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The Impact of HIV/AIDS in Zambia: Industry and the Public Sectors
(AIDS in Zambia Bibliography #178-92)

http://www.medguide.org.zm/aidsbibl/impact2.htm

(#178) "The Impact of Human Immunodeficiency Virus Infection and AIDS on a Primary Industry: Mining (a case study of Zambia) "
Nkowane, B.M, (1988), in Fleming, A.F., Carballo, M., FitzSimons, D.W., Bailey, M. and Mann, J., Global Impact of AIDS; pp 155-160
Geographical area: Copperbelt, National; Keywords: Private sector; Location: I.A.S.-Documentation and Information Unit

The author notes that the impact of HIV infection on a primary industry such as mining in Zambia will be shaped by numerous factors that are different from what is known in the industrialised countries that have mining industries. He discusses the possible impact of HIV infection and AIDS on mining on the Copperbelt Province of Zambia. The findings show that the impact of HIV/AIDS on the Zambian economy is difficult to quantify. However, the mining industry will have more expenses to take care of in terms of health and social services for its miners. It was also noted that the only way to avoid this would be to recruit only those who are free from HIV and to routinely screen all miners at frequent intervals and terminate the services of all who are infected.

(#179) "The Employer's Response to HIV/AIDS and Workplace "
Keembe, A.L. (1993), unpublished
Geographical area: Kitwe; Keywords: Private sector, workplace, costs; Location: Barclays Bank of Zambia Limited, Kitwe/ UNZA - Institute of African Studies

A commentary paper presented at the Employer's Response to HIV/AIDS workshop held at Barclays Bank Zambia Limited in Kitwe. Featured highly was the Company's concern about HIV/AIDS and its impact on the productivity of the industry. The purpose of this presentation was to sensitise the employees on the magnitude of the HIV/AIDS epidemic in the country. Furthermore, the paper provides a profile on the current status of HIV/AIDS epidemic within the work place. Their responses to counteract the existing problem were also emphasised. The response on the paper indicated that the Barclays Bank acknowledged and recognised AIDS as a national problem at every employers' door step. Its extent was difficult to measure in terms of numbers and the consequences were equally immeasurable. The threat of AIDS and the problems arising from it were viewed not to be left to Government and non-governmental organisations alone, but a responsibility for the whole society. The recent data at Barclays Bank showed that HIV/AIDS affects all age-groups. The peak has been observed among the 30-39 year olds who were sexually active and in their reproductive life span. The business concentration is along the line of rail and Eastern Province, where 95 per cent of the employees live and work. The level of exposure to HIV/AIDS infection cannot be underestimated.

Problems in estimating the existence of AIDS within the working place were evident. However, evidence was noted of an increase of deaths among the employees; 115 deaths since 1987 (without medical confirmation). Causes of death have been stated as tuberculosis, pneumonia, unknown etc. Despite the fact that inadequate accurate information on HIV/AIDS cases was evident, assumptions were made based on certain facts and consistencies which tend to confirm the general view that HIV/AIDS-related cases existed in the bank. Furthermore, statistics showed a concentration of staff deaths in the younger age groups (86 per cent of deaths were below 46 years). AIDS impact on Barclays has been determined through the expenditure costs on deceased staff. The ex-gratia payment linked to basic salaries of deceased staff affected profit levels. The 1991 and 1992 cost estimates spent on deceased staff accounted for K6.8 million and K24.6 million respectively. The trend in the cost was considered to continue to increase in future as other costs were not quantifiable but observed through an upswing in absenteeism due to ill-health of staff or family members, had an indication in the existence of the problem.

The AIDS impact on its labour force has made the industry respond positively to HIV/AIDS through its commitment to the direct need to control the spread of AIDS and remove discrimination against people with HIV-infection. The major commitments are the establishment of an HIV/AIDS personnel policy; conducting HIV/AIDS campaigns through information and education; home care visits and counselling; provision of condom distribution and collaboration with institutions/organisations involved in Anti-AIDS campaigns, i.e. Kara Counselling, Zambart and drama groups.

