SOCIO-ECONOMIC CAUSES AND CONSEQUENCES OF THE HIV EPIDEMIC IN SOUTHERN AFRICA:
A CASE STUDY OF NAMIBIA
Desmond Cohen

Issues Paper No. 31

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 are to become widely used. Organisations which have had some success elsewhere can rarely be transplanted to other settings - although some of the concepts may be transferable.

So what can be concluded from the evidence? It seems that Social Learning is central to the processes of both endogenous and exogenous change. New technologies are unlikely to be successful unless these are accompanied by other changes which are derived from social learning. It is an aim of public policy to help this social learning take place through building frameworks of laws and ethics, and respect for human rights, and through ensuring that everyone perceives the risks that the epidemic poses to society. In a word society will have to find ways of strengthening partnerships across gender, economic, class and ethnic divides.


Part 2: ESTIMATINGDEMOGRAPHIC AND DEVELOPMENTAL IMPACTS - A CASE STUDY OF NAMIBIA

Most of the lessons to be drawn from the foregoing are more or less self-evident. Nevertheless, it is probably worthwhile spelling out some of the more obvious conclusions and relating these to socio-economic conditions in Namibia. Data and information which are very relevant to analysis of the socio-economic factors affecting the HIV epidemic are contained in the Namibia Human Development Report, UNDP 1996.

• Poverty is obviously a factor in explaining who gets infected with HIV although, as noted above, there is no simple causal relationship, and the non-poor are also engaged in risk behaviours which expose them to infection. The evidence on poverty in Namibia is unambiguous C some 40% of households were classified as poor in 1994. There are essentially two nations; the white population (5% of the total), and an emerging black elite (1%), who have average annual per capita incomes of US$16,500, while blacks in the modern sector (39%) have incomes of US$750 and the rest of the population have an estimated annual income of US$85.
• Namibian society is also highly unequal. The World Bank concluded that, "There are at least 2 Namibias. The white population...is mostly urban and enjoys the incomes and amenities of a Western European country. The black population, mostly rural, lives in abject poverty". The result is that 65% of national income is received by 10% of the population, with the remaining 90% receiving the remaining 35% of the national pie. But it is not only inequality of income, it is also inequality of the ownership of assets, with most of the financial and business assets held by a small minority, and with ownership of the most valuable land and mining resources also concentrated in their ownership. Namibia is without doubt one of the most unequal countries both in the distribution of income and in the ownership of productive assets.
• Inequality of income and assets have effects which transcend issues of economic and political power. They have consequences also for patterns of demand and for employment, and have effects on the distribution of labour both within sectors as well as spatially. Thus an element in rural to urban labour migration is the demand for largely unskilled and often poorly educated labour to serve the needs of the urban elite. They come partly in search of jobs and to escape rural poverty, and in part they are attracted by the lifestyles of urban society. But once in the cities they engage often in behaviours which expose them to risk of HIV infection, and then on their return to their rural communities they further transmit the virus to their spouses. The urban population has been increasing at something like twice the national rate which in part reflects the gap between rural and urban incomes - rural households have on average about one third of the income of their urban counterparts.
• Inequality extends well beyond incomes and assets and differences in life styles. They are embedded in more or less all aspects of Namibian life. All of the social indicators for Namibia point to a situation of great inequality in access to schooling, in access to health care, in the provision of housing, electricity, water and sanitation. Thus 95% of rural households have no access to electricity and 35% have no ready access to piped water. While 66% of the population is literate, only 58% of those in the rural areas can read compared to 83% in urban areas. There are deep ethnic, regional and rural/urban differences in most of the aspects of life which determine the standard of living.
• These differences have great implications for the HIV epidemic both in terms of what they imply for risk behaviours but also in terms of what can be achieved through HIV-related programme activities. It becomes immensely difficult to reach largely illiterate rural populations through IEC programmes - whether these are targeted at adults or at children/youth. The ethnic diversity of the population and the use of multiple languages makes all programming that much more difficult for it has to be appropriate for the particular group. The lack of access to water will pose great problems for those who care for HIV infected persons at home, mainly women, given that access to water is absolutely essential given that many patients suffer from diarrhea.
• Many studies point to vast inequalities in Namibia in nutritional status with the poor, and especially poor children, particularly affected. This again has importance in terms of the epidemic since it is clear that nutritional status is a factor in the ability of HIV positive persons to deal with opportunistic infections.
• Many more women than men are infected with HIV and many more young women than young men. In part, this reflects the inequalities that women continue to endure in Namibia - in all aspects of economic and social life. Their health status is worse than for men; and they have much lower labour force participation rates than men. As the NHIES concluded, "About 40% of Namibian private households are headed by females. The private consumption level in female headed households is about half the consumption level in male headed households." While there has undoubtedly been progress in girls access to education and in improvements in the legal position of women (at least on paper but less so in implementation) there is still a long distance to travel in Namibia. As the UNDP HDR for Namibia concluded in 1996, "In many communities...attitudes to women are at best outdated and at worst abominable, as evidenced by the high rate of rape and violent crimes against women." In a world of HIV and of AIDS the lives of women have to be changed or there can be no progress in addressing the fundamental factors which are driving the epidemic in Namibia.
• Agriculture continues to be the base for most of the country's population and there is a clear duality in this sector with high productivity and incomes for commercial farmers and low productivity and basic subsistence for the mass of traditional farmers. Since the traditional farming sector is where most of the poor are concentrated, it follows that efforts need to be intensified to raise productivity and incomes. This is crucial if rural to urban migration is to be slowed. Similarly, there is a need to re-examine industrial development strategies so as to minimise the mobility of labour within Namibia. It is well known that Tourism can be a factor in HIV transmission, and while no one would suggest that development not take place in this sector, there is nevertheless a need to ensure that structures and programmes are in place to minimise the possibilities of HIV transmission. In the aggregate all areas of development strategy should be assessed so as to address the ways in which planned developments have adverse effects on the growth of HIV in the population.

