult to assess how much of the medical budget goes towards caring for HIV/AlDS patients. According to the causes of sickness, 50 percent were HIV and AIDS related. Therefore it is assumed that 50 percent of the drugs are used for AIDS patients. Staff costs consume the major part of the medical budget. It is worth noting that the drugs for the treatment of tuberculosis, which are very costly, are presently free of charge. Otherwise, the cost of drugs for a single tuberculosis patient (September 1993) would have been US$ 175. In 1993, 141 tuberculosis patients were treated; it can be assumed that 80 percent of these were HIV positive. This means that a further US$19 740 in drug costs may be assumed, but the company does not have to pay for this. The company provides staff and, if necessary, the transport of the patients to the clinic.
The drug costs (without TB) for a single AIDS patient at NSE's clinic ranged between US$ 44 and US$ 83, which is comparatively low. Most of the opportunistic infections associated with HIV can be treated with cheap drugs during the early stages of the disease. Furthermore, it is estimated that 30 percent of the remaining medical budget is attributed to HIV/AIDS. Out of that, staff costs account for the major part. It is debateable whether without the epidemic the budget for the medical department would be lower. Instead it is likely that the medical service would have been improved. On the other hand, as noted above two clinical officers have recently been recruited both in relation to HIV/AIDS. Without the epidemic the recruitment of these officers would not have been so urgent.
- Funerals
When a death occurs on the estate, the company's employees and their dependents are entitled to a coffin, firewood, foodstuffs and transport to the burial site. In 1992/93, there were 232 deaths among company employees and their dependents. The number of deaths has risen to such an extent, that the vehicle, which was assigned to transport the coffin, is no longer sufficient and the department has recently applied recently for a second vehicle.
As noted above, 75 percent of deaths at NSE can be attributed to HIV/AIDS. It is not known how many dependent adults and children have died of AIDS. But, according to medical statistics AIDS cases among dependents were lower. It can be estimated that at least 60 percent of the budget for funerals may be counted as costs generated as a result of AIDS.
- Medical retirement
In cases of medical retirement, an employee is entitled to a grant which is dependent on his or her salary and according to the amount of time the person has worked in the company. In cases of death the family are the beneficiaries. In 1992-93, it appears that four staff members died due to HIV/AIDS and two retired under the early retirement package. Among unionised employees, 36 died and 22 retired on medical grounds due to HIV/AIDS. It can be argued that these are not additional costs because employees go on retirement anyway and this entitlement depends on the time served. But in 199293, these costs have been generated by HIV/AIDS, which would not have otherwise occurred and furthermore their effective working life and the availability of their experience to their employer was truncated by the disease.
- Repatriation
In cases of medical retirement, the staff members and unionised workers are entitled to be repatriated. In case of death, the family of the deceased is taken back to their home areas. Transport costs take by far the major part of the repatriation allocation. There is a common budget for repatriation and recruitment. In general, recruitment is cheaper than repatriation. It is estimated that about 30 percent of the budget for staff and unionised employees can be costs attributed to repatriation due to AIDS-related death or retirement.
- Training
Nakambala is the only sugar estate in Zambia and ZSC has to invest substantially in training given the specialized nature of the work. This applies especially to cane growing activities, but also to areas in the factory. Once a highly skilled person is lost, he or she cannot be simply replaced from the Zambian labour market, because an already trained successor cannot be found. Added to this, ZSC competes on the Zambian, and increasingly on the Southern African, labour market with the mining industry for a limited number of engineers. The training process can take as much as two years during which the trainees are often sent abroad on special, and costly courses.
5.8.3 Summary of the costs
Table 7 shows that the largest portion of costs are associated with sickness. Nearly 50 percent of these expenses arise from the benefits which the company offers its employees. Companies in Uganda noted that morbidity has a higher impact than mortality (Pangs, 1992). At Nakambala, the costs of sickness (lost working days plus medical expenses) are about as high as the costs in the case of death.
In 1992-93, costs attributable to HIV/AIDS represented 1.9 percent of the total costs of Nakambala Estate. This appears to be quite low. Sales for 1992-93 for ZSC as a whole were about US$ 50.0 million. Even if US$ 2.2 million in head office costs are added to the Nakambala costs, the profit margin remains wide enough to cover the additional expenses arising from HIV/AIDS. The costs caused by HIV/AIDS make up about 2 percent of the profit.
