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SOCIO-ECONOMIC CAUSES AND
CONSEQUENCES OF THE HIV EPIDEMIC IN
SOUTHERN AFRICA:
A CASE STUDY OF NAMIBIA part
2
Parts:
1
2
3
Comments
The behaviour
of the HDI for Namibia for both scenarios is given in Chart
8. Scenario 1 is the less
worse case of
the two simulations for essentially two reasons. In the
first case life expectancy is
expected to
fall by less in the With AIDS case and income per capita to
also decline by less than in
Scenario 2.
These different assumptions with respect to life expectancy
are what are largely driving the
changes in
the HDI in the two different Scenarios. In the case of
Scenario 1, what the data suggests is
that human
development because of HIV and AIDS will more or less show
no improvement over the
decade,
whereas if HIV had not been present in the population there
would have been significant
improvement.
In effect, HIV and AIDS causes a loss equivalent to a 7%
improvement in the HDI
compared with
1996.
Scenario 2
represents a significantly worse case. In part this is due
to the much more severe
worsening in
life expectancy which is assumed in the With AIDS case
(without AIDS this would have
improved
between 1996 and 2006). There is also an assumed greater
impact of HIV on growth in GDP
per capita
compared with Scenario 1. Over the decade in the Without
AIDS case there would have been
significant
improvement in the index of the order of 7% compared with
1996. In the With AIDS case
there is an
actual fall in the HDI in the order of 3% compared to 1996.
In effect there is a net loss over
the decade
compared to 1996 in the With AIDS case of 10% of the level
of the HDI in that year. Or to
put it
another way the HIV epidemic will cause a loss equal to
about 5 years of the improvement in the
HDI due to
social and economic development that would otherwise have
taken place.
Both of these
Scenarios paint a picture of losses of human development
which are severe for a country
such as
Namibia where the HDI already places the country very low
down in the UNDP rankings (116
out of 174 in
1996). It represents for the mass of the population who live
in abject poverty yet a further
deterioration
in their living standards. Because the HDI is dealing in
aggregates it masks the scale of
the worsening
in human development that will be the outcome of HIV and
AIDS in Namibia for most of
the
population. Most of the impact of the decline in life
expectancy and of the slower growth in average
per capita
income caused by the epidemic will fall unequally on those
who are already the most
deprived, and
least able to cope with the multiple impacts of the
epidemic.
Part 3 :
ESTIMATING SECTORAL IMPACTS OF THE EPIDEMIC IN NAMIBIA
1. Households
The previous
sections have identified the probable effects of the
epidemic at the national and at the
personal
level. There can be no doubt that for individuals and their
families there will be intense personal
suffering as
families attempt to deal with the personal, social and
economic effects of illness and death.
The
expectation has to be that there will be both immediate
effects on individuals and their families as
they try to
cope with losses of earnings and additional medical costs.
But the effects at the personal
level will
also be longer term since households will attempt to deal
with the immediate effects of illness
through
depletion of savings (if there are any) and disposing of
other assets (such as land). This will
mean that in
the longer team the sustainability of households either as
social units (families where
children are
supported and socialised) and/or as productive units (as in
subsistence agriculture) will be
threatened.
The evidence
from other countries in sub-Saharan Africa is mixed, both in
terms of the impact on
individual
and family poverty and on the sustainability of households.
What is clear, as in the Kagera
Region of
Tanzania, is that households are only able to survive the
effects of HIV on family members
through
drawing down extensive assistance from NGOs and their
relatives. It is best to use as a
working
assumption that families affected by the epidemic will need
psycho-social support from their
communities
and from NGOs, and others, as well as economic support if
they are to cope. This
assistance
will not usually be automatically forthcoming and
communities and CBOs/NGOs, as well as
Government,
will have to support institutional and other development so
as to cushion the impacts on
families.
Unless this is done there will be intense social and
economic distress for those often least
able to cope
(the poorest) together with longer term problems of how to
maintain families as social, and
economic
institutions.
2. Productive
Sectors
a.
Subsistence Agriculture
Households
have been treated separately from other productive sectors
although it is obviously the
case that
they account for a significant part of the national output,
both measured and none-measured.