(#180) "Employers' Response to Manpower Shortage due to HIV/AIDS Cases in the Workplace"
Macwang'i, M. (1993), unpublished
Geographical area: Ndola; Keywords: Private sector, manpower, workplace; Location: Institute of African Studies

A case study of INDENI, a petroleum refinery company in Ndola, Copperbelt Province, Zambia was undertaken. The objective of the case study was to identify positive initiatives or aspects of current HIV/AIDS prevention and care in order to build on existing knowledge. Data for this study were collected in March, l993. Methods used to collect data included literature review, review of medical records at the INDENI Clinic, a questionnaire which was administered to 6 managers, 4 collaborators, 10 general and 8 providers (nurses and clinical officers) and focus group discussions. The case study concludes that African communities are active in organising and mobilising resources to manage and cope with the HIV/AIDS pandemic. Further to this, active involvement can be seen through an increase in local NGOs and a growing political and governmental involvement in the AIDS pandemic.

(#181) "Experiences at Barclays Bank"
Nyirenda, B.N. (1993) Paper presented at the National workshop for AIDS and the workplace, Siavonga, July 1993.
Geographical area: National; Keywords: Mortality, workplace, private sector, costs; Location: UNICEF

A paper summarising the impact of the AIDS epidemic on Barclays Bank. The death rate has risen from 0.4 per cent in 1987 to 2.2 per cent in 1992, and the bank paid out more than ZK 10 million in the form of ex-gratia to the bereaved families in 1992. Medical expenses are on the increase, man hours are being reduced, and training costs are increasing.

Barclay Bank Death Rate:

(#182) "Maize production, drought and AIDS in Monze District, Zambia"
Foster, S. (1993) Health Policy and Planning; 8(3): 247-254
Geographical area: Monze, Southern Province; Keywords: Drought, agricuture; Location: Location:

The 1992 Southern African drought focused the world's attention on the precarious food security situation of that region. In Monze District, southern Zambia, in addition to the drought there was also a serious epidemic of East Coast fever among the cattle, which resulted in the deaths of a large percentage of the district's herd causing further impoverishment among some of the district's poorer households. At the same time, AIDS and HIV disease are increasingly making an impact on the productivity of the district's population, with as many as one in 6.5 households already having experienced illness or a death due to AIDS. This paper describes the history of maize in Zambia, the impact of the 1992 drought and of the epidemic of East Coast fever, and the likely impact of AIDS on agriculture in the district.

(#183) "The Effects of HIV/AIDS on Agricultural Production Systems in Zambia"
Drinkwater, M. (1993) An analysis and field reports of case studies carried out in Mpongwe, Ndola Rural District and Teta, Serenje District, 1993. FAO
Geographical area: Ndola and Serenje; Keywords: Agriculture, households; Location: FAO, NASTLP

Objectives:

·         To investigate the effect of current health trends (including HIV/AIDS) on agricultural productivity and food security.

·         To explore how current income generating activities are being affected by loss of labour in households and how households are adapting (coping strategies).

·         To find out how household labour is being affected.

·         To identify especially vulnerable groups and the impact on them of labour loss.

·         To find out about the people's understanding of health issues and their impact.

·         To see how existing coping strategies can be strengthened and new ones initiated to support in particular the most vulnerable groups being affected by health problems.

·         To see how HIV/AIDS prevention and care programmes in the community can be carried out and strengthened.

Methods:
Both the Mpongwe and Teta surveys began with introductory meetings with farmers. These meetings were then followed by two to three days of detailed interviews, which once analysed were built upon through a few follow-up interviews and then final meetings. In both studies, farmers were divided into different groups by gender for the final meeting. Following the principles of Rapid Rural Appraisals (RRA) approach, several key features of the methodology can be noted:

·         A multidisciplinary research team is used which includes people from all disciplines and institutions relevant to the study.

·         The methodology used is qualitative in nature, but within the case studies effort is made to collect comparable quantitative information on production activities. This allows a categorisation of household types - or clusters.

·         The study is built around two types of interaction, that with members of the rural community, and that within the research team itself. This exercise is conducted in an extremely intensive way, with the research team working most evenings as well as during the day. This allows for a momentum and a common awareness of the issues to be built, even with the farmers, so it is easy to go back and follow up in greater depth on issues discussed with someone a day or so before.

·         The methodology is also interactive in nature, that is, it proceeds through a series of cycles (or spirals), in which information collected earlier is validated and elaborated. Our exercise consisted essentially of two interactions: I) analysis, ii) validation and elaboration of issues. In Mpongwe the third stage was carried out amongst the team, although not taken back to discuss with the community in any detail. This was the elucidation of follow up issues and options.

