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Confronting the Impact of HIV and AIDS:

the consequences of the pandemics for

education supply, demand and quality.

A global review from a Southern African

perspective

CAROL COOMBE

Adviser on HIV/AIDS and Education, Pretoria, South Africa

ABSTRACT The global spread of the HIV and AIDS pandemics will, for the next three generations at least, underline education access, quality and provision. Reforms within the sector will necessarily take account of the implications of this plague within national, provincial and local contexts. This article is based on several assumptions. The first is that HIV/AIDS is not only a medical problem: the spread of the disease has created a pandemic with social, economic, geopolitical and other consequences for all countries. Second, increasing numbers of countries, especially in sub-Saharan Africa and the Caribbean, are now facing one of the great crises of human history. The third is that other countries in Eastern Europe and the Asia and Pacific regions will confront similar challenges as the pandemic spreads. The article focuses specifically on the relationship between HIV/AIDS and education in countries with different levels of HIV/AIDS prevalence. It concentrates on the impact of the disease on education at schools level, with some attention to teacher education. It outlines our current understanding of the pandemic, analyses current and anticipated impact of HIV/AIDS on education in order to clarify probable changes in demand for and supply of education services, and looks at education’s current responses to HIV/AIDS, principally in high prevalence countries.

Introduction

This article focuses on the relationship between HIV/AIDS and education in countries with different levels of HIV/AIDS prevalence. It concentrates on the sector’s response to school issues, with some attention to teacher training colleges. For the purposes of this analysis, technical and vocational education, special education, adult basic education and training, universities and out-of-school programmes have been excluded.[2] The survey of experience has concentrated on sub-Saharan Africa, and on Asia and the Pacific, and the lessons that have been learned from high prevalence and low prevalence countries in those regions.

The current and anticipated impact of HIV/AIDS on education is analysed in order to clarify probable changes in demand for and supply of education services. Education’s responses to HIV/AIDS are discussed, principally in high prevalence countries. Finally, some summary conclusions are offered.

Definitions and Assumptions

This is a crisis. The article is based on several assumptions. The first is that increasing numbers of countries, especially in sub-Saharan Africa and the Caribbean, are facing one of the great crises of human history. The second is that other countries in Eastern Europe[3] and the Asia and Pacific regions will confront similar challenges as the pandemic spreads (Monitoring the AIDS Pandemic, 2001). Third, despite the difference in the nature of HIV and AIDS pandemics in the Americas and Europe, Africa, and Asia and the Pacific, it should be possible to extrapolate common ideas about what works and what doesn’t in the fight against AIDS.

HIV/AIDS the disease and HIV/AIDS the pandemic. The virus known as HIV/AIDS has been around since the late 1970s. Responses to it have been largely biomedical, focused on preventing the spread of the disease. Rising prevalence rates worldwide indicate that strategies to contain the virus have not been effective. As HIV/AIDS spreads, individuals, families, communities and nations have to learn to live with the disease. But HIV/AIDS is no longer just a disease. It is now a pandemic, an entirely different though clearly linked phenomenon that needs understanding in far broader geographical, demographic, environmental, economic and social terms. The full complexity of this phenomenon is not yet clearly understood. Governments and communities are only starting to define its social, economic and cultural characteristics. The fight against ‘HIV/AIDS the virus’ will continue while the battle with ‘HIV/AIDS the pandemic’ is joined.

The education sector. As the pandemic snowballs, health-driven national strategies are being replaced by multisectoral strategies in which ministries of education are now taking responsibility for identifying and driving education’s response to HIV, as in Botswana, Namibia, Rwanda and South Africa, for example. Ministries of education alone do not have the capacity to respond to the challenges HIV/AIDS poses for education. It is clear they can only achieve their strategic goals in partnership with others as in South Africa. The capacities of all partners within the education sector as a whole need to be strengthened, and policy and regulatory frameworks established for effective collaboration.

The role of the education sector in fighting AIDS. HIV/AIDS is raising four principal questions for the education sector for which answers are only starting to emerge:

1. What is the role of the education sector in preventing the spread of HIV/AIDS among young people?

2. How can the sector ensure that all young people, especially orphans and other vulnerable children, achieve their full potential?

3. How can the sector, which is the biggest employer in most countries, protect the viability of the education service, and therefore the quality of education provision?

4. How can the education sector continue to improve access to and quality of education services in the face of HIV/AIDS?

General agreement has emerged over the past three years (Coombe & Kelly, 2001; Inter-Agency Working Group, 2001; United States Agency for International Development [USAID], 2001, for example) that there are three principal areas of concern for sector partners:

1. prevention: helping prevent the spread of AIDS;

2. social support: working with others to provide a modicum of care and support for learners and educators affected by HIV/AIDS; and

3. protection: protecting the education sector’s capacity to provide adequate levels of quality education – by stabilising the sector, and responding to new learning needs.

In addition, an effective response will require capacity in the sector to manage this crisis (Coombe & Kelly, 2001).

High and low prevalence countries. The World Bank and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have identified three stages of HIV/AIDS spread. During stage 1, nascent or low-level infection, HIV is less than 5% in all known sub-populations presumed to practice high-risk behaviour. In stage 2, concentrated infection, HIV prevalence is above 5% in one or more sub-populations presumed to practice high-risk behaviour; but among women attending urban antenatal clinics it is still below 5%. During stage 3, generalised infection, HIV has spread far beyond the original sub-populations with high-risk behaviour, which are now heavily infected. Prevalence among women attending urban antenatal clinics is 5% or more (World Bank, 1997; UNAIDS/WHO [World Health Organization], 2000; UNAIDS/FHI [Family Health International], 2001).

These definitions distinguish between countries in east, west, central and southern sub-Saharan Africa, where infection rates have risen well above 5%, and those in South and South-East Asia and the Pacific, where infection rates continue to be low and in some cases confined to specific populations of sex workers, intravenous drug users and men who have sex with men. HIV prevalence among adults ranges from over 5% in 24 sub-Saharan countries to between 1% and 5% in 28 countries and less than 1% in 119 countries.[4] In some so-called low prevalence countries, however, average rates of infection mask substantial sub-epidemics, as in Russia, China and India.[5] A further set of distinctions is useful for understanding what prevention programmes really mean for morbidity and mortality. UNAIDS/FHI (2001, pp. 7ff.) note that an epidemic threshold is reached when enough critical mass of risk behaviours and contributing biological factors exist in a population to sustain an epidemic. This has been described in the scientific literature by the concept of reproductive rate, which is the number of new infections generated by each current infection. The threshold for supporting an epidemic occurs when the reproductive rate exceeds 1. This means that, if infected individuals, on average, infect more than one additional person in their lifetimes, the epidemic will be sustained and grow. On the other hand, if less than one new infection is generated in each current infection on average, the epidemic will ultimately die out. Thus, a certain level of risk behaviours may actually exist in a population without leading to an epidemic because the reproductive rate never exceeds 1. However, when biological enhancing factors are present and sexual and drug-injecting networks are intensive enough because of mixing patterns, concurrent partnerships, and a mix of core and bridge groups, the epidemic can be sustained and continued.

What needs to be done therefore to sustain low incidence levels in one country may not be the same as what needs to be done to mitigate the consequences of the virus once it is out of control in another country.

Thailand and Senegal – and perhaps Uganda – have demonstrated that it is possible for a country heading for trouble to reduce prevalence rates by taking appropriate action. UNAIDS and others[6] have suggested that Thailand’s success is due to the fact that while focusing programmes on high-risk populations, government also reached the general population extensively and intensively (‘rapid implementation, broad coverage’), combining knowledge and awareness with life skills training, condom promotion and shifting social norms and cultural values. It also made socioeconomic interventions to reduce vulnerability, by increasing girls’ educational opportunities and vocational education for example. Senegal’s success (‘starting early and working steadily’) has been attributed to existing societal norms including delay in age of sexual initiation, and strong political response early in the pandemic. High condom use during risky sex is reported, apparently as a result of effective STD (sexually transmitted disease) programmes, condom promotion and social marketing, as well as sex education in primary and secondary schools.

Where prevention measures have not kicked in, high prevalence countries will witness massive social disruption over the next decade and beyond as the full brunt of the HIV/AIDS pandemic takes effect.[7] HIV/AIDS is wiping out the development gains of a generation. The difficulty is that many of the worst-hit countries still lack strategies, tools, techniques and commitments to make headway against HIV/AIDS (World Bank, 2000a; Coombe, 2001a; Trengrove-Jones, 2001). The education sector can help bring the pandemic under control, and mitigate increasing social dislocation, and that is the theme of this article.

The next section examines the impact that HIV/AIDS is having – or is likely to have – on education supply and demand, and the quality of education provision, in high prevalence countries.