Namibia is a fractured society. How could it be otherwise given its recent history of colonialism and war of independence? It is divided on ethnic grounds, on the basis of income and wealth, on social class, and on gender. But the HIV epidemic requires that society perceive the risks to its continuation and its prosperity posed by the epidemic. As such, the whole of civil society - not just Government and one or two large private employers - have to understand that all are threatened in one way or the other by the epidemic. The challenge for Namibia is how under conditions of social and economic differentiation to build a partnership of all Namibians. There are no blueprints for how to do this but an attempt must be made, nevertheless. The changes in social policy of recent years with a better distribution and higher levels of expenditure on health and education are a start. But the depth of the social deprivation and inequalities - especially those that are gender based - are what is driving HIV transmission in Namibia. Unless there is a more intensive attack on many aspects of the things that make up the lives of the poor, including access to employment and better social services, there will be little that can be achieved in reining back the HIV epidemic.

Epidemiological Situation in Southern Africa

As noted above sub-Saharan Africa has some 70% of the global total of 30 million people living with HIV, with Southern Africa the worst affected region on the continent. Adult HIV infection rates of 20-25% are seen in countries with the highest prevalence, with urban rates in some cities double the average for the total adult population. In 1997 it was estimated that 2.4 million South Africans were living with HIV - an increase of more than a third compared with 1996. In Botswana the proportion of the adult population living with HIV has doubled over the past five years (to an estimated 25% in 1997). In Francistown the second largest city in Botswana the rate of HIV for pregnant women is now almost 50% (1997). In Zimbabwe the adult rate of HIV infection in 1996 was 20% - one in five of all adults in the population. With 32% of pregnant women testing HIV positive in Harare in 1995, and a staggering 59% in Beit Bridge (1996). Throughout the region HIV prevalence continues to increase with rates in cities increasingly being mirrored by those in rural areas.