This is most
obviously true in the case of subsistence agriculture from
which some 50% of Namibians
derive their
support. Most of the poorest in the country are concentrated
in this sector, where the
capacity to
withstand the effects of the epidemic on production is least
developed. What is evident from
other
countries' experience is that adjustment to losses of
productive labour through the illness and
death of
family members is possible but also difficult. Thus there is
evidence that surviving children,
who may have
lost both parents to HIV-related illnesses, often have
problems in retaining family land
and other
assets (such as housing and animals). There is a clear need
to strengthen the rights of
survivors -
which will often include widows as well as children - if
families are to continue to produce
food and
marketable outputs. These matters cannot and should not be
left to individuals to cope with,
and there is
a clear and identifiable role here for the Ministry of
Agriculture and for social sector
ministries,
as well as NGOs, if the sectoral effects of the epidemic on
this very large number of
Namibians is
to be minimised. Government, and others, have to begin now
to plan for the
consequences
so as to develop the structures and the programmes for what
is going to become the
largest
single problem flowing from the epidemic. While this sector
may account for only some 3% of
GDP it is,
nevertheless, the primary support for half of the
population.
b. Commercial
Agriculture
About 4000
farmers employing some 36000 workers account for some 9% of
GDP. This sector is thus
an important
contributor to national output and a major source of
employment. It follows that what will
happen to HIV
infection in this sector is of great importance. But the
sector (unlike mining) is
characterised
by many independent producers (farmers) which will make it
difficult to create a common
interest in
responding to HIV and AIDS. The same factor of physical
isolation as well as productive
independence
makes it difficult for the workers to respond (even if other
conditions made this possible -
such as
labour unionisation). But this important sector, like all
other sectors in Namibia, will be
significantly
affected by illness and death of workers - both skilled,
supervisory, and unskilled.
The evidence
from other countries in sub-Saharan Africa is that the
effects of the HIV epidemic are
already being
felt on commercial farmers, e.g., in Kenya and Zimbabwe.
These effects cannot now be
avoided for
HIV infection is already high in the adult population
throughout Namibia. The epidemic will
impose
significant costs for producers in terms of lower labour
productivity and higher costs generally -
some of these
will be direct and some indirect (as the epidemic effects
the suppliers of other services
such as
mechanical repair and transport) and as the epidemic effects
the general performance of the
economic
system. While some of the costs are now unavoidable there
are things that the sector can
do as a
sector through appropriate organisation. In part, the
objectives should be to minimise the
effects of
HIV and AIDS through planning for the consequences of
existing infection in the work force,
and also to
undertake those activities which can reduce future HIV
infection. It has to be assumed, for
example, that
many skilled and supervisory workers will be infected and
that these workers will not be
at all easy
to replace, even if this is possible in the case of
unskilled workers.
Whatever the
actual situation facing individual farmers, there is a joint
interest as a group in doing
whatever can
be done to minimise the effects on the commercial farming
sector. An obvious first step
would be to
communicate with commercial farmers in Zimbabwe in order to
observe and learn from their
activities.
There is also an obligation on this sector to help their
workers and their families cope with the
consequences
of illness and death. These are obligations which should not
be just shrugged-off by
farmers, nor
should Government permit this to happen. More generally the
farming community has a
social
responsibility to take a leadership position in the national
response to the epidemic and for this
to be
possible their organisations need to both formulate a
strategy for action and become active.
c. Mining
This sector
accounts for about 12% of GDP and for some 3.5% of
employment. As such it is not only a
major
contributor to national output but it also accounts for no
less that 50% of total merchandise
exports. It
has, therefore, a critical role in the economy - a role
which is currently irreplaceable both in
terms of
foreign exchange earnings but also as a source of financial
revenue for the financing of
Government.
As with other sectors it will have to deal with HIV
infection amongst its labour - at both
managerial,
skilled and unskilled levels. Since it is a "modern" sector
it will incur all the usual direct
costs
associated with the epidemic - absenteeism, health costs for
employees and sometimes for
dependents,
retraining costs and additional recruitment costs, etc. But
since labour costs account for
such a small
proportion of total costs, it is unlikely that these
additional costs will have dramatic effects
on what are
profitable activities. But effects the epidemic will have -
in addition to the direct costs listed
above -
largely through the effects of managerial and supervisory
labour losses. These losses of human
capacity will
not be easy to replace even if it is the case that more
unskilled labour losses can be
absorbed more
easily through new recruitment.
Again there
are possibilities of learning about what to do to prevent
new infections in the labour force
and how to
minimise the costs for the enterprises in this industry.