The Impact of HIV and AIDS on Education

In most high prevalence countries HIV/AIDS is affecting the supply of education, the demand for education, the quality of education, the way education is managed, and its capacity to respond to new and complex demands (Inter-Agency Working Group, 2000). The relationship between the HIV/AIDS pandemic and education provision can only properly be understood within the context of the lives of people – children and adolescents and their families, teachers and principals, education officials and college lecturers – who are coping in the first instance with the impossible demands the pandemic makes on them as individuals. The pandemic’s impact on households directly influences the choices that learners and educators make (Love Life, 2000; Desmond, in University of Natal, Health Economics and AIDS Research Division, 2001).

Contextual Factors Affecting Supply and Demand

The Sinosizo homebased care programme helps children aged nine to 14 who are the primary caregivers for parents dying of AIDS and for smaller brothers and sisters. The majority live in households with no incomes, many with parents who have been sent home from hospital – sometimes comatose – a day or two before they are expected to die. In the many homes where there are no beds, the children, often malnourished, struggle to lift and turn their parents and to help them to the toilet. Children from some of the 900 families with whom Sinisizo is working told … the [13th International AIDS Conference, Durban, July 2000] about their difficulties. ‘They say waste disposal is the most difficult thing – getting rid of soiled dressings and incontinence pads. They also have to find food for their families, cook for and feed their parents and younger siblings. They have to ask for food from the neighbours and it takes hours to get enough for one day. They have to cook on paraffin stoves and open fires while they are carrying smaller children on their backs or hips. They have to fetch water for drinking, cooking, bathing and washing clothes, and a small child can’t carry enough.’ If there is any medication available, the children also dispense that, ‘but most of the time they can’t even get aspirin’. So, the children help their parents die; there is no time to mourn, because they must go and seek assistance to arrange a funeral. (The Natal Witness, 11 July 2000)

Socioeconomic conditions. In southern Africa, the financial burden of HIV/AIDS-related illness or death on households is at least 30% greater than for deaths from other causes. Many of those who are ill, or caring for those who are, are poor and live in cramped housing with limited access to water or sanitation. Costs for treatment place a strain on savings, but most affected families cannot opt for drug therapy or even the most basic panaceas. By striking more than one family member HIV imposes major stress on the household, forcing single parents, older children or the elderly to take over responsibility. Affected households suffer from loss of medical and insurance benefits, treatment costs including transport, and reduced capacity for income generating work. Such households may depend solely on old-age income or sale of assets. Resources for education, food, housing, basic utilities and home maintenance decline substantially. Burial costs consume remaining resources, and children may be forced into low paid work, crime or sex work, thus increasing their own risk of infection.

Many at-risk learners come from the context of socioeconomic deprivation complicated by and further complicating HIV infection, whether they live in North America, Europe, Africa, Latin America, the Caribbean or Asia-Pacific. HIV/AIDS is not a disease of the poor, but the poor are at higher risk of HIV infection, the poor are more vulnerable to HIV infection, and the disease makes the poor poorer (Kelly, 2001a; Stillwaggon, 2001).

Stigma and isolation. Affected people are stigmatised and may be prevented from gaining access to social support mechanisms. HIV/AIDS-related stigmatisation is responsible for social rejection and alienation, and can compromise employment, housing, schooling and childcare. It means that HIV/AIDS-related loss of family and friends is not likely to be acknowledged. Fear of isolation is particularly strong among teachers who live and work in small communities, where confidentiality is problematic.

Psychosocial stress. The disease brings with it psychosocial stresses. Illness and the prospect of death in the family, often not discussed with children, are as traumatic for the child as for the adult. When illness becomes evident, family members are likely to experience rejection, ‘fear of contagion’, and anticipatory grief. When death occurs, high levels of grief enter households and communities, with implications for mental and physical health, as well as social and work relationships. Loss of a child particularly causes acute grief. Children are highly traumatised by watching parents die and not being able to talk about it. Stress and depression can compromise function and wellbeing in all areas of family life including school and work performance, family relationships and capacity for childcare. Responses to stress may include alcohol and drug abuse, and unsafe sexual behaviour. The difficulty here is that little is known yet about how children and young people process the stresses that engulf them (Ebersohn & Eloff, 2001; Solomon, 2001; Devine & Graham, n.d.)

The condition of women. Women are strongly affected by HIV/AIDS. They are at greater risk of infection, and more vulnerable to the socioeconomic effects of the pandemic. Women-headed households tend to be poorer than those headed by men, and have fewer reserves. Unemployment is generally higher among women than men, and even those who are married may be consistently subject to maltreatment without being able to resist for economic reasons. Violence against women often complements high prevalence rates. Women face risk of abandonment and abuse, and traditionally provide care for the terminally ill; girls may be withdrawn from school to do so. This is the backdrop against which the challenge of HIV to education services is being played out in the high prevalence countries of sub-Saharan Africa. It is these factors that will ultimately determine the profile of learner and educator populations, the supply of and demand for education (Collins & Rau, 2000).

Education Demand and Supply in High Prevalence Countries

Evaluating the evidence. Isolating and assessing the consequences of HIV/AIDS for education services in high prevalence developing countries is difficult for a number of reasons. Put very simply, children drop out of school but there is no way of knowing why they leave. It is only possible to guess at reasons for changes in enrolment, progression, completion and drop-out rates by using, with caution, what data are available. Use is also being made of anecdotal evidence and the observations of educators and social workers, and proxy measures like social welfare orphan registrations, rising incidence of child abuse presenting in paediatric units, and prevalence rates among school-age rather than school-going populations.

Teachers are known to be ill, absent from work and dying out of the teaching service, but HIV/AIDS is rarely named as the reason. There is no official procedure for terminating the services of African teachers who are HIV/AIDS positive and who should be pensioned off for medical reasons. Nor is there any way of determining whether teachers dying out of the service do so because of AIDS, except that – as in South Africa and Botswana – certain graphic data ring alarm bells for demographers.

Accurate information is hard to come by. Figures on which impact calculations are made for the education sector are meagre. They are collected with difficulty, and provide a poor base from which to generalise. Various models are used to predict national infection and prevalence rates with varying degrees of success, depending on surveillance methods, quality of data analysis and the interference of other factors.[8] National statistics can mask local variations in prevalence, and therefore in levels of impact on individual districts and schools. In most affected countries there are clearly risk ‘hot-spots’ that differ from the national average (Badcock-Walters, 2001). For education, additional information that must be factored into the demand and supply equation relates to the composition of the teaching force in terms of age, gender and marital status, relative salary levels, teacher perceptions of marketability, teacher education and qualification levels, levels of unionisation, and even ethnicity. This information is often difficult to obtain (Crouch, 2001a). Analysis of information is difficult. Because data collection is often flawed, the analysis of such statistics is fraught with peril. Misunderstanding, conscious or unconscious manipulation, political interest, the complex nature of pandemic statistics, modelling problems and uncertainties in extrapolating from them for particular purposes, all take their toll on the integrity of analysis. Added to this are puzzles related to what the statistics really mean. For example, is a downward curve the result of active intervention by government, or of intervention by others, or of personal choices to change behaviour, or the natural course of the pandemic (which is not well understood, and varies from place to place), or of the intersection of factors like incidence and morbidity which might suggest lower prevalence rates? It is often not possible to know whether shifts one way or the other are due to HIV/AIDS or to fiscal adjustments (up or down), adverse educational policies, the influences of increasing or decreasing socioeconomic deprivation, increasing or decreasing levels of international development support, or some other factor. For example, and very crudely, observable changes in enrolment at primary and secondary level in Uganda, and to some extent in Malawi, are due to Education for All (EFA)-driven progress in improving levels of primary provision. As more school places become available, more children attend primary school. With places at secondary level increasing more slowly and still falling short of demand, any place vacated by a student affected or infected by HIV/AIDS will be taken up by another candidate with the result that secondary enrolment figures will appear to remain stable, or even rise as levels of secondary provision improve (World Bank, 2000a, p. 59). In the South African province of KwaZulu Natal, where HIV infection rates are probably the highest in the world, changing regulations on age of entry have skewed grade 1 enrolment data. So the alarming drop of 24% in grade 1 enrolment in the province in 2000 was possibly a combination of new age of entry regulations, increasing poverty (much of it related to AIDS), and HIV-related reduction in school-age population. The relative proportions in the mix are impossible as yet to determine (University of Natal, Health Economics and AIDS Research Division, 2001, chapter 5).