The majority of new infections are in young people - those between the ages of 15 and 24 (sometimes younger). Thus in Zambia in one recent study over 12% of the 15-16 year olds seen at an ANC were HIV positive. In South Africa the % of pregnant 15-19 year olds infected with HIV rose to 13% in 1996 from about half that level two years earlier. In Botswana the HIV rate for the same age group stood at 28% in 1997. Infection rates in girls and young women are significantly higher than they are for boys and young men of the same age - thus in Malawi it is reported that HIV infection rates of young women are 5 to 6 times higher than for young men in the age range 15-20. The explanation of these differential rates of infection are complex, partly physiological and partly socio-economic. Whatever the causes the differentials both create gender biased socio-economic consequences, and at the same time call for programme responses which specifically address the problems of young men and young women.

The epidemiological situation in Namibia reflects that common to other countries in the Region. Data on HIV for pregnant women attending ANCs suggest an average rate for the country as a whole of 15.4% in 1996 - this is a tripling of the level of HIV nationwide in the 4 years since 1992. HIV prevalence for women ranges from just over 3% to more than 24% in the different districts; is higher in urban than in rural areas (17.6% and 10.9% respectively), and reaches its peak in the age range 20-34. While AIDS deaths are widely under-reported it is still the case that it is now the leading cause of death for all age groups in Namibia. For AIDS to have become the leading cause of death by 1996 it follows that the present estimates of HIV prevalence must be serious under-estimates of the actual situation in the country. It is thus much more probable that HIV rates are closer to those in neighboring countries such as Botswana and Zimbabwe.
Chart I is a summary representation of seroprevalence for pregnant women in Southern Africa C it is the best proxy available for measuring adult HIV infection. The visual picture is bleak: the realities of the lives of people even bleaker. The epidemic is without a doubt the greatest threat to sustained development facing the Region.

Demographic Effects of HIV and AIDS

No specific studies have been undertaken in Namibia into the demographic effects of HIV and AIDS and it is thus necessary to present data which relates to other high prevalence countries in sub-Saharan Africa. These have obvious relevance for Namibia given that HIV prevalence rates here are similar to other countries in the region and that demographic structures are also sufficiently similar as to make comparisons possible. The US Census Bureau has recently published its estimates of the demographic effects of HIV and AIDS on Africa and these are the most up to date and consistent estimates and projections currently available. In what follows the Census Bureau's estimates and projections are presented in the form of a commentary for the main aggregates under discussion, together with Charts to illustrate their projections which compare states with and without AIDS for the Southern Africa region. The following key outcomes are presented below:

- crude death rates
- infant mortality rates
- child mortality rates
- population growth rates
- life expectancy

1. The most immediate effect of the HIV epidemic is to increase the crude death rate for the populations affected. These will be higher where HIV prevalence is higher, which in sub-Saharan Africa is in the Eastern and Southern regions where the epidemic is most mature. Within these regions HIV is highest generally everywhere in urban settings and so also will be observable and predicted mortality. Chart 1 presents data on crude death rates for Southern Africa for the year 2010. Since crude death rates are generally lower in this region that elsewhere in sub-Saharan Africa so the increases will be relatively greater. By the year 2010 the crude death rate is projected to be 6 times higher in Zimbabwe, 4 time higher in Botswana and 3 time greater in Zambia than it would have been in the absence of AIDS ().

2. Infant mortality rates are already rising sharply in countries with mature epidemics. Children borne to mothers who are HIV positive have a 30-60% chance of becoming positive themselves. In 1996 infant mortality rates in Zambia and Zimbabwe are estimated as being already 25% higher than they would have been in the absence of AIDS. In Southern Africa projections for 2010 are that deaths due to AIDS will more than double infant mortality rates in Botswana and Zimbabwe, and be more than 40% higher in Malawi (where rates are currently higher than elsewhere in the Region) and 60% higher in Zambia ().

3. It is estimated that two-thirds of AIDS-deaths will occur in children aged 1-4 years. These rates will increase since many children who are positive survive past their first birthday. Child mortality rates are already higher today than they would have been without AIDS in some high prevalence countries. Thus child mortality rates are estimated as being 75% higher in Botswana in 1996. By the year 2010 child mortality rates are expected to be twice as high in Botswana, 4 times greater in Zimbabwe and about twice as high in Zambia and Malawi ().