·         In the field exercises effort is also made to triangulate and cross-check information. This is done through the interactive nature of the methodology, by having multi-disciplinary teams conducting interviews and meetings, by using different methods to examine the same issue, and by having enough farmers in the interview sample to be able to develop a firm classification of livelihood systems.

Results:
In Zambia, HIV/AIDS has so far been a largely urban phenomenon - at the beginning of the 1990s 45 per cent per cent of the recorded cases where within the Copperbelt urban centers alone. The pathways of the spread of infection from the main urban centres are the major transport routes and the carriers are those that use the route regularly - traders, truck drivers, business people. Where these carriers interact with people from rural areas, for instance, with women marketing crops, HIV/AIDS infection will spread into the rural areas. Nodal points may be identified where contact between carriers and rural dwellers is most intense and thus where rural infection rates are rising first. The Chipese area, just to the west of Mpongwe Mission Hospital, is a nodal point of this nature. Chipese was identified specifically as our case study area in the Mpongwe area by AIDS programme staff at Mpongwe Mission Hospital because the area has a high concentration of home-based care patients attended by the hospital - 8 patients out of a current total of 74.

Three primary sources of infection into the area were identified during the field survey - the Copperbelt towns; the Mission Hospital and farms themselves, particularly from staff such as drivers; and Nampamba, the workers' compound for the Mpongwe Development Company estate, which lies just south of Chipese (and which has 12 home based - care patients). These patients would represent only a small proportion of those in the places concerned with HIV/AIDS. Statistics for both Mpongwe Mission Hospital and St Theresa's Hospital at Ibenga are inconsistent but show a clear upward trend with regards to AIDS and AIDS-related mortalities.The first deaths from HIV/AIDS in both hospitals are recorded in 1987. The largest cause of death at St Theresa's in 1992 was malnutrition, but a significant factor in the increase in deaths due to PCM is because of AIDS babies' - children whose mothers are HIV-positive. Even malaria, which is the largest cause of admissions in both Mpongwe and St Theresa's Hospitals might well have increased because of the greater susceptibility of those who have HIV/AIDS (although there is no direct evidence yet to support this hypothesis).

In contrast with Chipese, Teta is not such a nodal point which has already attracted medical attention because of the relatively high rates of HIV/AIDS which appears to have occurred. District health staff from Serenje who participated in the Teta study report that the two parts of the district which have the highest infection rates, Mulilima and Chibale, are areas which traders enter in large numbers to buy crops such as beans and sweet potatoes.

Teta is an area where the Adaptive Research Planning Team (ARPT), has a farmer research group. In most rural areas, the first patients are those that come home from the urban areas to die. They come home because they can no longer hold their jobs, are not responding to western medicine, and can no longer be cared for effectively in the urban environment. This was the case in both Teta and Chipese. Now, however, there are AIDS patients who are of the communities themselves, and in particular in Chipese it is clear that these people have been infected within the area. This is the second stage of the epidemic.

The 18 members of the survey team in Chipese were in agreement that the third stage of the epidemic will probably be reached there within the next two to three years. By this time the impact of HIV/AIDS on agricultural production and livelihood security will have increased substantially. It is also clear that as morbidity and mortality due to HIV/AIDS rises, the effect will be to exacerbate the already significant vulnerability and food insecurity of large numbers of women and children.

This is because it is common amongst the matrilineal peoples who are prevalent across many parts of rural Zambia for the event of death to a parent, like the already common event of divorce, to lead to the break up of the nuclear family itself. Death, like divorce, causes social dislocation. Women with their children move back to the villages of their own mothers, or other matrilineal kin, leading in these villages to an increasing number of single parent producers and a growing dependency ratio. Programmes to assist in the amelioration of the impact of AIDS with respect to both the care of patients and with livelihood coping strategies will thus need to focus on women, but not exclusively so.

The summary also explains the processes which are leading to this heightened vulnerability of women and children. It is mainly the Mpongwe study that is referred to as the impact of HIV/AIDS having been greater there so far than in the Teta area of Serenje, but the latter study also shows that the trends can be expected to become more widespread in the future.