Virtually every prediction of the pandemic’s impact on education is surrounded with caveats. There is tension between those who prefer to rely on so-called hard data, and those who rely on qualitative evidence derived from the experience of educators, social and health workers, police and churches, home-based care volunteers, researchers and parents.[9] Either way, impact can remain invisible for long periods of time. For example, in a country or state of say fifty million people, with a service of 400,000 educators, a 10% prevalence rate would mean that 40,000 were HIV positive, at some point along the continuum from initial infection to morbidity and mortality, with or without access to drugs. With 30,000 schools, each school might have only one or two infected teachers. More probably, some schools would have no infections, while others might have many. The most severe critical-mass impact can be expected in future because of the long lag between infection and development of full-blown AIDS and death. That means infections in the 1990s, particularly heavy in South Africa and Botswana for example, will not be felt until the first decade of the millennium. Uganda, where the epidemic is thought to have peaked in the early 1990s at between 9-12%, may already have passed through size and quality of the pandemic differ radically.

What is truly ‘known’ about HIV’s impact on education services is questionable. Crouch (2001a), in a seminal interim analysis of HIV and teacher supply issues in South Africa, opens his study by confessing that there seems to be little doubt in the minds of most well-informed opinion-makers that the teacher work force in South Africa has been undergoing turbulent change in the last few years. Furthermore, with the onset of the HIV/AIDS epidemic, further turbulence is predicted. Sharing this commonly held view, and wanting to put some parameters around this presumed past and future turbulence, we started out to undertake a systematic analysis of the main data sources available [including national household surveys, labour force data, educators’ salary databases, demographic forward modelling, and administrative records]. We expected to be able to document great turbulence and dire trends. We expected to be able to make simple and portentous macro-level statements. What we found is worrying, but far too nuanced to drive statements that are both portentous and simple. (p. 4)[10]

It is only possible to estimate, to use the best data, information and models available, and to test predictions again and again. It is nevertheless necessary to indicate the most probable trends for education in future with the onset of

AIDS.

The following supply and demand analysis is based on a number of sources: the preliminary but systematic teacher supply analysis by Luis Crouch and colleagues in South Africa, the World Bank’s study of turbulence in four high-impact countries (Kenya, Uganda, Zambia and Zimbabwe), a review of Ugandan data by Parkhurst, assessments by Abt Associates of the impact of HIV/AIDS on education sectors in Botswana and South Africa, preliminary analysis of data for KwaZulu Natal Province in South Africa by the Health Economics and AIDS Research Division of the University of Natal, and the summary of case studies in eight sub-Saharan African countries by Michael Kelly for the Economic Commission for Africa/Africa Development Forum (Kelly, 2000a; Love Life, 2000; World Bank, 2000a; Abt Associates, 2001; Badcock-Walters, 2001; Crouch, 2001a; Parkhurst, 2001).

Demand for Education Services Size of learner populations. Demographically, HIV/AIDS will affect the size of learner populations. Where prevalence is high, rising deaths among adults of reproductive age and declining fertility rates result in fewer children being born. Combined with increased mortality among children infected around the time of birth, most of whom die before they are five years old, this means there are fewer potential learners than there would have been without AIDS. It is anticipated that Zimbabwe will experience a 24.1% reduction in primary school age population by 2010; Zambia 20.4%, Kenya 13.8% and Uganda 12.2% (World Bank, 2000a, p. 3; Abt Associates, 2001, p. 4).

In Botswana, there are likely to be 860,000 young people under 25 by 2015, rather than 1,200,000 if HIV/AIDS had not intervened. There is already evidence that the 0-4 year age group is declining in absolute numbers while the 5-9 year age group showed signs of starting to decline in 2001. Grade 1 intake, which appears to have been slowing for some time, declined by 3% in 1998. Declines in numbers of children in older age groups are likely to become apparent by the end of the decade (Abt Associates, 2001, p. 4).

In South Africa, the number of potential learners is expected to decline if orphans and other vulnerable children do not enrol, delay enrolling, or leave school in large numbers. In general, orphans, at-risk children and those in HIV/AIDS-affected homes are likely to be withdrawn from schooling and higher education. Introducing drugs to reduce mother to child transmission of HIV, assuming governments are able and willing to provide this option, will ultimately make a difference, but only over a long period of time (Love Life, 2000, pp. 26-27; Abt Associates, 2001; see also Unicef [United Nations International Children’s Emergency Fund] & USAID, 2000).

It is essential that the accuracy of demographic projections be monitored, their assumptions interrogated, and changed circumstances, like the provision of anti-retrovirals, be factored into these equations. In the short term, planning will need to take account of reductions in enrolments as fewer children are born and many HIV-infected children fail to thrive or survive to school-going age.

Growth rate of learner populations. HIV/AIDS will affect the growth rate of learner populations. In the past, population growth rates in eastern and southern Africa were very high. HIV/AIDS seems to be responsible for substantially reducing average annual growth rates for primary school age populations. In Zambia and Kenya the rate of growth of the primary school age population is expected to slow significantly because of HIV/AIDS. The apparent decline in prevalence in Uganda may mean that the primary school age population will grow rapidly, although the success of the Government’s UPE (Universal Primary Education)/EFA policies are likely to mask any HIV effects (World Bank, 2000a, p. 4).

Demand for education. HIV/AIDS will influence demand for education throughout the region. Declining primary enrolment over the next decade will translate into subsequent reductions of qualified candidates for high school and tertiary training. In South Africa, younger people are most severely affected by the disease with around 60% of all adults who acquire HIV becoming infected before they turn 25. Young women are particularly vulnerable for biological, social and economic reasons. A recent voluntary and anonymous survey at a university in KwaZulu Natal Province in South Africa estimated infection rates of 26% in women and 12% in men aged 20-24, and 36% in women and 23% in men aged 25-29 (Love Life, 2000, p. 3).

Orphans are more likely to be denied education. In Mozambique, for example, only 24% of orphans attend school, compared with 60% of those with living parents. Children affected by AIDS often perform poorly at school and their drop-out rates in parts of Botswana are reported to be unacceptably high (Kelly, 2000a; Abt Associates, 2001).

Botswana, South Africa, Swaziland, Zimbabwe and Zambia already have evidence of stagnating or declining enrolments, much of it very likely attributable directly or indirectly to HIV/AIDS (Kelly, 2000a; Abt Associates, 2001).[11] Observable factors likely related to changes in demand include fewer resources for education in HIV/AIDS-affected households because of high death rates resulting from HIV/AIDS. Learners will be withdrawn from school as orphaning and poverty rise, or will not enrol because of fees and opportunity costs, and the need to care for those who are ill. Communities will be unable to provide support for schools as they did in the past although some communities are already reacting positively by building community schools for their own children.

More complex learner cohorts. HIV/AIDS is affecting the potential clientele for education services by creating large cohorts of orphans and other vulnerable learners. In most parts of the industrialised world usually no more than 1% of the child population is orphaned. In developing countries, the proportion would normally be 2% of the child population, and orphans (under 15s who have lost mother or both parents) could be absorbed into the extended family. Globally, the rate at which children have been orphaned doubled, tripled or even quadrupled in 35 countries between 1994 and 1997. The sharpest increases in AIDS orphaning took place in countries as diverse as Botswana, Cambodia, India, Malaysia, Namibia, South Africa and Swaziland, followed by Argentina, Lesotho, Mozambique, Myanmar, Venezuela and Vietnam (Unicef, 1999). Recent estimates for eastern and southern Africa suggest that more than 18 million children below the age of 15 have lost one or both parents, in about 70% of cases because of AIDS (Kelly, 2000a).

By 2010, it is estimated that maternal and double orphans will rise to more than 25% of children in Zimbabwe, to nearly 19% in Zambia and about 17% in Kenya. The addition of paternal orphans and orphans from causes other than AIDS would raise the proportions for these countries even further (Unicef, 1999; World Bank, 2000a, p. 7). By 2005 there will be 800,000 orphans under 15 in South Africa, rising to almost two million by 2010. The number of orphans in Botswana is projected to rise rapidly from 38,000 in 2000 to 161,000 by 2010 (current population 1.8 million) with one in two children aged 10-14 orphaned.

Rates of orphanhood will be higher in some districts, schools and classrooms than in others. Some secondary schools in Botswana already report that 20-30% of students in some classes are orphans (Abt Associates, 2001). In Malawi, during 1999, the percentage of children in school who had lost one or both parents increased from 12% to 17%. One-third of children in one study reported they missed school in order to care for the sick. This percentage doubled for children who had lost both parents. Six percent of children reported missing school for funerals. Children with both parents dead were twice as likely to drop out (17.1%) during the 2000 school year as children with one parent dead (9.1%), or both parents living (9.5%). Repetition rates for children whose parents were dead were 5-15% higher (depending on cohort and grade) than for children with living parents. The average age for pupils with both parents dead was about six months older than the average age in their grade cohort (Harris & Schubert, 2000).