Table 7: Costs generated by HIV/AIDS at Nakambala in 1992/93
Description Costs (US$) Costs (%)
Lost workforce 148, 920 31.8
Extension of expatriate
contracts 60,000 12.7
Medical Department 70,124 14.7
Funerals 24,314 5.1
Pension for deaths +medical retirements 75,184 15.9
Repatriation 59,448 12.5
Training 35,208 7.3
Total 473,198 100.0
Source: Haslwimmer, 1994
The following table provides an estimate of how the costs could be allocated between labour and materials.
Out of the total labour costs, 4.7 percent are due to HIV/AIDS, while only 0.7 percent of the total material costs can be attributed to the disease. This lends weight to the hypothesis that AIDS is predominantly a burden for the labour budget.
Table 8: Costs resulting from HIV/AIDS divided between labour and materials
Description Labour Materials
(%) (US $) (%) (US $)
Lost workforce 100 148920 0 0
Extension of
expatriates 100 60000 0 0
Medical
Department 50 35062 50 35062
Funerals 10 2431 90 21883
Pension for death+ medical
retirement 100 75184 0 0
Repatriation 20 11890 80 47558
Training 40 14083 60 21124
Total 73.5 347570 26.5 125627
Source. Haslwimmer, 1994
The aims of the study of NSE were to determine the present position on the estate vis a vis HIV and to make projections for the future; to assess the knowledge and attitude towards HIV/AIDS among NSE employees as well as the social implications of the disease; and to consider the present economic impact in terms of costs caused by HIV/AIDS in affected departments and make projections for the near future.
5.1 About the Nakambala Sugar Estate
The Zambia Sugar Company is the sole producer of sugar in the country. The head office is in Lusaka while all the sugar cane is grown at NSE. The Estate is situated near Mazabuka, in Southern
Province where good soil and climatic conditions exist for growing sugar-cane under irrigated conditions. Rains falling between mid November and March result in an effective cultivation season between April and October. The Estate has experienced several periods of expansion and now has a nominal capacity of 140 000 tonnes of sugar per year with some 10 000 hectares under cane cultivation. In addition, 1785 hectares of sugar cane is provided by the Kaleya Smallholders Scheme, where 140 smallholders manage 560 ha and the remainder is run as an estate. Two neighbouring farmers own 450 ha of sugar cane which they deliver to Nakambala for processing.
Employment structure on the Nakambala Estate
Some 22 000 people live at Nakambala Estate (Census 1993). It is estimated that a further 10 000 people, who live outside Nakambala, derive their livelihoods from the sugar estate.
The Nakambala Sugar Estate provides permanent employment to 3 250 people. Seasonal employees bring the total to 8 100 during certain periods of peak operation. Fourteen expatriates also work at NSE mainly in senior management positions.
The labour force is strongly male-dominated; women are overrepresented among the seasonal workers and underrepresented among the unionised employees. Altogether women make up about 12 percent of the workforce, and are mostly in low paid positions.
At present the company is not able to provide housing for all employees. but the aim is eventually to house all permanent employees. There are five townships on the estate and a senior staff housing area. Nakambala provides utilities and community services such as water, refuse collection, electricity and community halls. There are fifteen churches dotted around the estate. The estate employs two doctors and operates one main clinic and several subsidiary ones in the townships. The clinics are inevitably one of the most heavily used facilities provided on the Estate, frequently seeing 300 patients per day.
HIV/AIDS care and education at Nakambala Estate
Medical staff at the estate currently carry out HIV/AIDS education at the clinics and also conduct seminars on AIDS for a limited number of more senior employees. Condoms are distributed free of charge at the clinic on demand. Two officers with clinical experience in the running of the Chest and Skin/STD clinics had also lately recruited. Pre-employment testing is not practiced by Zambia Sugar Company. HIV/AIDS is treated as any other life threatening illness. Employees continue to work as long as they are able to do so. After retirement on medical grounds or death they or their families receive the same benefits as any other employee.