(#184) "Cost and Burden of AIDS on the Zambian health Care System: Policies to Mitigate the impact on Health Services"
Foster, S., (1993), unpublished
Geographical area: National; Keywords: Health care delivery, costs, ; Location: Ministry of Health

A documentary report prepared on the basis of interviews with key staff from various facilities and review of documents from the Ministry of Health (MOH), Central Statistical Office (CSO) and other institutions. Much use was made of information and data collected as part of the AIDS study of Adult Disease in Zambia based at Monze District Hospital. The report reviews the epidemiological evidence regarding the number of cases of AIDS the health service should expect; the impact in the health services in both urban and rural areas and the impact on households; the costs of care at various levels of health system including home based care. Recommendations as to ways to lessen the impact of AIDS or spread the impact more evenly and more efficiently among the various parts of the health services. The terms of reference for this report are centered at:

·         determining the impact of AIDS on the health care system taking into account the average cost of care;

·         describing current treatment options and offer alternative care strategies;

·         describing the present modality of care for AIDS patients and propose alternative strategies;

·         assessing the impact of various care strategies on households.

The analysis revealed on the expected numbers of cases presented into two scenarios derived from WHO Epimodel programme projecting the 1990-95 estimates indicated an increase in trend for (56242 and 73547) new cases of AIDS to occur in Zambia in 1995. The geographical distribution of cases still shows sero-prevalence among antenatal attenders in urban areas being higher (25 per cent) than the rural with 13 per cent.

The results further suggest that planning and providing care for people with HIV diseases in Zambia is still considered a major problem. Care continues to be offered regardless of the cost. The present situation indicates that the entire burden of providing care is falling on the hospitals, e.g. U.T.H., and on families, with the health centres having a non-existence of AIDS cases. The current status of about 15,000 hospital beds in 82 hospitals and 6,000 health centre beds in 950 health centers still shows most of the health centers beds are under-utilised or even un-utilised, while the hospital beds are at very high occupancy rates of 90 per cent or more with 50 per cent+ of the beds being taken up by patients with HIV disease.

The suggestion of health centres taking on much more of the burden of caring for AIDS patients is considered but this will require equipment, training and motivation of staff. Home based care which is proven to be well developed in Zambia, needs of patients, and on serving the most needy patients and coverage needs to be extended to areas covered by Government hospital. Counselling of patients with HIV also needs to be integrated with provision of basic care such as treatment of STDs, skin complaints, pneumonia etc as well as advice about hygiene, nutrition family planning and condom use. An urgent need for a "halfway house" providing respite care, terminal care, and a place for homeless and destitute AIDS patients in urban Lusaka and other areas has to be considered.

Some recommendations are made regarding ways to lessen the impact of AIDS; spread the burden more evenly and effectively and more cheaply among the various parts of the health services. The report therefore draws the conclusion that the best way to provide care for AIDS patients is by strengthening the health services especially at the primary health care level.

(#185) "Impact of HIV on Zambian Businesses"
Baggaley, R., Godfrey-Faussett, P., Msiska, R., Chilangwa, D., Chitu, E. et al., (1994) British Medical Journal, Vol 309, pp 1549- 1550
Geographical area: Lusaka and Copperbelt; Keywords: Workplace, private sector, health education, counselling, mortality; Location: UNZA Medical Library

Objectives:
To evaluate the impact of HIV on businesses in Zambia. To assess the level of HIV education which is being undertaken in the workplace and see if there is a demand for further HIV education there.

Methods:
The personnel managers of 21 companies with a total workforce of 6447 in Lusaka and in towns in the Copperbelt were visited by one of the study team. The study was discussed and a questionnaire about the impact of HIV on their company was explained and left for completion from company records. Results: All 21 questionnaires were returned. HIV was felt to have affected productivity in 48 per cent of companies and recruitment in 19 per cent. 14 per cent of companies knew of employees who were infected with HIV, 81 per cent did not know, many commenting that this was not something which would be revealed to the personnel department, and 5 per cent said they had no staff who were HIV seropositive. All companies except 1 kept records of employee mortality. The crude death rate for this population increased sequentially (p<0.001).

More deaths were recorded as due to unknown causes though death from TB, diarrhoea and AIDS were recorded with increasing frequency. 8 companies had some HIV education at the workplace, 3 had HIV counselling available and 4 supplied condoms free to their employees. All expressed an interest in having further HIV education for their workforce.

Conclusion:

·         HIV is recognised as having an important impact in th

·         There is a trend of increasing mortality in the working population in this survey.

·         Although some companies have instituted HIV education in the workplace, there is a demand for this service too be available more widely.