The consequences for education of large numbers of HIV/AIDS-affected learners are likely to be profound. Such learners are often at physical disadvantage for nutritional and economic reasons. Their attendance and performance decline and they are likely to suffer HIV-related discrimination. Their attendance at school becomes increasingly random, and they must learn under a cloud of trauma and loss. When teachers suffer for the same reasons, and are unable to respond to the needs of children in distress, decline in motivation, morale and performance on both sides is inevitable.

Supply of Education Services

Predicting basic supply and demand for teachers is virtually impossible. It must be understood that forecasting something so susceptible to social trends and policy shifts as teacher supply and demand is extremely hazardous. Furthermore, these sorts of forecasts have absolutely no rigorous confidence intervals: that is we cannot state our confidence in the results with any degree of precision … . The demand side is relatively easy to forecast, but the supply side (and therefore the gap between supply and demand) is really quite chancy. All we can say therefore is that … projections [are] conditional on a whole host of assumptions, some of which have to do with the likely course of say, normal demography or the AIDS epidemic, and some of which have to do with possible policy choices in the future. (Crouch, 2001a, p. 28)[12]

Nevertheless, it is remarkable that, at a time when the business community in high prevalence countries is being forced to assess the potential impact of HIV/AIDS on workforces, and attendant cost and inefficiency problems, governments have given little or no attention to protecting the education service, the largest, most expensive and highly trained cohort of workers in any developing country. (Moore & Kramer, 1999, p. 4)

Increased educator morbidity and mortality. HIV/AIDS will affect the supply of education services through increased mortality of educators. The World Bank assumes very generally that losses of educators will parallel those in adult populations. Zimbabwe would therefore lose about 2.1% of educators to AIDS between 2000 and 2010, Zambia and Kenya 1.7% and 1.4%, and Uganda (where AIDS mortality appears to be lower) an estimated 0.5% (World Bank, 2000a, p. 5). The Zambian Ministry of Education reported that 2.2% of all teachers died in 1996. This was already more than the number of teachers produced by colleges that year, but it has been estimated that teacher death rates might triple by 2005 (Love Life, 2000). The World Bank reported a study that projected 14,460 Tanzanian teachers would die by 2010, costing US $21 million in replacement training (Save the Children UK [United Kingdom], 2001a). Crouch’s round-number projections for South Africa suggest that whereas teacher education production capacity is now 5000 annually, at least 30,000 new teachers will be required to be trained each year by the end of the decade (Crouch, 2001b).

Kelly and others [13] suggest that the educator cohort is at high risk of infection because of relative affluence, mobility and status in the community, their expectations of sexual ‘bonuses’ in lieu of better conditions of service, and circumstances that separate them from their families.[14] Recent analysis suggests that for teachers, as for other professionals, early high incidence rates are reducing gradually to below-average rates (Botswana Ministry of Education & United Kingdom Department for International Development, 2000; Abt Associates, 2001).

Death rates in excess of 3% of educators per year have been reported in at least two countries (Abt Associates, 2001). There are indications that primary school teachers are at greater risk than secondary educators. Teachers are also being lost to other sectors of government and to the private sector to replace personnel lost to AIDS (Swaziland Ministry of Education, 1999). Educator productivity is reported to be down and absenteeism up because of AIDS-related sickness, care for family members and attendance at funerals. There are increasing problems finding replacements for specialist teaching and other staff, especially as teacher mortality outstrips teacher provision in countries like Zambia.

Increased costs of provision. HIV/AIDS will affect the supply of education services because of the costs it imposes on the system. In Botswana, direct costs of HIV/AIDS to education include employee benefits, hiring of temporary staff and costs of recruitment and training. Indirect costs include loss of productivity due to absenteeism, loss of skills, declining morale and low performance among ill employees. Most studies of HIV/AIDS impacts on employees and organisations indicate that the impact on organisation function and costs is seldom disastrous in any one year, unless a key official is lost at a critical time.

The greatest concern is for the relentless loss of skills that build up to a significant human resource deficit and gradual decline in quality. For Botswana, possibly the only country where these calculations have been done for the education service, Abt Associates suggest that if the total education workforce were provided with anti-retroviral treatment, medical costs might well exceed 0.9% of the basic salary bill by 2005, and 1.8% in 2010. Pension funds are structured in a way that means the cost implications of illness and deaths to the sector will be neutral. There is concern however that levels of benefits provided to employees who are ill or die could be considered inadequate. Benefits currently give sick employees a financial incentive to stay in post until they die, even though this is clearly undesirable for them and their families, as well as for learners and colleagues (Abt Associates, 2001).

The Quality of Education Provision

Challenges to education quality. The HIV/AIDS pandemic will affect the quality of education services. Teachers are being lost through illness and mortality (KwaZulu Natal Province and Botswana), and transfers to other sectors (Swaziland). AIDS-related illness means educators become increasingly unproductive. Death or absence of even a single educator is particularly serious because this affects the education of 50 or more children. Because teaching service management have made no provision for medically boarding educators who are ill (and may refuse to be tested), teachers continue to teach even during terminal illness (Botswana and South Africa). With high teacher and pupil absenteeism, instructional time is disrupted. Textbooks and teachers’ manuals are designed for a full school year of full-class instruction. There is no evidence that provision is being made for individual learning or for adjusting lessons to learner needs. Repetition is not the answer, for this merely increases class size, reduces efficiency and puts girls at risk when older boys join the class (Caillods, 2000; Harris & Schubert, 2000; Love Life, 2000) .

Current shortages of educators in critical fields such as science, mathematics and technical skills will become more acute. Loss of key individuals in management or senior leadership – planners, principals, inspectors, teacher educators – may compromise quality and efficiency. Concentration of deaths among staff in the 30-39 year age group, just when they have accumulated important experience, means not only loss of their skills but may jeopardise less formal processes of mentoring and skills transfer within the sector.

As the average age and experience of teachers falls, systems will rely increasingly on less qualified teachers, young teachers with less experience and poorly qualified new recruits whose secondary and teacher education may have been disrupted by the loss of qualified teachers and lecturers. These effects are likely to be compounded by the reduction of numbers of qualified entrants to teacher education from secondary schools (Love Life, 2000). HIV/AIDS is impacting on the emotional status of educators and young people (Kelly, 2000a). Teacher morale is low where impact is high, combined with considerable student and teacher trauma. Teachers who, at least in Africa, have generally resisted voluntary testing and counselling may be uncertain about their own HIV/AIDS status (Abt Associates, 2001). Both educators and learners have difficulty concentrating in the face of illness, death, mourning and dislocation (Kelly, 2000a). Many learners affected by the presence of HIV/AIDS have a widespread sense of anxiety, confusion and insecurity (Ebersohn & Eloff, 2001; Devine & Graham, n.d.). The psychosocial needs of affected children are not as well understood as their material needs (Coombe, 2001b;

Save the Children UK, 2001a; Unicef et al, 2001). Adult caregivers may fail to identify psychological difficulties as the cause of more visible problems like truancy or anti-social behaviour. And where emotional problems do manifest themselves, few people responsible for children are equipped to handle them. Further, where abuse and violence along with teacher misconduct characterise the learners’ community, young girls and boys fear they will be sexually abused or maltreated.[15] There may be uncertainty and distrust between learners and educators if the latter are seen to be those responsible for introducing or spreading HIV/AIDS (Kelly, 2000a; Leach & Machakanja, 2001).

All this adds up to a school environment characterised by constant change and distress. Even children from intact, healthy families are surrounded by death and loss. Stress is unrelenting, and contributes to what one educator described as the ‘inchoate unease’ which textures the learning environment in heavily infected countries (Harris & Schubert, 2000). Not all schools will suffer to the same extent. But there is enough personal and systemic trauma to undermine education quality generally.

Finally, and ironically, policies intended to support children affected by HIV/AIDS, such as Malawi and Uganda’s introduction of free primary education for all children, have dramatically overstretched the education system and reduced quality of provision.

Getting the balance right between demand and supply. HIV/AIDS will likely affect the demand for educational services slightly more than the supply through 2010. It is probable, on the basis of statistical analysis for Kenya, Uganda, Zambia and Zimbabwe, (1) that fewer teachers will be needed because the school-age population will be smaller and (2) that fewer teachers will be available because of increased teacher mortality. This is a very tentative conclusion because the calculation on which it is based does not take into account teacher absenteeism and early mortality caused by opportunistic infections, or many others of the complex panoply of factors that influence educator supply and learner demand (World Bank, 2000a; Crouch, 2001a).