5.2 Socio-economic conditions
Women are in an especially vulnerable position to contract the AIDS virus. At Nakambala as in the rest of Zambia, women have an inferior economic and social status to men. The majority are economically dependent on men. Some women at NSE have the possibility to cultivate vegetable gardens and thus earn a small cash income, but others in other townships have limited possibilities to generate income. Economic dependence may also determine with whom a woman has sex. The women at NSE reported that the first reason to have sex with a "boyfriend" is money. Single women are especially at risk, but married women often have to use sexual relations to supplement their incomes because men at NSE do not always share their earnings with their families. This limits the ability which women have to control their sexuality and to protect themselves. In interviews women said that they cannot determine the terms under which they have sex, including whether a condom is used and whether their partner is sexually faithful. While infidelity is by no means exclusive to men, it is more acceptable for a man to have more than one regular partner. Therefore it happens that women who are infected are monogamous and have contracted HIV from their nonmonogamous partners
Migration is a factor which may often be associated with the spread of HIV. Although Nakambala Sugar Estate is a rural area, a lot of migration and movement takes place. People looking for work, such as cane cutters, are recruited seasonally from other parts of Zambia and many truck drivers pass Nakambala daily on their way along major communications routes. In any case, the tradition of labour migration which has become a pronounced feature of Zambian life in the last seventy years, with long separations and frequent breakdown in family patterns, contributed to a rise in prostitution and the incidence of STDs long before HIV appeared. Migrants who contract HIV may infect their spouses when returning home.
5.3 The incidence of HIV/AIDS on NSE
The Zambia Sugar Company has not yet developed a policy towards HIV/AIDS, but the management is very concerned about the development of the disease. However in view of the fact that the epidemic has spread rapidly in Zambia in the last decade, what was originally a more urban disease has now reached rural areas.
According to the medical records for 1991 and 1992, 75 percent of deaths in 1991 were attributed to HIV/AIDS as well as 70 percent of the medical retirements. In the medical report 1992/93 the causes of death are classified as tuberculosis/AIDS, gastroenteritis, pneumonia, malaria, malnutrition and others. In this classification only 45 % of deaths are attributed officially to TB/AIDS, but in reality it is suspected that many AIDS cases are hidden in other categories, such as "gastroenteritis" and "others". Therefore it is assumed that also in 1992193 probably as many as seventy-five percent of deaths were HIV/AIDS related.
As elsewhere, so also the Estate Sector, and as noted in Chapter 3, HIV/AIDS incidence has been age selective. Sixty-two percent of the deaths among company employees were in the age group 21 40 years in 1992-93. No employees died above the age of 50. This lends weight to the hypothesis that AIDS takes its toll from the younger age groups. The overall mortality rate among all company employees was 9 per I 000.
It was also observed that there was a marked decrease in AIDS-xrelated deaths between 1991 and 1992-93. While this may simply be attributable to the fact that the small numbers in total could be within the range of reporting and sample variation, another explanation is also possible. In Zambia the epidemic was initially more prevalent among the educated, well-off and mobile in urban areas. Most of these people are now relatively knowledgeable about the disease, thus they may well have adapted their behaviour accordingly. The basic knowledge about HIV/AIDS has only recently and or partially trickled down to the less educated or illiterate in remote areas. Most of those who die today were infected before 1987. It is possible that this particular group has already reached a peak of AIDS cases. In future, the death rate among staff may stagnate or decrease while the rate may increase among unionised and seasonal employees. But this is only a hypothesis which has not yet been confirmed by any research in Zambia. What is known is, that the gap between company professionals and the poor with regard to seroprevalence is narrowing fast.
In 1992-93 the mortality rate among staff and unionised company employees was 14.9 per 1 000 much higher than the rate among seasonal workers which stood at 3.9 per 1 000. The usual yearly rate of adult mortality in sub-Saharan Africa is about 5 per 1000. This does not necessarily mean that seasonal workers are less affected by HIV. One of the reasons for the difference between the groups could be that the seasonal workers are characterized by a high turnover rate and that they are hired every year anew. It is less likely that a very sick person will apply given that most of the seasonal jobs are physically very demanding. The company does not monitor the deaths of seasonal workers who have stopped working for the company, therefore many cases of AIDS in this occupational group will go undetected.
From January 1993 until September 1993, 16 employees were given early retirement on medical grounds due to HIV-related symptoms. Projections for the future indicate that the number of AIDS deaths and medical releases due to HIV/AIDS could increase by 70 percent from 1992-93 to 1995-96'. Even after 1996, the number of people with AIDS will certainly increase, but the longer these data are projected into the future, the more imprecise any forecasts become. The annual adult mortality rate due to the epidemic could rise to 28.2 per 1 000 for permanent staff members.