There is a clear gap between firms
such as
Namdeb which have instituted prevention activities and that
of other firms in the industry. This
gap needs to
be closed as also are industry practices which recruit
single sex (male) labour. This
pattern of
recruitment has been a major element in HIV transmission in
Southern Africa and needs to
be ended as a
matter of urgency. This splitting of families through single
sex recruitment has not only
led to male
HIV infection but has been part of the process whereby HIV
is passed to wives and
spouses in
the rural areas. It is thus part of the mechanism for
increasing rural HIV infection rates.
Government
should act to prohibit such practices if the industry is
unable or unwilling to do so in its
own interest.
It would be useful for the industry and the National AIDS
programme to look at what has
been
accomplished in Botswana (by DEBSWANA) and to see what can
be done for the labour force in
terms of
recruitment practices and in health/welfare provision for
the families of workers.
d. Financial
Sector
This sector
performs essential services which are integral to the smooth
operation of the economy. It
accounts for
only a small proportion of GDP and for only small numbers of
workers. But these
indicators in
no way measure the central importance that banks, other
financial intermediaries such as
insurance,
brokers, etc., play in economic life. It is instructive that
some of the larger enterprises
operating in
Namibia have instituted HIV prevention programmes and again
it is essential that all of the
major
institutions establish similar activities for their staff.
It is also
important that Government concern itself with some of the
business activities of these firms.
Elsewhere in
Africa (and in other parts of the world) these financial
enterprises have introduced policies
which, while
they serve the interests of their shareholders, are
definitely NOT in the interest of clients -
nor of
society as a whole. There is a clear conflict here between
private business interests and those of
society. For
reasons, which are perfectly plausible for the companies,
they have introduced restrictions
of life
insurance cover (often denying benefits to those who die
from AIDS), restrictions on health cover,
and
restrictions on access to mortgage finance for housing. The
industry should not be allowed such
freedom in
respect of activities which are so central to the lives of
many Namibians. They make it
possible for
the industry to impose conditions in respect of financial
contracts which are inimical to an
effective
national response to the epidemic. As such, it is essential
that Government look at existing
practices by
FI in conjunction with industry representatives; look at the
changing patterns of industry
regulation in
other countries who have had to face similar practices, and
then establish new regulatory
structures
and controls. This should be done preferably through
agreement, but if this proves
impossible,
then through the use of the law.
e. Fishing
The fishing
industry is a growing sector of the economy. At
independence, this sector produced 1.5%
of GDP; by
1996 it had increased its share to 4%. The sector provides a
large amount of employment,
and is
expected to surpass the mining sector in the number of jobs
provided by the year 2000.
The boom in
the fishing industry has been one of the major factors in
the migration of job seekers to
Walvis Bay
and Luderitz, the two principal sites of the fishing
industry. The HIV epidemic can affect this
development
in a number of ways. Firstly, the industry acts as a focal
point for the transmission of HIV
by drawing
job seekers and workers from various parts of the country.
When infected with HIV workers
spread
infection to their home areas during their frequent visits.
Secondly, as has been the case in the
mining sector
throughout Southern Africa, schemes for housing workers
contribute to conditions in
which
infection can spread rapidly. Many workers live in either
large dormitory compounds or in
severely-cramped single quarters, where a room built for
one person now accommodates twenty or
more. Coupled
with their isolation from families and communities,
conditions in these areas increase
the
possibilities for the spread of HIV and other STDs among
workers. Finally, the fishing industry
requires
large numbers of trained workers both on fishing boats and
in processing. As HIV/AIDS leads
to losses of
human resources, the industry will be forced to spend more
on training, pensions and
medical aid
and other costs.
f. Government
The
Government accounts for about 30% of GDP and for about the
same proportion of formal sector
employment in
Namibia. As such, it is by far the largest sector in the
economy, and it is also a major
user of
highly trained and professional/managerial workers.
Government in all economies provides
services
which are essential to the smooth running of the rest of the
society and economy. It is
inconceivable
that Namibia could achieve its development objectives
without an effective and efficient
public
sector. Whether one is looking at public administration pure
and simple, or public services (such
as legal and
judicial) or economic services (such as communications and
water). These are all
essential
services and the extent that they are there and provided
efficiently has implications for the
functioning
of the whole system.
But
Government is also the largest source of employment in
Namibia with obligations to its employees
and to their
families. Not only does Government have an obligation to
ensure that it provides the
services
needed by other sectors, it also has an obligation to secure
the health of its employees and
their
families. As was noted elsewhere in this Paper, HIV is no
respector of class or position and, if
anything,
there are higher rates of infection in higher occupational
groups - almost certainly including
employees in
the public sector. In other countries in the region there
are already major problems in
maintaining
human resource capacity in the public sector, with high
levels of absenteeism and labour
turnover at
all levels of the public services and in public sector
industries. The effects are evident in the
costs that
fall on the public sector and on the deterioration in public
services associated with morbidity
and
mortality.