(#186) "The Social and Economic Impact of HIV/AIDS on Nakambala Sugar Estate "
Haslwimmer, M. (1994) FAO, unpublished
Geographical area: Mazabuka; Keywords: KAPB, condoms, costs, agriculture; Location: FAO, UNICEF

Objectives:

·         To describe the present state of HIV at Nakambala Sugar Estates (NSE) and make projections for the near future.

·         To assess the knowledge and attitudes towards HIV/AIDS among NSE employees.

·         To assess the social implications of the disease.

·         To assess the present economic impact in terms of costs caused by HIV/AIDS in affected departments and make projections for the near future.

·         To propose recommendations for different sectors.

Methods:
The report is based on the findings from visit to Nakambala Sugar estate from 25 October-11 November 1993. During the visit numerous employees, ranging from the low-skilled to the top management level were met and interviewed. Group interviews were conducted with factory workers and with women from the townships. Data on issues of the labour force and the costs caused by HIV/AIDS were collected from different departments.

Results:

·         In 1990, at the NSE a total of 130 patients were tested for HIV, out of these 80 had AIDS-related complex (ARC) on clinical grounds and were drawn from the STD/skin clinic. The other 50 patients were selected randomly from patients attending clinics for other reasons. 55 per cent of the STD patients were HIV-positive, while the randomly selected persons reached 28 per cent.

·         The man-hours lost due to TB/AIDS account for 50 per cent.

·         Malnutrition has also continued to be a problem at NSE; 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.

·         The level of STDs is high among the population of NSE.

·         The level of knowledge among the population at NSE varies considerably. Everybody who was interviewed has heard about HIV/AIDS, although people are differently informed, with 42 per cent not knowing that HIV can be transmitted through blood transfusion.

·         The willingness to use condoms is low: only 32 per cent had ever used a condom. A possible reason is the prevailing misconception that condoms are already infected with the HIV virus. 7. In 1992/1993, the sale of sugar reached its peak since the founding of NSE, implying that AIDS had so far not has a serious impact on production.

Conclusions:
The impact of HIV/AIDS on NSE has been noticeable and worrying, but not devastating. There are two main responses for HIV/AIDS: HIV prevention and mitigation. In an environment with limited financial resources, they have to be cost-effective. As HIV/AIDS affects the different sectors at NSE, the measures should be multi-sectorial.

(#187) "Mortality among female nurses in the face of the AIDS epidemic: a pilot study in Zambia"
Buve, A., Foster, S., Mbwili, C., Mungo, E., Tollenare, N. et al., (1994) AIDS 1994, Vol 8, No.3 p396
Geographical area: NA; Keywords: Health care workers, mortality; Location: UNZA Medical Library

Objective:
To study the mortality among nurses in the face of the AIDS epidemic.

Methods:
Based on the employment register, the number of person-years in service and the mortality rate were calculated for three-time periods: 1 January 1980 to 31 December 1985, 1 January 1986 to 31 December 1988, and 1 January 1989 to 31 December 1991. At Hospital A the register is complete from 1980 onwards, at Hospital B from 1986 only. The mortality rates for the three time-periods and 2 hospitals are shown below:

Hospital A:

Hospital B:

Total:

note: 95% confidence intervals

Results:
The mortality rate in the second time-period showed a fourfold increase (rate ratio, 3.7; 95 per cent confidence interval (CI), 1.0-9.5) compared to the mortality rate in the third time period, the mortality rate in the third time-period a 13-fold increase (rate ratio, 13.4; 95 per cent CI, 7.8-21.4). The death certificates were retrieved for nine nurses who died in 1989-1991. 4 certificates documented HIV infection; a fifth recorded tuberculosis as the cause of death. The remaining certificates recorded cause of death as: diabetes mellitus (two), carcinoma of the cervix (one) and severe anaemia with congestive cardiac failure (one).

Conclusions:

·         1. The study found out that the observed increase in mortality was probably attributable to HIV infection.

·         The high mortality among nurses in the range found (i.e., 27 per 1000), has serious implications for manpower planning at the Ministry of Health and for the health services' ability to cope with the increasing burden of AIDS-related disease.

·         Policy-makers urgently need estimates of the relative and attributable risks of occupational exposure to HIV infection.