Current Education Responses to HIV/AIDS

Introduction

Responses to the pandemic vary worldwide relative to infection rates, geographical, cultural and religious variables, the leadership and management capacity of governments, and the level of commitment in non-government sectors. Where prevalence is low, or confined to high-risk groups, there is little evidence of concern in the sector about the potential implications of the pandemic for education. Learning institutions may fairly routinely deliver safe sex messages as in Thailand and the UK. But education systems in low prevalence areas are not yet confronting large numbers of AIDS-affected learners or high teacher attrition, and the pandemic for the moment remains largely invisible.

This analysis of current policy responses concentrates on experience in high prevalence countries, mainly but not exclusively in sub-Saharan Africa and the Asia-Pacific Region, in 1. helping to contain the spread of HIV/AIDS, 2. providing social support for affected learners and educators, and 3. protecting the system of education. The review focuses principally on the response of the official or formal system. It emphasises the increasing role being played by non-government agencies, and the importance of strengthening their contribution to the fight against AIDS.

Prevention: containing the spread of HIV/AIDS among children and adolescents

Governments in high prevalence countries have accepted responsibility for delivering mass prevention campaigns through learning institutions and non-government partners. While the intended responses of such campaigns can be categorised, their actual achievements are poorly described in the literature and are very rarely evaluated. Much supplementary prevention work is carried out by communities, non-governmental organisations and faith-based organisations, with support from the international community. What follows is a description of what is known from observation, experience, case studies, information from conference reports, a survey of Southern African Development Community (SADC) ministries of education and so-called grey literature.

Developing life skills curriculum and learning and teaching materials. The teaching response to HIV/AIDS (known as HIV/AIDS education, reproductive health and sex education, life skills or life orientation)[16] is generally supposed to communicate relevant knowledge, engender appropriate values and attitudes, and build personal capacity among learners to maintain or adopt behaviour that will minimise or eliminate the risk of becoming infected by HIV. An indirect benefit of such programmes is that teachers, too, lacking educator-focused prevention programmes of their own, learn about HIV. Curricula generally aim at equipping learners with skills such as decision making, problem solving, effective communication, assertiveness and conflict resolution (Kelly, 2000a).

Most countries in eastern and southern Africa have either elaborated HIV/AIDS-related curricula or are ‘planning to do so’. Problems persist about how to include life skills and reproductive health in the school curriculum – a separate subject, or integrated in other subjects? (Neither is believed to be particularly effective.) There is ubiquitous evidence that few teaching and learning materials are getting into classrooms, and that teachers have virtually no guidelines for coping with the pandemic (Berkhof, 2001). South Africa’s emergency guidelines for educators and similar guidelines drafted by Zambia’s

Ministry of Education are intended to provide basic guidance for educators, but are not known to be available in other countries (South Africa Department of Education, 2001b; Zambia Ministry of Education, 2001). Although one in nine of those who are HIV positive globally live in India, school-based education programmes do not yet seem to be a principal element of India’s IEC (information, education, communication) strategies. The Government of India has gone only as far as distributing a training module (Learning for Life) to all states to assist with training teachers and peer educators among students. A number of states are reported to have initiated school-based programmes (India Ministry of Health and Family Welfare, 2001).

Disseminating information. Youth-focused media campaigns like Love Life and Soul City (see www.comminit.com) in Botswana, Namibia and South Africa, the media campaign of the Johns Hopkins University unit in Rwanda, the Saraprogramme in Tanzania, and the Recross AIDS Network for Youth (West Africa) (Adu-Aryee, 2001) effectively supplement school-based and college-based HIV/AIDS programmes. But media campaigns focused at youth in Africa have for the most part tended to be limited in coverage, poorly designed and disseminated, and sometimes thematically inappropriate where they fail to take account of adolescent and contextual realities. They are best when youth are upfront.

Providing guidance on the distribution and use of condoms. The idea of condoms for youth is a persistent cause of conflict between ministers and their constituencies, between parents and teachers, and between teachers and students. There is no evidence that guidance on condom availability, accessibility and use has been issued to teachers or school heads in any country surveyed. Resistance by church leaders, older teachers and traditional leaders has created an aura of ambivalence. One girls’ hostel matron in Botswana obtained condoms from the local clinic but, without guidance, feared to make them available and hid them under her bed.

To get around ambivalence and confrontation, Uganda is reported to have waged a ‘silent campaign’ during which, without public debate, condoms were made available to those who needed and wanted them. The Thai 100% condom programme succeeded because it concentrated on a limited goal and excluded questions of morality or the elimination of prostitution. ‘Other countries would do well to consider this aspect when drawing up their own programmes’ (Larson & Narain, 2001, p. 35). This is true even where many schools are concerned. Difficult decisions will need to be made by young people and their parents, locally by communities and school governing bodies, rather than by central authorities, about condoms.

Problems of accessibility to voluntary testing and counselling, the  confidentiality of test results, and treatment of STDs has undermined the  transparency necessary for successful prevention programmes. Fear, denial and  silence still characterise the sub-Saharan pandemic particularly for university  students and all educators. There is evidence from Botswana that teachers who  are eligible to receive anti-retroviral treatment under their medical aid scheme  coverage refuse to do so for fear of being identified as HIV positive (Botswana

Ministry of Education & United Kingdom Department for International  Development, 2000).

In-service and pre-service preparation of educators. Sub-Saharan Africa education  sector strategic plans commonly ignore or fail to address the need to adjust in- service teacher education (INSET) and pre-service teacher education (PRESET)  programmes, their curricula, their delivery and their purpose, and the urgent  importance of adjusting guidance manuals and teaching/learning materials  appropriately. A review of university-based and college-based teacher  education programmes in South Africa demonstrated recently that while some  institutions were ‘thinking about’ preparing to teach HIV/AIDS curricula, most  had done little or nothing to move in that direction.[17] Neither are there any  known programmes for upgrading the skills and knowledge of teacher  educators.

Thirteen of the 14 countries in the SADC region were surveyed in  February-March 2001 about their response to the pandemic, including  introduction of life skills curriculum and preparation of teachers.[18] Although  HIV/AIDS has been present in the region for 20 years, ministries of education  reported as follows (see Table I).  An analysis of case studies from Ethiopia, Kenya, Malawi, Rwanda, South  Africa, Tanzania, Uganda and Zimbabwe for the United Nations Economic  Commission for Africa highlights the shortcomings of current prevention  programmes in the sub-region (Kelly, 2000a). Most programmes start too late,  for children age nine and up. They are developed from the top with little  consultation with parents, teachers and young people, and are more concerned  with the biology of human reproduction and barrier methods of prevention  than about understanding relationships, showing respect for others and  protecting the rights of all. Delivery is almost exclusively in the hands of  teachers although they are for the greatest part poorly prepared, and generally  lack knowledge and understanding. The discredited cascade model used to  train them (if they receive training at all) often dilutes or even misrepresents  content. Many teachers are poor role models and feel uncomfortable talking about sexuality. Cultural beliefs, expectations, traditions and taboos related to  behaviour receive little attention, and materials generally portray sexuality as  heterosexual and consensual, ignoring problematic issues of rape and  harassment and rising levels of incest, homosexuality and child abuse.  Programmes are driven by ministries of education, with little except ad hoc  unofficial support from stakeholders in the sector or other social sectors.

Finally, there has been no effective evaluation of life skills programme content,  implementation and outcomes. The extent to which such programmes reduce  HIV transmission, STDs, rape or coerced sex is not known.  Helping to limit the spread of AIDS: the SADC region

Appropriate curriculum in all learning institutions: Are learners being guided through the curriculum on safe sex and appropriate behaviours and attitudes? 

Materials developed and distributed: Have materials suitable for learners in schools and post-school institutions been developed and distributed to institutions? Are they up to date? 

Serving educators prepared: Are school teachers adequately prepared through pre-service and in-service to teach life skills curricula? Have they accepted this responsibility? 

Teacher educators prepared: Have university, teacher training college and local teacher support staff been trained in HIV/AIDS issues and curriculum implementation?

Evaluation of curriculum and materials: Have materials and courses been evaluated in terms of content, implementation and outcomes?

Partnerships: Are other partners helping with prevention programmes?  

Evidence was produced at the 6th International Congress on AIDS in Asia and the Pacific (Melbourne, October 2001), that there is serious potential for extensive spread of HIV in that region, in part at least because prevention programmes still have not reached most people. Coverage is too limited. There is only 40% awareness among Indian women, and vast areas of rural China remain unreached (Brown, 2001).

Challenges. AIDS prevention delivered through schools is agreed to have  potential for helping to keep children and young people safe, and allow them to  help others. Effective skills-based health education for learners, from the time  they enter school, must be a key education sector strategy. But its potential is  not being realised for a number of reasons (Inter-Agency Working Group,  2000; Kelly, 2000a; Coombe, 2001a).