These are not
easy matters to rectify but as with everything else it is
possible to minimise the
consequences
of the impacts on public services through appropriate
planning for what is going to
happen as a
result of existing HIV infection amongst employees. This
means establishing
interdepartmental committees assisted by expertise from
outside to monitor what is happening (on
sickness and
absenteeism) and to begin to plan for some of the effects on
public services - both at
central and
local levels. It is also necessary to establish for the
public service appropriate conditions for
those
infected with HIV to ensure that there is no discrimination
at the place of work, and that
appropriate
policies are introduced to maintain people in employment for
as long as possible through
access to
health care and social support. Workers can, with
appropriate support systems and access
to health
care, remain productive for many years, and it is efficient
that they be enabled to do so. It is
also morally
right that they be supported so as to be able to continue to
work for as long as possible for
personal
reasons - including supporting their families. At the
present time there are very few Ministries
which have
introduced HIV in the Workplace programmes and this is
something that they should be
supported to
do, drawing on the considerable experience that now exists
in the region about how to
introduce and
manage such programmes.
This is by no
means a complete analysis of the conditions facing the
different sectors in Namibia but it
provides a
starting point for planning for the changes required because
of the epidemic. Changes in
policies and
in programmes there will have to be. The responsibility lies
with Government, but little will
be
accomplished unless there is a partnership between the
various concerned parties. There is much
expertise in
Africa now which can be exploited, and there is no need to
begin these activities as if there
was no
existing stock of knowledge and capacity in existence.
CONCLUSIONS
It is now
generally recognised that the HIV epidemic is not only a
threat to the nation's health, which it
is, but also
has fundamental consequences for sustainable development.
The transmission of HIV is
not random in
the population, who gets infected with the virus and what is
the spatial distribution of
infection is
determined by factors which reflect structural social,
cultural and economic forces in a
country.
Namibia is no exception to the pattern which is being
repeated throughout sub-Saharan Africa.
Elsewhere in
Africa, particularly in the East, Central and Southern
regions, the epidemic has cut a
swathe
through the population, causing intense personal suffering
for those infected and affected. But
the effects
of the epidemic extend beyond the personal, terrible as
these are, and communities and
nations also
have to live and cope with the damaging consequences of the
losses of their most able
and
productive members. None of this is inevitable, although
countries including Namibia have no
choice but to
try and ameliorate the consequences for the society and
economy of past HIV infection.
Those
infected will have to be cared for through public and
private provision for them and their families.
There will
inevitably be social costs, including an intensification of
the already extensive poverty in
Namibia, just
as there will be economic costs as productive sectors try to
grapple with the losses of
productive
labour. But these consequences, while inevitable, can be
managed and can be minimised
through
policy and programme responses.
There are two
challenges facing the nation -- not just Government.
The first is
to address through policies and programmes the fundamental
factors -- some health related
and others
social (such as gender inequality) and others economic (such
as poverty and income and
asset
inequality) -- which have created ideal conditions within
which HIV can be transmitted.
Government
has already embarked on actions which begin to address many
of these issues but there
remains much
that needs to be done.
The second is
to seek to create a national awareness of the risk that HIV
and AIDS poses for the
nation. This
means seeing the epidemic as an ongoing threat to
development and as such a factor
which will
constrain all of the futures open to Namibia. It requires no
less than a social mobilisation;
everyone from
the poorest Namibian to the richest has a stake in
overcoming this threat to human
development.
BIOGRAPHICAL
NOTE
Desmond Cohen
is an economist with university teaching experience in
Africa, Canada, the UK and the
USA. Formerly
he was a Governor and Associate Fellow at the Institute of
Development Studies,
University of
Sussex in the United Kingdom and until 1990, he was Dean of
the School of Social
Sciences. He
has both research and applied macro-economic policy
experience in a number of African
and Asian
countries. Previously he was an adviser to the British
Treasury on international financial
policy. In
1997-98 he was Director of the HIV and Development Programme
(UNDP), and currently he is
Senior
Adviser on HIV and Development.