4. Projecting the overall effects on population growth is difficult in part because it depends on fertility decisions which are themselves partly the outcome of the effects of AIDS, and on decisions made in the knowledge of the effects of AIDS. Almost all past projections have supported the proposition that in spite of AIDS most countries will continue to experience positive population growth. Nevertheless the Census Bureau estimates suggest that 2 countries in sub-Saharan Africa will experience negative population growth by the year 2010 - in Botswana the rate is estimated to be minus 0.4 %(compared to a without AIDS rate of 1.9%), in Zimbabwe minus 0.5% (compared to 1.8%), and in Zambia 1.2% (compared to 3.1%), and in Malawi 0.1% (compared to 2.2%), see .

5. The most striking demographic effects are on life expectancy (). Without AIDS all countries in the region would have been expected to have increased life expectancy as has been the case in recent decades more or less everywhere in sub-Saharan Africa. The effects of AIDS will be to increase mortality for children and young adults where mortality would otherwise have been low (and falling). The result is that AIDS will have the greatest impact on life expectancy, which other things being equal is one of the most important ways in which improvements in the standard of living are achieved and measured. It is indeed one of the three important elements in the UNDP HDI because of its value in summarising the benefits to individuals (societies) of sustainable human development.

The estimates suggest that life expectancy has already been reduced from 64.1 years in Zimbabwe to 41.9. But the situation in Zimbabwe is projected to deteriorate even further; without AIDS life expectancy in 2010 would have been an estimated 70 years but with AIDS it falls to less than 35 years. A disastrous decline and the worst projected for any country in sub-Saharan Africa. All of the countries in the Southern Africa Region are projected to suffer major declines in life expectancy caused by AIDS by the year 2010 -- for Botswana from 66.3 to 33.4; for Malawi from 56.8 to 29.5; for South Africa from 67.9 to 47.8, and for Zambia from 60.1 to 30.3 years.

Estimating the Impact of HIV and AIDS on Human Development

It is now generally accepted that the HIV epidemic has multiple and complex effects on sustainable human development. These impacts have their origins in the effects of HIV and AIDS on the growth in the labour force and on the productivity of labour and capital. It also has effects on demographic factors in ways which have been identified above, with the probability that labour losses due to HIV and AIDS will erode the human resource base of the country. It is also the case that the HIV epidemic will distort the uses of national income and through changing its composition over time will reduce the growth rate of potential economic growth.

This effect will come through two channels. Firstly, a diversion of savings into less productive uses (primarily into health and related expenditures by households and governments) so that fewer resources are available for investment which is the main instrument for achieving economic growth. With less productive investment there will be slower growth in GDP, and, very importantly less growth in employment. For countries which already have severe employment problems and with large projected numbers of youths entering the labour force in the coming years, such as Namibia, the loss of employment opportunities is indeed a major problem.

The second main channel whereby economic growth may be reduced is through what might be described as "system failure". this could take many forms and have many causes. The most likely effect on the economic system's capacity to function will occur through the losses of human resources which are projected on account of HIV and AIDS. Both the economic and social systems depend on the expectation that individuals and institutions (both public and private) function more or less normally. Thus the expectation is that the legal system functions - that cases are prepared and heard in a timely fashion. But there is evidence that this can no longer be assumed to be the case for all sorts of reasons to do with the effects of HIV and AIDS (witnesses are sick and do not turn up, lawyers and court officials similarly). The examples could be multiplied but the point is fairly obvious that HIV and AIDS will have effects which reduce the capacity of systems to function and thus will reduce the overall efficiency of the country. These are effects which will compound over time, and are far from easy to address through policy and programme interventions. This is not to suggest that nothing can be done to reduce system losses in efficiency, because there are things that can be done, and indeed it should be part of the plans of both the private and public sectors to develop appropriate programme responses in advance of the problems becoming too severe.