5.4 HIV/AIDS-related morbidity and absenteeism at NSE
Morbidity due to AIDS has a strong impact on a company like the Zambia Sugar Company. Once an individual develops AIDS, the average survival time appears to be between six months and two years. In cases of prolonged illness, the salaries of the permanent employees are paid for the obligatory three months, after which a further three months are paid at a reduced level. As shown in Table 5, the person-hours lost due to tuberculosis/AIDS account for 50 percent of cases. If gastroenteritis is added to this total, because it is often associated with HIV, the figure rises to 60 percent. Experience at NSE indicates that AIDS patients are variously in and out of their work places for one year. When they return to work they often cannot perform their duties as well as before. On average a person with tuberculosis is absent from work for 60 days a year.
Table 5: Person-hours lost due to major illnesses in 1990, 1991 and 1992 at NSE
Disease Year
1990 1991 1992
Malaria 36,024 25,268 20,060
Accidents & Injuries 28,232 17,224 12,346
Gastroenteritis 12,576 10,792 12,176
TB/AIDS 102,591 71,507 61,713
TOTAL 179,423 124,691 107,295
Total all diseases 266,752 162,584 122,567
Source: Medical Department, Zambia Sugar Company
Since 1990 there has been a continuing decline in the incidence of major illnesses affecting the employees on the estate. There could be different reasons for this decline. One, the health status of the employees may have improved due to better medical care and an improved sanitary infrastructure. Two, it is also possible that the criteria used for including employees on the sick-list have become stricter. Any absence from work is recorded officially under the following categories: paid leave, unpaid leave, sickness and absenteeism. Healthy employees are absent from their workplace for various reasons, which could be HIV-related such as caring for sick relatives. Furthermore, employees can leave the workplace for some hours at the discretion of their supervisor for special occasions such as funerals, medical reasons and other urgent matters. Thus, different types of absence can be influenced by HIV/AIDS but the quantity is difficult to estimate.
The overall rate of work due to illness was about two percent. This is a very low figure and even lower than in industrialized countries. By contrast, among nurses in a University Teaching Hospital in Lusaka, the rate of sickness is usually assumed at 8 percent, while the absenteeism rate is 16 percent. In England, the sickness-absence rate was 4.7 percent in 1989-90 (Foster, 1993). As stated above, 50 to 60 percent of recorded sickness cases can be attributed to HIV/AIDS.
In studying the records for NSE, it appears that as recorded by the company, funerals have become a major reason for employee absences from work. There is a strong social obligation to attend the funerals of near and distant relatives, friends and neighbours. Compassionate leave has been abolished for unionised employees in order to harmonize the working conditions with staff and unionised labourers. Thus employees must use their annual leave if they have to attend a funeral, which takes place some distance away. There its anecdotal evidence that some employees spend all their annual leave attending funerals and even have to take additional unpaid leave to meet their social obligations in this respect. In the case of the death of a company employee, at least 80 colleagues attend the burial and some are occupied with the preparations for several days.
The increasing incidence of Tuberculosis
Tuberculosis is increasing at NSE and Pulmonary Tuberculosis is part of the clinical case definition of AIDS. Tuberculosis is especially serious for the company because patients are absent from work for a minimum of 60 days. In 1991, for example, 73 cases of tuberculosis were registered as compared with 106 cases in 1992 and 141 in 1993. It should be noted, however, that this rise can also be partly attributed to better diagnostic facilities. By far the largest number of cases were reported in the age group 25-34, some 52 percent of cases, and compared to 27.8 percent and 11.3 percent for the age groups 35-44 and 45-54, respectively. The clinical staff do not know who among these patients is HIV-positive, because they do not have any HIV testing facilities. Patients presenting HIV-associated chest problems end up receiving treatment for suspected tuberculosis when they fail to respond to the usual antibiotics. This means that half of the patients are not treated appropriately due to the lack of testing facilities. However, currently available national data suggest that between 70 and 80 percent of tuberculosis patients are HIV positive. Although drugs against tuberculosis are distributed without cost at the NSE clinic, treatment for one patient costs US$ 175. Therefore the medical staff strongly expressed the need for HIV test kits.