Issues Paper No. 31
SOCIO-ECONOMIC CAUSES AND CONSEQUENCES OF THE HIV EPIDEMIC
IN
SOUTHERN AFRICA:
A CASE STUDY OF NAMIBIA
Desmond Cohen
INTRODUCTION
Part 1:
Socio-economic Causes of the HIV Epidemic
1. The Roles
of Income, Occupational Status and Poverty
2. Economic
Organisation and Public Policy
3. Social
Organisation, Gender and Public Policy
4. Social
Learning
Part 2:
Estimating Demographic and Developmental Impacts - a Case
Study of Namibia
Epidemiological Situation in Southern Africa
Demographic
Effects of HIV and AIDS
Estimating
the Impact of HIV and AIDS on Human Development
Results
Comments
Part 3 :
Estimating Sectoral Impacts of the Epidemic in Namibia
1. Households
2. Productive
Sectors
Conclusions
INTRODUCTION
This paper is
in three parts. Part 1 reviews in a schematic way existing
knowledge of the
socio-economic causes and consequences of the HIV epidemic
in sub-Saharan Africa. Part 2 looks
more closely
at the socio-economic impact of the epidemic on Southern
Africa. Analysis is focused on
Namibia as a
specific case study, within a framework which addresses both
demographic and
developmental
impacts. Estimates are presented on the effects of the
epidemic on human
development,
the UNDP Human Development Index, for both Southern Africa
and for Namibia. Part 3 is
a review of
the impact on economic sectors in Namibia.
It needs to
be stressed at the outset that much of the applied research
on socio-economic causes and
consequences
of the HIV epidemic in sub-Saharan Africa has yet to be
done. This is even more true in
Namibia where
the absence of appropriate policy and programme related
research imposes severe
constraints
on effective responses to the epidemic. It is thus a
priority area for Namibia and for other
countries in
the region to strengthen national capacity for undertaking
applied policy and programme
relevant
research on the epidemic. It has to be stressed that such
research on both the causes and
consequences
of the epidemic needs to be timely -- the problems to be
addressed are important -- but
are generally
everywhere under-recognised. There has been a fair amount of
research undertaken in
some
countries in the region but this has often been of low value
to those with policy and programme
responsibilities. This can be avoided from the outset
through appropriately designed strategies for
undertaking
socio-economic research on the epidemic.
Part 1:
SOCIO-ECONOMIC CAUSES OF THE HIV EPIDEMIC
More than ten
years into the global HIV epidemic there is still great
unclarity as to the precise
importance of
different factors in explaining both the levels and the
distribution of HIV infection in Africa.
About 70% or
more of total HIV infections globally are in sub-Saharan
Africa, with some 90% of all
infections
concentrated in developing countries. The distribution of
global infections will change in the
next 5 to 10
years as the share of the total which is African shrinks as
Asia experiences a growth in
HIV
transmission. It was already the case in 1997 that about one
half of new infections worldwide were
in Asia, a
trend which is expected to deepen in the coming years. There
is some very preliminary
evidence
which suggests that in a number of countries in sub-Saharan
Africa the epidemic may be
stabilising.
But it is also the case that rural rates of HIV infection in
many countries in sub-Saharan
Africa are
moving closer to urban rates (which have typically always
been higher).
The issue to
be addressed is why HIV infection has been so concentrated
in the past-decade in
sub-Saharan
Africa, more especially in Eastern, Southern and Central
Africa? What have been the
dynamics of
the various sub-epidemics, and what role have social and
economic factors played in the
development
of the epidemic? Socio-economic and cultural factors appear
to have been significant in
explaining
HIV transmission throughout the region. The process in the
following discussion is partly
inductive and
partly empirical, with the ultimate objective of identifying
those factors which are
amenable to
policy and programme response. In no sense is this a fully
comprehensive analysis of the
issues. The
aim is to deepen understanding of those factors which seem
to be important in explaining
what is
happening to the HIV epidemic in sub-Saharan Africa and more
particularly in Namibia.
1. The Roles
of Income, Occupational Status and Poverty
The poor
account absolutely for the largest numbers of those infected
with HIV. But the relationship
with poverty
is by no means simple and many of the poor, even the poorest
of the poor, remain
uninfected in
many countries. Furthermore, and this is very important and
to some extent reasonably
well
documented, HIV infection is also high among those who are
better educated and highly trained.