In many communities, belief persists that any kind of sexual education  leads to increased sexual activity. Adult conservatism, cultural taboos and the   ‘sensitivity’ of the content area create tension around implementing effective  life skills programmes. African case studies confirm what has been found  elsewhere: that young people who participate in reproductive health  programmes do not become promiscuous. They do not engage in sex earlier or  seek more frequent sexual intercourse, and in some cases delay initiation of  sexual activity (Kelly, 2000a).

There have been very high expectations that prevention education will  result in desired behaviour change. When changes fail to appear quickly, the  assumption is made that the programme has failed. Clearly, HIV/AIDS  prevention education, to be successful, must be complemented by a range of  consistent, long-term, supportive strategies. (Nevertheless, it is discouraging to  note that in Botswana, ‘antenatal survey data and various surveys of  knowledge, attitudes and practices indicate that despite high levels of  awareness of AIDS and basic HIV/AIDS knowledge, there has been no change  in behaviour that seriously begins to turn back the pandemic’ (Abt Associates,  2001, p. 5).

Life skills programmes are just not getting out to those who need them.  Prevention programmes are often under-funded, with inadequate attention to  training teachers, sensitising managers, providing supportive health services,  and linking programmes with other community services. There is serious concern about the capacity or willingness of many teachers to engage with life  skills programmes, or to provide complementary care and counselling support  to affected learners or colleagues (Coombe, 2001b). Many so-called national strategies remain at pilot project level, although countries like Kenya are now making efforts to scale up to national level, especially in the areas of materials development and distribution, and teacher training. The current challenge is to continue to expand and strengthen education-driven programmes aimed at  AIDS-related behaviours (World Bank, 2000a, p. 38).

Education ministries and their non-government partners are struggling to deliver. HIV/AIDS is only one of many problems faced by education services.  Failure to deliver prevention messages effectively is compounded by the dire physical environment of many schools (lack of water, latrines, adequate classrooms and teachers’ housing, decent hostels, furniture and books), by the teacher-unfriendly and child-unfriendly ambience in many learning institutions  (where physical and sexual abuse are present along with corporal punishment and poverty-related or HIV/AIDS-related trauma), and by inadequate management support for teachers (overcrowded classes, low and irregular  salaries, an inappropriate policy framework which may discriminate against  HIV/AIDS-affected learners and educators, and comprehensive failure to make  provision for educators affected by HIV/AIDS) (Coombe, 2001c).

In many countries, sexuality education cannot, for religious reasons, be part of the educational curriculum. Talking about sex publicly continues to be taboo in much of Pakistan for example, where illiteracy and school exclusion rates continue to be high.[19]

Social Support: care and counselling for learners and educators affected by HIV/AIDS  

Unicef’s strategic paper, Principles to Guide Programming for Orphans and  Other Children Affected by HIV/AIDS (2001), stresses that although they are  less tangible than the violations of other rights that children suffer,  [HIV/AIDS-related] psychosocial problems are rarely addressed in  HIV/AIDS programmes, and yet can have long term impact on  development. A child’s progression through basic developmental stages is  jeopardised if HIV-related illness reduces and then ends a parent’s capacity  to provide consistent love and care. (Unicef, 2001, p. 8)

Adequate socialisation might have been added to the list. While there have  been regional conferences and much informal discussion on issues relating to  HIV, gender and sexuality for example, and there is significant literature on  orphan care,[20] little is known in practice about how children and their  families are coping with HIV/AIDS-related trauma, and the impact it has in the  classroom (Ebersohn & Eloff, 2001). The South Africa Department of Health, HIV/AIDS and STD Directorate (2001) has produced a guidebook, HIV and AIDS: care and support of affected and infected learners: a guide for educators, to  supplement the ‘emergency guidelines for educators’ (South Africa  Department of Education, 2001b). There is talk about lay counselling INSET and PRESET courses for educators, and Botswana has provided counsellor  training for a few educators through its Institute of Development Management.

But most countries are at an early stage in their orphan epidemics, and it  appears difficult for them to anticipate or plan how educators will cope with  very large numbers of distressed children. Re-orphaning of children is expected to be common, and the group psychological effects of the epidemic may change current norms around schooling in unpredictable ways. Many non-orphans will be affected indirectly by AIDS impacts on friends, teachers and families, especially in households that assume extra orphan-care burdens (Abt Associates, 2001).

The SADC review graphically demonstrated the failure of countries to provide  even a modicum of social support in schools or to engage with the likely  consequences of having increasing numbers of intellectually, socially and  psychologically dysfunctional learners (Table II). There is substantial evidence from principals and teachers that non-government agencies are providing support to schools through peer group programmes, teacher advice and counselling, and training. Such programmes are generally ad hoc, often grossly under-funded relative to the role they play (or could play), and are not generally recognised, resourced or formally contracted by the official system to undertake tasks that the system itself is apparently not capable of doing.[21]

Challenges. The education sector’s responsibilities here need defining. What do teachers need to be able to do, and when should they hand over to other social service staff? Should some or all teachers be prepared to identify children in difficulty? … to provide a modicum of compassionate care? … to help institute a culture of care in each school? Should not all educators be held accountable for creating safe and secure environments for girls in schools and hostels?

Potential problems can be predicted because of limited systematic leadership on social support issues in learning institutions. With concentration focused on prevention programmes, there has been no clear definition of the sector’s role in social support, or of schools’ role in local strategic planning. Teachers clearly feel daunted by the challenge of responding to increasing orphan numbers. Although many teachers, especially women, are responding generously as individuals, the education service generally does not promote social support.

And guidance and counselling programmes are not a suitable alternative. There is potential for forming a circle of care network involving education, social and health systems but for the most part there is poor coordination among social sector staff at all levels, and between them and local volunteers.

Protecting Quality: sustaining education provision

Here is the core of the education demand and supply equation: the need to stabilise provision and maintain education quality. Education is big business. In any country, the education budget commands one of the largest slices of the national fiscus. Nevertheless, government managers have been, perhaps inexplicably, slow to take action to maintain efficiency, sustain output and reduce cost in the face of this pandemic.

Education sector ‘strategic plans’ are widely variable in the extent to which they recognise and incorporate (if at all) the turbulence caused by HIV/AIDS in planning for the sector, although the situation is fluid.[22] Botswana, Namibia and Zimbabwe are currently assessing the impact of HIV/AIDS on the sector, and Zambia has prepared an HIV/AIDS strategy within the context of its SWAp (sector-wide approach) programme. In Kenya, projections used for education planning take account of likely HIV/AIDS impact scenarios but are not factored into planning. In Uganda, though official projections incorporate assumptions about HIV/AIDS, planning projections in the ministry are based more on assumed intake and repetition rates than on projections of the size of the school-age population and assumed enrolment ratios during a period when Uganda is moving strongly toward UPE goals

(World Bank, 2000a; Abt Associates, 2001).

Evidence from both SADC and the Economic Community of West African States (ECOWAS) (Baku, 2001; Casely-Hayford, 2001) shows that current HIV and education strategic plans are characterised by concentration on curriculum interventions aimed at behaviour change. They focus principally on primary and secondary schools to the exclusion of early childhood development, the post-secondary training, university and college sector, and out-of-school children. They generally fail to address issues related to the management of the teaching service affected by HIV/AIDS (Ghana and South Africa may be exceptions) and the needs of learners affected by HIV/AIDS.

Perhaps the implications are too large and too complex. There is no evidence in the region of workplace policies in schools and offices,[23] codes of conduct, HIV monitoring protocols for the service, guidance on the rights and responsibilities of teachers, or management guidelines for senior managers. Current teaching service regulations need major review, as well as human resource management policies.

Finally, and fatally, there is no observable attention being given to the managerial capacity, funding, human resources and infrastructural requirements that need to be in place to support practical strategic action in the sector (Association for the Development of Education in Africa, 2001). African ministries are failing consistently, in their planning and in their practice, to seek to sustain education quality and levels of provision, or to create new learning opportunities for the disadvantaged.[24] Neither are they attempting to ensure that demand and supply are in qualitative and quantitative balance so that the level and quality of education provision is sustained through the future period of extreme dislocation. There is little research or expert analysis of complex cost factors, and no evidence of teacher training colleges or universities adjusting pre-service and in-service models and curricula appropriately. SADC evidence demonstrates the extent to which most ministries have failed to address the planning and management complexities that HIV/AIDS imposes (Coombe, 2001d; Southern African Development Community, 2001). Mitigating the impact of HIV and AIDS on the education sector 

Assessment: Has an assessment been done of the likely impact of HIV/AIDS on the education sector in future?

Risk profile: Is there some understanding of the factors that make educators and learners vulnerable to infection?

Stabilising: Are steps being taken to sustain the quality of education provision and to replace teachers and managers lost to the system?

Projecting: Have relatively accurate projections been made of likely enrolments and teacher requirements at various levels of the system over the next five to ten years? 