(#188) "The effects of HIV/AIDS on farming systems and rural livelihoods in Uganda, Tanzania and Zambia"
Barnett, T. (1994) FAO
Geographical area: National; Keywords: Agriculture; Location: FAO, World Food Programme

This report for the FAO looks to understand the actual and potential impacts of HIV/AIDS on farming systems, especially the estate sector in Zambia. Fieldwork was carried out in 1993, using various participatory methods. The emphasis of the research was on identifying different levels of vulnerability, which is a function of the farming type and the extent of the epidemic: a vulnerability map was produced for Zambia. With vulnerability analysis the production of an early warning system is possible using three information sources:

·         national broad classification to produce a vulnerability map

·         detailed information from district level agricultural and administrative sources and

·         the nature of the impact in specific communities using RRA techniques. In Zambia it appears that the most labour vulnerable farming systems are not immediately vulnerable to the epidemic. Also the impact varies widely making generalisation difficult. Matrilineal societies are more vulnerable to labour loss than patrilineal. The impact of AIDS in the Zambian estate sector is limited so far, and concentrated on the supply of skilled and educated members of the workforce. An important finding was the significance that the loss of male household members has for management of household economies and marketing of agricultural produce. Types of programme activities in relation to agriculture are:

o        Improving returns to labour, e.g. better storage techniques

o        Extending the planting period

o        Crop diversification and reducing external input requirements

o        Cattle and livestock loans, especially for women

o        Small credit schemes

27 specific projects are outlined such as pest control, encouragement of better marketing techniques, formation of women's groups, training of orphans in agricultural techniques, crop diversification for income generation etc.

In intervention programme design, the temporal aspects of the disease and its impact should be considered. There are three stages - pre impact, early impact and full impact:

·         Pre impact: Here the emphasis should be on (1) health and behavioural education to impede the development of the epidemic and (2) inclusion in extension messages of clear HIV/AIDS impact material indicating the types of effect that the epidemic may have on people's livelihoods

·         Early impact: Here, the emphasis should be on health and behavioural education, the development and support of community based diagnosis of the current impact, the development and support of existing community support mechanisms and the development in consultation with community of livelihood and farming adaptations which facilitate labour economising activities, technologies and techniques.

·         Full impact: In addition to the above, there will be a need to focus on the development of support groups for the survivors and to ensure that relief assistance is available where necessary.

Various projects are outlined with respect to the different stages of impact.

(#189) "Human resource development and training in relation to HIV/AIDS in the formal sector"
Tembo, R. (1994) unpublished
Geographical area: Lusaka; Keywords: Workplace, private sector; Location: NASTLP, MOH

Objectives:
To look at employment policies and tertiary level training in regard to human resources development in the formal sector. To find out the attitudes of employers about the advantages and disadvantages of employing HIV-positive individuals.

Methods:
A questionnaire was distributed to 10 selected companies in September 1994. Interviews were also held with persons in charge of Human Resources departments to find out about their employment policies and their attitudes towards employing an HIV-positive individual.

Results:

·         All the companies indicated that they have specific and programmes on human resource development and training.

·         89 per cent of the organisations bonded their employees upon completion of the training programme, the period of bonding being dependent on the duration of the training.

·         There was a noted increase in rates of sick leave: with 5 out of 10 noting an increase in sick leaves, 4 registering an increase in absenteeism, and 6 experiencing an increase in rates of funerals.

·         Four organisations stated that AIDS was a problem in their companies. The number of employees dying due to HIV was high and affecting the productivity of the organisations. No organisation reported having integrated HIV/AIDS in human resources development and training. 4 Organisations have, however, put in place preventive measures on HIV/AIDS. This includes the integration of issues of HIV/AIDS into the organisations' occupational health programmes.

Conclusions:
Issues relating to HIV/AIDS, funerals, leave and absenteeism are important for human resources development and training.

(#190) "The economic impact of AIDS in Zambia "
Forgy, L., Mwanza, A., (1994) Unpublished.
Geographical area: National; Keywords: Manpower, costs; Location: NASTLP/UNICEF, Family Health Trust

This paper presents a simple economic simulation model which projects possible impacts of AIDS on economic growth in Zambia, per capita incomes, foreign financing requirements, the ability of the economy to augment its capital stock, and the size of the government deficit.

Without AIDS:
The baseline model shows the that the economy would have to grow from $4.1 billion in 1991,to $5.5 billion in the year 2000 just to maintain annual per capita incomes at the 1991 level of $513. The stock of capital would have to grow over the nine years from 1991 to 2000 by about 33 per cent. Even with these, the government budget deficit would be persistent, and, in fact, would grow throughout the decade. Therefore, Zambia would require increasing amounts of foreign resources to maintain economic stability.