An interesting attempt to capture some of the effects of the HIV epidemic has been attempted by researchers from Columbia University. This is, as with most estimates, only a partial measurement of what is a dynamic process with many contributing elements. As we have seen above, the epidemic will have catastrophic effects on life expectancy in sub-Saharan Africa - including Namibia. Life expectancy is one of the three elements in the UNDP Human Development Index with an approximate weight in the index of one-third (for an explanation of the index and its construction for Namibia, see the Namibia Human Development Report, UNDP, 1996). As was also noted earlier, the life expectancy indicator can be seen as a summarising variable which measures standard of living achievements for the population as a whole. It follows that charting the effects of changes in life expectancy caused by HIV and AIDS is very important for aggregate measures of human development such as the HDI.

The Box summarises the results of the estimations undertaken by the Columbia researchers of the effects of HIV and AIDS on the HDI for a number of countries. As can be seen from the Box the effects of HIV as measured by the HDI are very substantial. As was to be expected those countries with mature epidemics and high HIV prevalence rates are most affected. In the case of Zambia there is a loss of ten years of human development progress, for Tanzania a loss of 8 years, and for Malawi and Zimbabwe losses of 3-5 years. It should be noted that these losses relate to the years 1980-1992 when the HIV epidemic was exhibiting nothing like the severity it has imposed on countries of Southern Africa in recent years. Furthermore, the predicted reductions in life expectancy over the next decade or so (as projected above by the US Census Bureau) are far greater than those which occurred during the decade 1980-1992. It follows that the losses of human development as measured by the Human Development Index will be much greater in the coming years than those estimated by the Columbia research team for the past decade of the 1980s.

The HDI for selected countries in Southern Africa has been re-estimated to take account of the effects of changes in Life Expectancy as calculated by the Census Bureau. These data are given in  which represents the HDI on a With AIDS and Without AIDS basis for 1996 and 2010. These calculations need to be treated with caution because of the underlying assumptions made about the data over the projected period. As would be expected given the weight of Life Expectancy in the HDI there are quite strong changes in the level of the index for individual countries in 1996 when all of the countries show a decline in their HDI value. It is difficult to interpret what these changes mean in any absolute sense (losses of human development due to AIDS), and it may be simpler to view the data for a single year in terms of the changes in relative ranking of these countries - a worsening of their HDI performance in all cases.

It is possible to draw somewhat stronger conclusions from the projected movements of the HDI over the period 1996-2010, again bearing in mind the caveats noted above about the assumptions underlying the projections. One way to interpret the data is to look at individual countries and compare the Without AIDS case in 1996 and 2010, such as Botswana where over this period there would have been an increase of the HDI. This can be compared with the With AIDS case where over this period there is a decline in the HDI. In other words the improvement in human development that would have occurred in the absence of AIDS in Botswana does not materialise. Instead Botswana will witness an actual fall in its HDI over the projected period such that human development in 2010 is reduced below what it was in the Without and With AIDS cases in 1996. Confirming the expectation that potential human development is lost because of the AIDS epidemic. This experience is not confined to Botswana alone but is general to other countries in the region with high levels of HIV prevalance.

It is similarly possible to construct a forward looking HDI for Namibia which takes account of HIV and AIDS. The results of doing this are reported below. It needs to be realised that the 2 Scenarios which are given are based on estimated data and have unknown errors. They are presented in order to get an idea of the effects on human development as measured by the HDI and are NOT projections. Two scenarios are developed:

• Scenario 1 is the better case and has used Life Expectancy data for South Africa (US Census Bureau Institute estimates) to derive the with and without AIDS information, and has applied a negative factor of 0.5% each year to the Income per Capita data. The Educational component of the Index is assumed to be unaffected by the epidemic.
• Scenario 2 is the worse case and has used Life Expectancy data for Botswana as a country with similar HIV prevalence and many other characteristics which are similar to Namibia. A factor of minus 1.0% per annum has been applied to the Income per Capita component of the Index on the grounds that the effects of the epidemic will be more severe in this Scenario than in 1. The Educational Attainment Index has been assumed to be the same as in Scenario 1.

Results
HUMAN DEVELOPMENT INDEX - NAMIBIA, 1996-2006

Comments

The behaviour of the HDI for Namibia for both scenarios is given in . 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