Responding creatively: Is the system trying to provide meaningful, relevant educational services to learners affected by HIV/AIDS, finding new times, places and techniques for learning and teaching?

All sub-sectors: Is attention being paid to the planning requirements of all education sub-sectors – from early childhood development through to university? 

Challenges. Strategic action to protect the education service may be anticipated following completion of the impact assessments currently under way. But while impact assessments are being undertaken, there is no concurrent effort to establish strong, viable, executive HIV/AIDS divisions in ministries that can drive strategic plans, and have the technical capacity to develop them.

Protecting Quality: responding creatively to more complex learning needs

Perhaps the greatest provocation to education quality will come from the ‘randomisation’ of learning and the complexity of learner cohorts which include large numbers of vulnerable, orphaned and otherwise traumatised children. At the same time as educational systems and institutions become more fragile, appropriate learning opportunities will need to be created for multitudes of AIDS orphans and other vulnerable children. That means, for example, making special learning provision for orphans suffering disorientation or isolation, for children caring for younger children, and for girls caring for the sick. Young people and selected teachers will need to learn basic caring and counselling skills so they can help those in physical or emotional difficulty. Alternative learning opportunities are required for those forced out of school early, or who need to move in and out of learning. This probably means moving in the direction of a lifelong learning paradigm, and a broader and fresher definition of ‘nonformal education’.[25]

Schools have a critical role to play as centres of support for communities in the grip of HIV/AIDS, the principal community-based organisations (CBOs) in the fight against the pandemic and attendant poverty, sexual violence, female disempowerment and abuse of human rights (Kelly, 2000a). There is growing recognition among policy makers and educators that each school can be a fulcrum for community welfare. That means working more closely with health and social services, and providing a physical focus for community effort (including providing fax, phones and electricity in some instances).

Challenges. The problems faced by governments, districts and schools in creating new opportunities for challenged learners are generalised. There is a profound lack of creativity in bureaucracies at all levels, especially where conditions of service for teachers are poor. Schools often lack resources to share with communities. Educators are already under pressure from HIV/AIDS, and are having enough difficulties delivering basic HIV-related knowledge. Being creative may be a step too far. To expect them to make a swift transition to providing care and counselling is unreasonable. Most schools are very basic places, with far too many problems already. The need to make measurable, creative responses to the HIV crisis shines a bright torch on the difficult circumstances of most schools and their staff.

Evaluating Current Responses

Many countries around the world have established national AIDS councils and secretariats, and HIV units in their ministries of education, though they are typically understaffed and lack executive power. There is extensive political commitment at the highest level in countries like Uganda and Botswana, although others like South Africa, for example, have fallen short in this regard. Many countries are now emphasising a multisectoral approach that deals with HIV/AIDS as a development issue that transcends health, and the importance of working together both multisectorally and with other stakeholders.[26] It is difficult to ascertain whether governments are keen to hand to communities because they know local strategies can work, or because they recognise the problem is too big, too costly and too complex for central government to handle.

Several countries have commissioned education sector impact assessments (Botswana, Mozambique, Namibia, South Africa, Swaziland, Zimbabwe) and have created HIV/AIDS and education policy and strategic plans. But implementing such plans reveals persistent management weakness. Most managers have not received professional preparation for their responsibilities and many hold posts by virtue of their seniority or experience gained as they rose through the ranks. HIV/AIDS is wreaking havoc with fragile management systems (Kelly, 2000a). Financial resources are reducing because of the pandemic’s impact on availability of private and public funds for the sector, reducing total disposable assets, diverting resources away from education to other areas like health and social welfare, increasing costs and reducing taxable income from the private sector. Ministries have been deficient in planning how to make best use of international resources.

Combined approach: Is equal consideration given to (1) preventing spread of the disease and to (2) reducing the anticipated impact of the pandemic on education? 

Leadership: Are political leaders, senior officials, unions, the teaching service and school governing bodies knowledgeable and committed to action? 

Collective dedication: Are partners outside government involved in the fight against HIV/AIDS? Do mechanisms exist for partnerships? 

Research agenda: Is information about HIV/AIDS being collected, analysed, stored and spread? Is there an HIV/AIDS and education research agenda for the education sector? 

Effective management: Has a full-time senior manager been appointed? Does a standing structure exist which includes partners in and out of government? 

Policy and regulations: Are HIV/AIDS sector policies and regulations in place? Are there appropriate codes of conduct for teachers and learners, and are they applied rigorously? 

Strategic plan: Is there an education sector HIV/AIDS strategic plan which covers all levels of the whole education sector, and is it funded? 

Resource allocation: Are plans being funded adequately? Are funds being channelled to various levels of the system, and to partners outside government who can use them?  

Conclusion

HIV/AIDS lurks in communities and families, in the most intimate, private moments of human relationships. It is a creature of culture and circumstances, local perceptions and behaviours, custom and religious belief. That means it is virtually impossible to generalise about good practice: what works to break the power of HIV/AIDS in one place may not work in another. There are perhaps four ways to categorise good practice in the education sector, according to whether the intervention is aimed at:

• containing the virus;

• providing social support for affected educators and learners;

• protecting education quality; and

• creating a foundation for action.

Radical, humanitarian interventions in these areas – tackling STDs, providing condoms, establishing home-based care and school feeding schemes, and training peer health teams for all institutions for starters – can save lives in the short term, while pilots are being tried, governments are mobilising and allocating resources, the capacity of NGOs is strengthened, planning kicks in and behaviour change programmes start up.

Global experience suggests there are a number of longer-term generic tools that can make a difference with regard to HIV and education, save lives and protect education quality.

The first tool is honesty. It is essential to stop pretending progress is being made against AIDS. This is an overwhelming disaster and so far little has been done to confront it effectively. It is essential to analyse, diagnose and then manage properly. It is absolutely essential to enhance crisis management capacity in and out of government, with appropriate senior executives, resources and mandates, and to design interventions appropriate to the management capacity of the sector. That probably means keeping them simple while strengthening the capacity of sector non-government partners. Second, working together, making use of all available resources – and especially the skills of girls and women – is the best route to take. All poverty reduction plans must factor HIV/AIDS into their schema (it is not clear that this is being done) so that HIV/AIDS can be addressed within the context of poverty that drives it. Governments, though increasingly well intentioned, are largely characterised by inertia. There are thousands of examples of good, very good and potentially good practice at community level, but these are generally on a small scale, ad hoc and under-funded.

In theory governments are committed to cooperating with NGOs. In practice, however, it is not clear how partners at national and local level are being strengthened and resourced so that they can support governments’ strategies. At local level, NGOs, CBOs and FBOs are making a difference in the lives of women and children. They provide support to teachers and heads as counsellors. They train children and teachers in peer counselling. They teach lessons of safe sex, work in communities to defuse violence, and care for the abused and violated. They are at the coalface. They are doing the job. Their contribution is not just considerable, it is fundamental – however fragmented it may be. Strengthening education’s response now depends on how the programmes of non-government partners are integrated into the sector’s strategic planning and resource allocations, and whether or not they can be taken to scale.

Governments clearly have a role to play in coordinating and strengthening local responses, creating policy and establishing a regulatory framework, delivering health and social welfare services appropriate to community requirements, as well as shifting school and clinic programmes to cope with changing demands, and ensuring that sufficient funds are mobilised and channelled to those who can make best use of them. Ultimately however, governments must work in support of communities, and national management strategies must reflect this balance.

No one underestimates the difficulties of creating mechanisms, structures and processes that can achieve this. There are few models from which to learn. Ministries of education have struggled for years to decentralise decision making and executive responsibility. Now that lives depend on decentralising responsibilities to communities and schools, perhaps they will make faster headway in this regard.

Third, it is only by monitoring the success of interventions, and evaluating whether they can be replicated or generalised, that governments and agencies can be held accountable for taking effective action, against agreed performance benchmarks wherever possible. There is as yet no clear perception that the potential of HIV and AIDS to create havoc for education requires immediate intensive and extensive response throughout the education sector, especially in low prevalence countries. But that is what is required. The challenge of millions of AIDS orphans in several regions by 2010 may serve to concentrate a global sense of responsibility to learners and educators. Finally, it is possible that HIV/AIDS is, for many countries, the most significant issue in education today, and probably the biggest challenge to development. The need to confront the pandemic responsibly will require a fundamental rethink of development principles and procedures, and the relationships between governments and their funding partners. HIV/AIDS is rooted in poverty, and, until poverty is reduced, little progress will be made in limiting its transmission or coping with its consequences. A development, rather than an AIDS-specific, focus is essential now.

Correspondence

Carol Coombe, 184 Lisdogan Avenue Arcadia, Pretoria, South Africa 0083 (coombe@mweb.co.za).