Malnutrition
Malnutrition continued to be a problem; from July 1992 to March 1993, 19 children died of malnutrition at NSE. After pneumonia, it was the second highest cause of death among children. Malnutrition is considered more of a social than a medical problem. Social workers support women with malnourished children with High-Energy-Protein (HEPS) food. Presently they care for 68 severe and 194 non- severe malnourished children.
The social workers observe that a lot of malnourished children do not respond to HEPS, even after 4 weeks. Considering the high incidence of HIV at NSE it can be assumed that a number of these children are children of HIV positive mothers and themselves positive. Despite the efforts to combat malnutrition, these cases are likely to increase in the near future due to the epidemic.
5.5 The spread of HIV/AIDS infection at NSE
Polygamy is quite widespread in Zambia and is practiced by people living and working on Nakambala Estate. In addition, in a number of interviews, respondents reported high frequencies of change of sexual partners and multiple sexual partners. According to the Medical Department, the level of sexually transmitted diseases (STD) is high among the population of NSE. STDs are associated with the same behaviour that exposes individuals to potential HIV infection and greatly facilitates both the acquisition and transmission of the AIDS virus.
Some culturally enjoined sexual practices, in particular the tradition of "sexual cleansing" associated with the levirate may further contribute to the spread of HIV at NSE. But these traditions are starting to change. Group discussions with women in the townships showed that a lot of women would not agree any more to be sexually cleansed after the death of their husbands because of the existence of AIDS. Accordingly, other methods of cleansing, which do not involve sexual intercourse, are becoming more common.
5.6 Knowledge of HIV/AIDS at NSE
The level of knowledge among the population at NSE varies considerably. Everybody, who was interviewed at Nakambala had heard about HIV/AIDS, although people are differently informed. Generally men know more than women, because they have better access to information. One woman from a township asked: "Everybody speaks about AIDS, but what is it?". Women have heard about condoms, but some have never seen one. A survey which was conducted by the Medical Department at NSE on the subject of health issues showed the incomplete knowledge which respondents have about HIV/AIDS. Two hundred and sixty employees of different departments filled out questionnaires. Nearly all knew about HIV and that it is sexually transmitted. But 42 percent did not know that HIV also can be contracted through blood transfusion. The higher the level of education the greater was the understanding of the disease and the way it is transmitted.
Another finding of the survey was that willingness to use condoms is low. It should be a matter of concern that only 32 percent of the employees stated that they have ever used condoms, especially given that a lot of men are reputed to have extramarital affairs.
Witchcraft is still very strong in Zambia and is often given as the cause for sickness and death instead of AIDS. People indicated in interviews that they have a contradictory attitude towards witchcraft and AIDS. Some reported that they can identify a person with AIDS, but if a member of their own family or they themselves are concerned, they say it is witchcraft. AIDS cases which are attributed to witchcraft have already caused problems at NSE. The AIDS afflicted, or the relatives of people who have died of AIDS have reputedly accused colleagues of bewitching them for various reasons. This is a harmful phenomenon in any work environment, but it is even more so in one where places of work and residence are the same.
5.7 The social impact of HIV/AIDS at NSE
Although the company has to deal with the serious impact of the epidemic, HIV/AIDS-affected households carry the major burden.
These households have to care for the sick and face increasing medical expenses. They lose the income and entitlement to housing after six months after the employee's death. Seasonal labourers are in an even more vulnerable position than permanent employees, because they do not receive the full range of benefits. Although the estate is not concerned, because HIV-affected families leave the estate, the number of orphans in the villages around Nakambala is growing, with all the additional pressures that this places on relatives and the community at large.
5.8 The economic impact of HIV/AIDS.
5.8.1 Production loss
5.8.2 Costs caused by HIV/AIDS
5.8.3 Summary of the costs
5.8.4 Projections of the economic impact for the near future
The economic impact of HIV/AIDS is basically felt as a result of two factors; in the loss of production and by increasing costs.
5.8.1 Production loss
The production of sugar cane and sugar has increased continuously since the creation of NSE. In 1992/93, the sale of sugar reached its peak since the founding of NSE. It can be concluded that AIDS has not so far had a serious impact on production. The question arises however, how high can the number of AIDS cases rise without affecting production? What is the threshold?