The epidemic
is thus bi-modal in its distribution with peaks in both the
poorest segments of the
population
BUT also amongst the richest and best educated. So the
relationship cannot simply run
from poverty
to behaviours which expose individuals and their families to
HIV infection because there
are the
non-poor who also exhibit risk behaviours which can and do
lead to HIV infection. The non-poor
in Africa are
the region's most scarce resource who are essential for the
effective governance of their
countries and
who play essential economic and social roles. As will be
seen in a later Section, the fact
that HIV
infection is also present amongst the most economically
favoured - with high levels of HIV
prevalence in
some countries - will lead to substantial economic losses
through the erosion of Africa's
most able and
most educated segment of the population.
So quite
different factors other than poverty must be operating in
the cases of the skilled, professional
and the well
educated to explain their behaviours. These are clearly not
behaviours which are income
constrained
(as are those of the poor) nor are they behaviours which can
be simply attributed to lack of
information
on how HIV is transmitted and how it can be prevented. For
these are among the educated
elite of the
region who have absorbed many years of schooling often
subsidised by the State. Rather
the
explanation would seem to lie in the opportunities which are
available to these groups through their
access to
income and their position in society to engage in sexual
behaviours which place themselves
and their
spouses at risk of HIV infection. Such groups seem also to
be characterised by patterns of
employment
which include high levels of mobility, and it would seem
that this is a feature of their life
style which
provides an additional opportunity for unsafe sex. For this
group it is certainly not poverty
which
explains their behaviour but the opposite; nor can behaviour
be attributed to lack of access to
education
since many have achieved both secondary and often tertiary
levels; but it does seem to be
related to
work and leisure patterns, and with high levels of labour
mobility. There is even some
evidence that
HIV infection rises with the level of education and
occupational status which is quite the
opposite of
what might have been expected given the widespread
assumption that knowledge
empowers.
Typically, the spouses of men who are HIV positive are
themselves often infected
(husbands
infecting wives seems the more normal case).
In the case
of the poor who are infected with the virus the evidence is
less counter intuitive. Poverty will
lead to
economic strategies which expose the poor to risks of HIV
infection. Thus both men and women
will seek out
livelihoods which offer the possibility of survival, and
this will often require migration from
villages to
towns and cities in search of jobs. Doing so will often lead
to relaxation of traditional norms
of behaviour
and in the case of men particularly will often lead to
sexual activity where they have many
partners. But
poor women, especially those who head poor households who
are many in Africa, will
also engage
in sexual transactions so as to support their families. This
exposes such women, who
cannot be
categorised at all as being CSWs, to risks of HIV infection.
For some women the pressures
of poverty
for them and their families may lead to activities which can
be classed as those of a CSW,
but even for
this group of women it is not simply and only poverty which
explains their actions. It should
be recalled
that HIV infection is higher amongst women than men in
Africa and is very much higher
amongst young
women and girls than amongst their male counterparts.
Evidence supports the
proposition
that most married women who are infected with HIV have only
a single partner - their
husband. It
follows that changing the behaviour of both men and women is
essential for reducing further
HIV
transmission - changes cannot be confined to only one
gender.
There are
many other factors also operating in the case of the
poorest. They have generally poor health
status which
is the outcome of their poverty and their lack of access
since childhood to those things
which
determine health status. In part, this is a matter of access
to formal sector health services but it
is much more
a matter of environmental conditions (such as poor housing,
clean water and poor
nutrition).
Addressing these environmental aspects of the life of the
poorest will have significant effects
both on
health status as well as on their labour productivity, for
low output per person is often related to
poor health.
These conditions are true irrespective of gender but seem to
be severest for girls and
women which
may in part explain their greater susceptibility to HIV
infection than males. What is
undoubtedly
clear is that women receive less health care than men
generally and the failure to treat
STDs in women
is indeed a major problem given the link between STDs and
HIV transmission. Poor
health status
of both men and women in part explains the more rapid
progression from HIV infection to
death for
those who are HIV positive in Africa compared with rich
countries - compounded in the case of
women by
excessive numbers of pregnancies. This evidence leads to
important policy conclusions for
Namibia which
are summarised below.
Finally,
there is the issue of access to and the quality of the
education received by the poorest. In spite
of major
efforts by many countries in Africa, there still remains a
major educational deficit. The recent
decade has
seen a worsening of the effective education received by the
poorest in many countries,
which
reflects public policy decisions under conditions of
constrained resources. Particularly severe in
countries
following structural adjustment policies, but also
reflecting increasing demands caused by a
rapidly
increasing and youthful population. One consequence is a
perpetuation of poverty associated
with little
or no education, and another is illiteracy for many
Africans, which compounds their problems
of full
participation in civil society.