Notes

[1] This article was prepared under the auspices of the Unicef Innocenti Research Institute, Florence. A fuller version is available from the Institute.

[2] HIV and AIDS are assaulting all education sub-sectors, from early childhood development to colleges and universities. This understanding makes it clear that HIV and AIDS is not just a schools issue: the pandemics must be tackled at all levels of the education sector. The education sector’s response must also include concern for out-of-school youth, and the creation of adult basic education, non-formal and distance education opportunities for children and young people disadvantaged by AIDS. There is little evidence of critical analysis of HIV’s implications for these education sub-sectors, even in high prevalence countries. The lack of strategic thinking in the areas of technical education, early childhood development and out-of-school programmes has been highlighted regularly with little effect.

[3] In advance of AIDS Day 2001, the United Nations reported that ‘the AIDS epidemic is sweeping across Eastern Europe, with HIV infection rates rising faster within the former Soviet Union than anywhere else in the world. The combination of economic insecurity, high unemployment and deteriorating health services in this region are behind the steep rise, which shows no signs of abating’. So far, infections are confined mainly to young people experimenting with drugs (Report from Associated Press, 28 November 2001). The International Coalition on AIDS and Development (2001a) likewise reports that HIV shows no signs of curbing its exponential growth in the Russian Federation, and that it is now spreading into the general population.

[4] The only countries in the world outside sub-Saharan Africa to have over 1% of population HIV-infected are Haiti, Bahamas, Cambodia, Guyana, Dominican Republic, Thailand, Belize, Myanmar, Honduras, Panama, Guatemala, Suriname, Barbados, and Trinidad and Tobago (UNAIDS/FHI, 2001).

[5] The complexity of ‘high and low prevalence’ is further highlighted by Kelly (2001b, p. 1): ‘We should not make the mistake of thinking that HIV/AIDS is an African disease or a disease of poor countries. It is true that currently the disease is heavily concentrated in Africa and in the SADC countries, but ominous signs of rapid growth in other parts of the world may result in the situation becoming worse there than it is in Africa. For instance, in the year 2000, growth in the Russian Federation was so rapid that more new HIV infections were recorded there than in all previous years of the epidemic combined (UNAIDS), while in India the number of adults infected is believed to be doubling every 18 months or so. In fact, the World Bank has warned that unless aggressive measures are taken, 35 million residents in India may have HIV by 2005 (Washington Post, 4th January, 2001). In other words, in a few years’ time there could possibly be many more HIV-infected persons in India alone than there are at present in the whole of Africa, and indeed in the whole world outside of India. As for being a disease of poor countries, let us not forget that the United States has some 900,000 infected persons. This is more than there are in Zambia, or in Botswana, Lesotho, Namibia and Swaziland combined. Moreover, within Africa HIV prevalence tends to be highest in countries like Botswana, Namibia and South Africa, which are also the countries with the highest per capita income’.

[6] See UNAIDS (2001); UNAIDS/FHI (2001), p. 29. The apparent success of Uganda is considered elsewhere in this article.

[7] The Medical Research Council of South Africa (2001) has estimated that ‘while there is inevitably some degree of uncertainty because of the assumptions underlying the [prediction] model and the interpretation of the empirical data, we estimate that about 40% of the adult deaths aged 15-49 that occurred in the year 2000 were due to HIV/AIDS … When this is combined with the excess deaths in childhood, it is estimated that AIDS accounts for about 25% of all deaths in the year 2000 and has become the single biggest cause of death [in South Africa]’ (p. 6).

[8] Projections for South Africa for example are based on the most recent statistics using the Metropolitan-Doyle model. ‘The Metropolitan-Doyle model was first published in October 1990, with a view to producing reliable estimates of the progress of HIV/AIDS in South Africa. The model has been extensively used in Southern Africa by many sectors … and has performed well when used in practical applications at the sub-group and general population level. The model is continually reviewed in the light of new demographic and population statistics, as well as interventions that may influence the course of the epidemic and result in changing incidence of infection, morbidity and mortality. The model is able to consider various interventions including behavioural changes (increased condom usage, reduced numbers of partners, etc) and medical interventions (improved treatment of STDs, vaccinations, treatment of HIV positive and AIDS sick individuals)’ (Moore & Kramer, 1999, p. 14).

[9] See for example Crouch (2001a).

[10] Crouch, an economist, notes (2001a, p. 2) that ‘the in-depth sociological and economic analyses of teacher identity, occupational choice, and the dynamics of the teacher labour market in South Africa, which would be needed to underpin a serious policy and planning position on these matters simply have not been done. We are offering a first approximation to extremely complex issues … perhaps 1/20th of the work that needs to be done before really firm conclusions about teacher identity and dynamics can be established. We challenge our colleagues and the education establishment in South Africa to undertake the necessary studies. In particular we call for an in-depth socio-economic random sample survey of teachers and case-controls in the labour market and society at large, combined with a qualitative analysis; a study that takes the individual and collective voice of teachers seriously enough to honour it with the best research possible. We feel that the choices young people make, in terms of choosing or not choosing the teaching occupation, are simply not sufficiently understood, and that unless this understanding is improved many-fold, policy and planning mistakes are very likely.’

[11] See also World Bank (2000a, p. 3); Coombe & Kelly (2001).

[12] Crouch’s list of the assumptions that need to be factored into a relatively accurate teacher demand and supply projection are set out in Table 7 of his paper.

[13] See Kelly (2000a); Love Life (2000, p. 27); Badcock-Walters (2001); Desmond, in University of Natal Health Economics and AIDS Research Division (2001).

[14] Whether teachers have higher infection rates for these reasons, or because teachers are predominantly young women at high risk, is not clear.

[15] The Medical Research Council of South Africa reported late in 2000 that one-half of all schoolgirls had been forced to have sex against their will, one-third of them by teachers. ‘We were shocked by the finding that teachers are the major perpetrators of child rape, but no one experienced in education seems to be surprised’ (quoted in Coombe, 2001b). The Minister of Education reported subsequently to Parliament that there were perhaps six to eight cases involving sexual abuse pending with the South African Council for Educators, and that in most cases the accused were still in the classroom (Coombe, 2001b).

[16] Generally defined as including the ability to distinguish between healthy lifestyles and risky behaviours (such as unsafe sex, substance abuse and violence); the development of a strong self-concept and skills to resist peer pressure; and an examination of the situation of women, gender equity and healthy family relationships.

[17] Unofficial but comprehensive survey of schools undertaken by staff of the University of Pretoria Faculty of Education in 2002.

[18] Southern African Development Community (2001). The thirteen countries that reported are Angola, Botswana, Lesotho, Malawi, Mauritius, Mozambique, Namibia, Seychelles, Swaziland, South Africa, Tanzania, Zambia and Zimbabwe.

[19] Contribution to International Institute for Educational Planning Internet dialogue, October 2001.

[20] Hunter & Williamson (2000); Williamson (2000a, b); Subbarao et al (2001), for example.

[21] Phiri & Webb (2002).

[22] The Cambodian Strategic Plan 2001-2005 for the education sector is limited to prevention measures (Cambodia Ministry of Education, 2001).

[23] The South Africa Department of Education has included workplace policy as one of the eight pillars of its HIV plan 2001-2002 (South Africa Department of Education, 2001c).

[24] Evidence from fieldwork in SADC and ECOWAS regions, and in Asia and Pacific region.

[25] Communication from Aster Haregot, Unicef New York.

[26] Information from Family Health International & IMPACT Rwanda (2001).

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Acronyms

AIDS Acquired immune deficiency syndrome

CBO Community-based organisation

ECOWAS Economic Community of West African States

EFA Education for All

FBO Faith-based organisation

FHI Family Health International

HEARD Health Economics and AIDS Research Division, University of Natal

HIV Human immunodeficiency virus

HRD SCU Human Resource Development Sector Coordinating Unit (of

SADC)

IEC Information, education, communication strategy

IIEP International Institute for Educational Planning, UNESCO, Paris

ILO International Labour Organization

INSET In-service teacher education

MAP Monitoring the AIDS Pandemic

MRC Medical Research Council (South Africa)

NGO Non-governmental organisation

PRESET Pre-service teacher education

SADC Southern African Development Community

SCF Save the Children, UK

STD Sexually transmitted disease

STI Sexually transmitted infection

SWAp Sector-wide approach

UNAIDS Joint United Nations Programme on HIV/AIDS

UNDP United Nations Development Programme

UNECA United Nations Economic Commission for Africa

UNGASS United Nations General Assembly Special Session (on HIV and AIDS)

Unicef United Nations International Children’s Emergency Fund

UPE Universal Primary Education

USAID United States Agency for International Development

WHO World Health Organization