AIDS will significantly affect these outcomes. The population of Zambia in the year 2000 will be more than five per cent less than it would have been without AIDS. These deaths will be accompanied by the related medical expenses, worker transition costs (that is, the costs of replacing a skilled worker who dies of AIDS with a more unskilled worker), and loss of human capital. The model incorporates these facts; it can then be used to estimate the different impacts that would be realised if, on the other hand, all cost associated with AIDS were borne by the Zambian economy without foreign resources and, on the other hand, if such resources were available. The first case is the "worst case" scenario and the second is the "best case" option.

With AIDS, Without Foreign Resource:
If the economy was forced to absorb the additional costs associated with AIDS internally, that is, without any increased foreign resources, GDP would fall by about 9 per cent below the baseline projection, reaching only $5 billion in the year 2000. Per capita income at the end of the decade would be only $494, or about four per cent lower than the baseline simulation.

With AIDS, with Foreign Resources:
If, however, foreign resources would flow to Zambia in sufficient quantities to pay for the extra medical costs and worker shifts and re-training, then the GDP would fall only to $ 5.2 billion by the year 2000 (a drop of only about five per cent). This loss would be due solely to the absolute reduction in the size of the workforce.

The total economic impact of AIDS is a combination of two effects: the loss of skilled manpower and use of production for consumption rather than investment, which lowers production by about 5.5 per cent; and the loss of productivity of the survivors (as there will be less capital to work with) of about 4 per cent. Foreign resources can help to mitigate the productivity loss; adjustments to the capital stock (increasing the amount of capital per worker) might compensate for the loss of skilled workers. It seems clear that, without unprecedented infusions of free foreign aid to mitigate the effects of AIDS, the economy of Zambia will suffer considerable damage. Projections indicate that the reduction in normal income could be as high as 10 per cent. This is an enormous impact for a disease that would reduce the population by only five per cent.

Some of the expenditures to mitigate the impact of AIDS on national income are actually quite modest. For example, foreign resource inflows to compensate for expenditures of about $37 million on health care and worker transition costs (including increased training) have the potential to reduce this impact by about $200 million.

For the long run, an obvious strategy is to reduce the number of AIDS patients. An emphasis on AIDS prevention activities in the workplace might reduce the most expensive deaths, since it reduces the cost of death benefits as well as retraining costs. Programmes aimed at youth also will have higher- than- average payoff if they reduce the number of individuals who receive training and education only to die early of AIDS. Programmes to reduce sexually-transmitted diseases (STDs), to the extent they also reduce the transmission of HIV, will also be beneficial.

There are also a number of related economic policies that could help mitigate the impact of AIDS on the economy. Such policies would:

·         Encourage greater use of labour in the Zambian economy. Policies that favour, or at least reduce restrictions on labour intensive industries would provide greater employment overall and help to reduce the adverse impact on income distribution which results from greater-than-average death rates among skilled workers.

·         Make optimal use of resources, including workers who are already HIV- positive. Greater investment on vocational and on -the -job training for a broad range of staff is likely to have large payoffs as lower productivity reductions will be experienced during worker transactions. Other approaches might include:

o        Offering employers compensation for training to replace workers who have died of AIDS. Such a policy might also reduce the hesitancy of employers to hire workers who are HIV- positive or to keep them on the payroll as long as they can;

o        Limiting the legal liabilities of employers who hire individuals who are HIV-positive. The argument is that it is in the interest of society to have trained workers who are HIV-positive continue to be productive until they actually develop AIDS. On the other hand, it is in the interest of the employers to rid themselves of a possible future liability as soon as they can.

·         Consider the dynamics of AIDS in the workplace. There is a general lack of knowledge on the issues of HIV and employment, and on providing AIDS prevention activities in the workplace. Projects often seek to convince employers that it is expensive to have an employee die of AIDS, and that they should permit and possibly pay for training programmes in the workplace which would increase AIDS awareness. However, convincing employers of this could cause them to choose a strategy of eliminating any worker who is HIV-positive. This strategy becomes more viable as testing becomes more accessible and inexpensive. Structuring activities to build on the possibly greater incentives of the workers themselves might be more effective. If they are convinced that AIDS has a detrimental effect on their own livelihood, they may put pressure on their employers to permit or pay for AIDS education programmes.