In order to answer these questions, it is necessary to identify the most important and therefore vulnerable phase of the labour process of cane cultivating, harvesting, processing and selling, plus the support services to ensure smooth integration of these processes. According to senior management, the post of a farm officer is quite crucial for the development of the cane. Each farm officer is in charge of 200 ha of cane. Production levels depend very much on timely farming operations. Although some of the farm officers had developed AIDS in recent years, their absence was compensated for, and thus no serious impact on the cane yield occurred.
Table 6: Cost statement for the Nakambala Estate 1992-93
Description Labour Materials Total
(US $) % total (US $) % total
Agricultural costs 3143465 33.5 6229841 66.5 9373306
Cane purchase 0 0 6350007 100.0 6350007
Factory cost 932378 20.4 3636946 79.6 4569324
Business Dept. 151985 38.7 238262 61.3 390346
Purchase &Supplies 137556 50.4 134554 49.6 272110
Personnel Dept. 2111724 77.6 608481 22.4 2720206
Medical & Public Health 138091 49.5 140970 50.5 279061
Estate Services 321334 46.6 365642 53.4 686876
Total Dept. Costs 6936532 28.1 17704603 71.9 24641136
Depreciation 0 0 1252787 100.0 1252787
Insurance 0 0 364981 100.0 364981
Forward Crop
Adjustment 0 0 (3736835) 100.0 (3736835)
Total Op. Costs 6936532 30.8 15585537 69.2 22522069
Refinery Cost 40370 40.8 57649 59.2 98018
Packing Cost 469107 20.3 1.840682 79.7 2309789
Total Nakambala
Cost 7446008 29.8 17483867 70.2 24929875
Source: Business Department, Zambia Sugar Company
Overtime working is common at NSE to compensate for absences from the workplace. In some sections of the factory, overtime is not exceptional. Indeed employee complaints suggested that it appears to be all too common. According to interviews with management, the quality of work suffers under these circumstances. Unfortunately, it is not possible to quantify this possibly important factor.
5.8.2 Costs caused by HIV/AIDS
Material costs make up the major part of the costs while those caused by HIV/AIDS are mostly labour-related.
- Absenteeism and sickness
About 50 percent of the absenteeism at the company is due to sickness of which 2 percent can be attributed to HIV/AIDS. It is also assumed that one percent of the labour force is lost by leaving the workplace for some hours a day to attend burials, to go to the clinic and to attend to various other exigencies of daily life.
- Additional employment of expatriates
Zambia Sugar Company trains and promotes highly qualified Zambians to gradually replace expatriates. However, this process is now in danger due to the epidemic. In 1992-93, for example, one senior Zambian manager was supposed to substitute an expatriate. This person died of AIDS and the contract of the expatriate engineer had to be extended because there was no other Zambian who could have filled this position quickly. This is costing the company about US$ 60,000 per year.
- Medical care
It is difficult to assess how much of the medical budget goes towards caring for HIV/AlDS patients. According to the causes of sickness, 50 percent were HIV and AIDS related. Therefore it is assumed that 50 percent of the drugs are used for AIDS patients. Staff costs consume the major part of the medical budget. It is worth noting that the drugs for the treatment of tuberculosis, which are very costly, are presently free of charge. Otherwise, the cost of drugs for a single tuberculosis patient (September 1993) would have been US$ 175. In 1993, 141 tuberculosis patients were treated; it can be assumed that 80 percent of these were HIV positive. This means that a further US$19 740 in drug costs may be assumed, but the company does not have to pay for this. The company provides staff and, if necessary, the transport of the patients to the clinic.
The drug costs (without TB) for a single AIDS patient at NSE's clinic ranged between US$ 44 and US$ 83, which is comparatively low. Most of the opportunistic infections associated with HIV can be treated with cheap drugs during the early stages of the disease. Furthermore, it is estimated that 30 percent of the remaining medical budget is attributed to HIV/AIDS. Out of that, staff costs account for the major part. It is debateable whether without the epidemic the budget for the medical department would be lower. Instead it is likely that the medical service would have been improved. On the other hand, as noted above two clinical officers have recently been recruited both in relation to HIV/AIDS. Without the epidemic the recruitment of these officers would not have been so urgent.