2. Economic
Organisation and Public Policy
This is a
categorisation which covers many factors which seem to have
had an influence on the
dynamics of
the HIV epidemic. Their particular role is difficult to
identify and assess but they have
some
importance. Thus it is evident that patterns of labour
mobility and migration are affected by
particular
economic strategies, and that mobility of labour plays an
important role in the transmission of
HIV
throughout the region. But economic strategies can be
modified and be different and in a world of
HIV it is
important to re-examine those being followed by a country.
Thus most countries in Africa have
pursued
economic and social policies which are urban biased -
favouring those who live and work in
cities to the
disadvantage of rural populations. These biases in policies
and in access to public services
are factors
in the transmission of HIV and thus the spread of the
epidemic.
Rural to
urban migration has been in part the consequence of the
imbalance between living standards,
access to
education and health and to employment that exists.
Different allocations of public resources
in favour of
poorer rural populations, especially in education and
health, and different pro-agricultural
strategies
(different exchange rate policies, improved access to
credit, better transport infrastructure,
rural
development, and so on) would have major effects on the
mobility of labour and on rural poverty. Of
particular
importance is the need to improve employment opportunities
for adolescent youth - both boys
and girls in
rural and urban settings. There are many instruments of
public policy which can be used to
raise
employment for young people and this could be a potent force
for affecting positively their sexual
and other
behaviours.
Many
countries in the region have followed policies of structural
adjustment which have had the effect of
generating
additional unemployment, particularly for workers in the
public sector. These policies have
disproportionately reduced expenditures on health and
education along with other social sector
spending. As
such, the SAPs have added to more general forces at work
over the past two decades
which have
caused widespread social distress and rising unemployment
together with reduced access
to essential
social services. Governments have had few degrees of freedom
to change some of the
factors at
work (such as an adverse external environment for trade) but
that is not to say that they have
no
independence of policy making.
In
particular, they have had the capacity to change public
expenditure allocations in ways that would
have
prevented much of the deterioration in essential public
services such as education and health.
They have
also had choices in terms of the allocation of expenditure
within broad functional categories,
and could at
any time have redistributed expenditure to primary health
(away from acute/hospital care),
and to
primary and secondary education (with less for very
expensive and highly subsidised tertiary
education).
More broadly, there has always existed the choice of using
public services as a vehicle for
redistribution in favour of the poor and away from the rich.
This they have failed to accomplish and they
have through
their policies helped to maintain and to expand those
underlying factors which have
contributed
to the epidemic - such as poverty, poor and unequal access
to key public services, and too
little
provision for primary health and basic education for all.
In part,
economic development in the region has been dependent for
far too long on families being
disrupted
through the migration of family members in search of
employment. This is most evident in the
case of
mining where recruitment of male workers without their
families has been only too typical.
These
employment practices have been important in the spread of
HIV not only for the miners but also
to their
wives and their rural communities. But what is most
obviously true of mining is only an example
of the more
general problem with development which is a failure to
locate employment closer to where
people live.
This is not inevitable, and in a world of HIV and AIDS it is
necessary to revisit policies for
industrial
and agricultural development. This is also true for large
scale infrastructure developments
which have
the effect of generating localised flows of migrant labour
with consequences in terms of HIV
transmission
which are only too evident. It is possible to build into
such developments an awareness of
their effects
on the epidemic, and to design appropriate interventions to
limit the spread of infection
within the
work force and local communities.
3. Social
Organisation, Gender and Public Policy
This is a
massive topic and the following represents only a few but
important observations on issues
which are not
generally well documented. The easiest is Gender where there
now exists considerable
evidence on
the role that male and female relationships play in the
epidemic. As has been noted
several times
already, women now outnumber men in terms of HIV infection
in Africa; young women
have rates of
HIV infection several orders of magnitude higher than their
male counterparts, and most
married women
in Africa who are infected with HIV say that they have only
had a single partner - their
spouse. At
the heart of this heartrending picture are relationships
between men and women - not
simply sexual
relationships important though these are in terms of the
epidemic. Evidence suggests
that where
women are not valued, and where they are largely excluded
from protection of their rights as
full members
of society that the epidemic flourishes. This is often
reflected in unequal access to
education for
women, unequal access to credit, a lack of protection under
the law for women's property,
the
continuing treatment of women as chattels to be disposed of
at the will of their husbands,
discrimination in access to health services, and so on. All
of these matters can be remedied by
appropriate
public policy although to achieve this there may have to be
firstly changes in women's
access to
political power. This is itself amenable to policy and is
unlikely to happen unless there is
action by men
to include women in the processes of civil society. But
happen they must if the present
rates of HIV
infection of both men and women are to be reduced.