(#191) "Study of Adult Disease in Zambia (Final Report - preliminary version)"
Foster, S. (1995) Unpublished
Geographical area: Southern Province (Monze, Choma); Keywords: Mortality, surveillance, health care delivery, costs, home based care; Location: ODA, UNICEF

The overall aim of this ODA funded project was to improve the knowledge base regarding the impact of the HIV/AIDS epidemic on developing countries. This small series of studies was conducted in 1991-1992 in Choma and Monze districts. The studies gathered data on socioeconomic and demographic profiles of patients, HIV surveillance, hospital treatment costs and patient and family costs related to illness episodes.

Summary of results:

·         About 55 per cent of inpatients are accompanied by a helper'. 75 per cent of these are female, with food provision being their largest concern after the disease itself.

·         The estimate of HIV prevalence among the entire population of Monze District was 10 per cent, implying that 1 in 4 of the districts' 20,000 households will have experienced a death from AIDS by 1997.

·         At Monze and Choma hospitals, 43 per cent and 47 per cent of bed days respectively were taken up by patients with HIV disease.

·         In the home based care programme, 69 per cent of the budget was spent on transport, 27 per cent on salaries and 4 per cent on drugs, stationary and supplies. The cost per visit was about seven pounds (1995 = KW 10,500-00).

·         Patients attending health services in Monze district are in general more wealthy than the population as a whole.

·         There do not appear to be any differences in socioeconomic status between patients with HIV and those without. Among patients attending the district health services, HIV infected patients are more likely to be skilled workers than HIV negative patients.

·         Mortality amongst nurses had risen from 2/1,000 in 1980-85 to 26.7/1,000 in 1989-91, and was still rising.

·         In 1991 a total of 150 HIV infections were averted by HIV screening. Benefits in terms of lives saved were most apparent in the under six age group.

·         Of the patients in the bed census, 87 per cent had one or more clinical reasons for being in hospital that day, 12 per cent non-clinical, and 24 per cent could have been treated at a lower level facility.

(#192) "The impact of HIV/AIDS on education in Zambia "
Mukuka, L., Kalikiti, W. (1995) Ministry of Health
Geographical area: Lusaka, Northern Province; Keywords: Students, costs; Location: NASTLP, UNICEF

This study was designed to examine the impact of the AIDS epidemic on the sector of education, particularly of primary and secondary schools. The study used a survey covering a random sample size of 346 students and 74 teachers drawn from 20 selected rural and urban primary and secondary schools in the two Provinces of Lusaka and Northern.

In both urban and rural schools, malaria was the number one perceived cause of illness among teachers, followed by chest problems, TB, stomach problems, dysentery and diarrhoea. 59 per cent of teachers in urban schools responded that there were no cases of AIDS in their school in the previous three years. 37 per cent indicated that there had been. Similar figures came out of the rural schools. On questioned on the causes of death, however, AIDS was given as the major cause (contradicting the previous finding). In the 11 rural schools, there was an average of 5 teacher deaths over the previous three years, compared to an average of 17 in the urban. School enrolment rates are unlikely to be affected due to the large existing deficit of places. Absenteeism rates are expected to increase, especially for the girls. AIDS had caused a perceived increase in drop out rates in the urban schools in particular. In general, teachers and students were unsure if AIDS had affected the quality of education in the schools. AIDS cases among teachers had various perceived negative impacts:

·         teachers overly concerned about their health and therefore becoming nervous and depressed

·         teachers frequently absent

·         teachers deteriorating attitudes to work

·         inability to perform well

·         negative psychological impacts on children

Regarding absences, the average number of teaching hours per week lost to teacher illness and/or teacher attendance of funerals were 2-3 in the rural schools and about four in the urban. Increased mortality rates among teachers is expected to increase the teacher/pupil ratio in schools, expand class size and reduce the hours of instruction. Costs, both human and economic, will be incurred in five areas:

·         Loss of man-hours due to illness

·         Loss of man-hours due to attendance of funerals

·         Replacement costs to mitigate impact of teacher's premature deaths: Public costs will increase by 25 per cent to cover teacher recruitment and training. The current output of 1,800 trained teachers from colleges needs to be increased by at least 30%, i.e. 540 more teacher graduates.

·         Payment of costs for funerals of teachers

·         Payment of benefits in the case of teacher deaths

Various policy options are discussed, related to the curriculum, teacher training, school maintenance and community services.