- Funerals
When a death occurs on the estate, the company's employees and their dependents are entitled to a coffin, firewood, foodstuffs and transport to the burial site. In 1992/93, there were 232 deaths among company employees and their dependents. The number of deaths has risen to such an extent, that the vehicle, which was assigned to transport the coffin, is no longer sufficient and the department has recently applied recently for a second vehicle.
As noted above, 75 percent of deaths at NSE can be attributed to HIV/AIDS. It is not known how many dependent adults and children have died of AIDS. But, according to medical statistics AIDS cases among dependents were lower. It can be estimated that at least 60 percent of the budget for funerals may be counted as costs generated as a result of AIDS.
- Medical retirement
In cases of medical retirement, an employee is entitled to a grant which is dependent on his or her salary and according to the amount of time the person has worked in the company. In cases of death the family are the beneficiaries. In 1992-93, it appears that four staff members died due to HIV/AIDS and two retired under the early retirement package. Among unionised employees, 36 died and 22 retired on medical grounds due to HIV/AIDS. It can be argued that these are not additional costs because employees go on retirement anyway and this entitlement depends on the time served. But in 199293, these costs have been generated by HIV/AIDS, which would not have otherwise occurred and furthermore their effective working life and the availability of their experience to their employer was truncated by the disease.
- Repatriation
In cases of medical retirement, the staff members and unionised workers are entitled to be repatriated. In case of death, the family of the deceased is taken back to their home areas. Transport costs take by far the major part of the repatriation allocation. There is a common budget for repatriation and recruitment. In general, recruitment is cheaper than repatriation. It is estimated that about 30 percent of the budget for staff and unionised employees can be costs attributed to repatriation due to AIDS-related death or retirement.
- Training
Nakambala is the only sugar estate in Zambia and ZSC has to invest substantially in training given the specialized nature of the work. This applies especially to cane growing activities, but also to areas in the factory. Once a highly skilled person is lost, he or she cannot be simply replaced from the Zambian labour market, because an already trained successor cannot be found. Added to this, ZSC competes on the Zambian, and increasingly on the Southern African, labour market with the mining industry for a limited number of engineers. The training process can take as much as two years during which the trainees are often sent abroad on special, and costly courses.
5.8.3 Summary of the costs
Table 7 shows that the largest portion of costs are associated with sickness. Nearly 50 percent of these expenses arise from the benefits which the company offers its employees. Companies in Uganda noted that morbidity has a higher impact than mortality (Pangs, 1992). At Nakambala, the costs of sickness (lost working days plus medical expenses) are about as high as the costs in the case of death.
In 1992-93, costs attributable to HIV/AIDS represented 1.9 percent of the total costs of Nakambala Estate. This appears to be quite low. Sales for 1992-93 for ZSC as a whole were about US$ 50.0 million. Even if US$ 2.2 million in head office costs are added to the Nakambala costs, the profit margin remains wide enough to cover the additional expenses arising from HIV/AIDS. The costs caused by HIV/AIDS make up about 2 percent of the profit.
Table 7: Costs generated by HIV/AIDS at Nakambala in 1992/93
Description Costs (US$) Costs (%)
Lost workforce 148, 920 31.8
Extension of expatriate
contracts 60,000 12.7
Medical Department 70,124 14.7
Funerals 24,314 5.1
Pension for deaths +medical retirements 75,184 15.9
Repatriation 59,448 12.5
Training 35,208 7.3
Total 473,198 100.0
Source: Haslwimmer, 1994
The following table provides an estimate of how the costs could be allocated between labour and materials.
Out of the total labour costs, 4.7 percent are due to HIV/AIDS, while only 0.7 percent of the total material costs can be attributed to the disease. This lends weight to the hypothesis that AIDS is predominantly a burden for the labour budget.
Table 8: Costs resulting from HIV/AIDS divided between labour and materials
Description Labour Materials
(%) (US $) (%) (US $)
Lost workforce 100 148920 0 0
Extension of
expatriates 100 60000 0 0
Medical
Department 50 35062 50 35062
Funerals 10 2431 90 21883
Pension for death+ medical
retirement 100 75184 0 0
Repatriation 20 11890 80 47558
Training 40 14083 60 21124
Total 73.5 347570 26.5 125627
Source. Haslwimmer, 1994
Subscribe to:
Posts (Atom)