Related to
the foregoing are issues of inequality between men and women
and between different social
classes. It
appears that HIV infection is higher where the economic gaps
separating men and women
are greatest.
Addressing these sources of gender inequality thus becomes
an important area for social
and economic
policy. It is also the case that social stratification can
be a source of inactive social and
economic
policy as those with power (the rich) follow policies in
their own interest to the neglect of the
rest of the
population. Thus policies will be followed that are to the
benefit of the rich (in economic
matters
generally, in access to credit, in employment, in education
and in health provision, and so on).
The exercise
of such powers often continued after the formal passing of
power to the rest of the
population as
democratisation has occurred in Africa, with the old elites
continuing to set the policy
agenda in
their own interest.
The power of
self-interest in combination with continuing misconceptions
about the HIV epidemic have
been part of
the problem in sub-Saharan Africa. One explanation of the
rapid process of transmission in
South Africa
was that the former colonial government was simply
uninterested in taking appropriate
responses to
the epidemic as it emerged. It seemed to the government to
be an irrelevance given their
particular
class interests and so they failed to institute effective
policies and programmes at the time
that it was
essential that they do so. This legacy is apparent both in
RSA and in Namibia, and through
relationships
with other "dependent" economies in the region in other
countries as well. Once the
epidemic
reaches a prevalence rate of 3-4% it is then exceedingly
difficult to rein-in the subsequent rise
in HIV
infection. All the countries in the region are having to
live with the consequences of the initial
failures of
Government in RSA to act decisively and early in relation to
the epidemic. It should be noted
that class
economic interests can continue to prevent effective policy
and programme responses, for
the latter
will often require fundamental changes in relations within
civil society.
4. Social
Learning
This can be
brief although it is at the heart of an effective response
to the epidemic. In the early days of
the HIV
epidemic in Africa, it was assumed that HIV infection was
confined to core groups in the
population -
to those with immoral behaviours such as CSWs and their
clients. In time, this perception
of the
epidemic has changed, although not everywhere. Clearly it
does not make sense to think of the
HIV epidemic
in terms of "high risk groups" where 20, 30 or 40% of adults
are infected as is now
unfortunately
the case in many countries and cities in the region. The HIV
epidemic needs to be
perceived as
the responsibility of all - young and old, the poor and the
rich, the governors and the
governed, and
men and women. But this recognition that a social
partnership is required has been very
slow in
emerging and the question arises as to why this is so. It is
also the case that many
governments
still do not perceive the risk that the HIV epidemic poses
for all aspects of social and
economic
development. Again, how can this be explained and what needs
to change?
It may be
useful to distinguish between "endogenous change" and
"exogenous change". In the case of
the former,
one is interested in those processes of change which are
internal to a society or
community, or
other social group, or within a family. What brings change
about? More specifically,
what are the
forces which lead to changes in behaviours and attitudes
such that those who are
excluded
(those living with HIV and their families) are accepted by
society? So that people are enabled
to understand
the epidemic and are able to perceive what needs to change
in their own behaviour and in
social norms
and conventions. The initial presumption of experts was that
these changes would be
brought about
over time as societies experienced the illness and the
deaths of their friends and loved
ones. That
there would indeed be Social Learning so that societies
would adjust to the issues raised by
the epidemic,
become more socially inclusive, be reforming, and be
generally capable of those social
changes
necessary for responding to the epidemic.
There are
examples within countries where this transformation has
taken place, e.g., in some areas of
Uganda. But
generally the processes of social learning have been slow to
operate with the result that
social,
economic and political changes have been slow in coming
about. A consequence of this has
been that the
HIV epidemic has developed a severity in terms of the size
of the populations infected
which far
exceeds original projections. Unless these processes of
Social Learning occur it is difficult to
see what can
prevent the epidemic from continuing to effect the lives of
everyone from one generation to
the next.
Unless there
can be "exogenous changes" which can be imported from
outside a society. Examples of
this are
condoms as also would be a vaccine where the technologies
come from outside a society, or
forms of
social organisation which have been successful elsewhere. At
the present time there seems
little hope
that a vaccine will be available and in any case when one
does there will have to be an
infrastructure to deliver it. Condoms have been more or less
unpopular in most settings and it seems
obvious that
social attitudes and behaviours need to change first if they
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