what do we (need to) know about the development impact of aids in africa? hiv/aids and development...
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What do we (need to) know about the development
impact of AIDS in Africa?
HIV/AIDS and Development in ZambiaTaking Stock and Rethinking Policies
Lusaka, February 4, 2010
Robert Greener
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Magnitude of the Epidemic
• 33 million living with HIV– 67% in sub-Saharan Africa
• 2.7 million new infections per annum
• 2 million deaths per annum– number infected still growing
• More than 3 million on ARV treatment
• Most infections are in low and middle-income countries
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The World of HIV
© Copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).
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The World of Income
© Copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).
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Prevalence and Impact – the “long waves”
T1 T2 Time
Numbers
A1A2
HIV prevalence
B1
A
B
AIDS - cumulative
Impact
T.Barnett, A.Whiteside
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Top Causes of Death in Africa
1. HIV/AIDS2. Malaria3. Lower respiratory infections4. Diarrhoeal diseases5. Perinatal conditions6. Cerebrovasuclar disease7. Tuberculosis8. Ischaemic heart disease 9. Measles10.Road traffic accidents
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Change in Under-Five Mortality Rate in Selected Countries with High HIV Prevalence, 1990–2003
R. Hecht et al. Putting It Together: AIDS and the Millennium Development Goals. PLoS Medicine, 2005
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HIV and GDP per capita - SSA
0%
5%
10%
15%
20%
25%
30%
35%
100 1000 10000 100000
Botswana
Lesotho
Zimbabwe
Zambia
MalawiMozambique
Tanzania
Ethiopia
Côte d'IvoireKenya
DRC
South Africa
Nigeria
Cameroon
Senegal
Swaziland
Namibia
Gabon
Equatorial Guinea
Mauritius
Central African Republic
Uganda
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HIV and Income Poverty
0%
5%
10%
15%
20%
25%
0 10 20 30 40 50 60 70
Botswana
Lesotho
Zimbabwe
Zambia
Malawi
Mozambique
TanzaniaCôte d'Ivoire
UgandaKenya
South Africa
Nigeria
Cameroon
Ghana
Central African Republic
Mali
Namibia
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HIV and Literacy
0%
5%
10%
15%
20%
25%
30%
35%
0 20 40 60 80 100
Ethiopia
Swaziland
South Africa
Nigeria
Mozambique
Zimbabwe
Zambia
Malawi
Côte d'Ivoire
Burkina Faso
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HIV and Nutritional Status
0%
5%
10%
15%
20%
25%
30%
35%
0 10 20 30 40 50
Botswana
Lesotho
NamibiaZimbabwe
Zambia
Malawi
Mozambique
Ethiopia
South Africa
Nigeria
Swaziland
KenyaUganda
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HIV and Income Inequality
0%
5%
10%
15%
20%
25%
30%
35%
25 35 45 55 65 75
Botswana
Lesotho
Namibia
Zimbabwe
Zambia
Malawi
Mozambique
Tanzania
Central African Republic
Ethiopia
Côte d'IvoireUganda
Kenya
Rwanda
South Africa
NigeriaCameroon
BurundiGhana
Senegal
Swaziland
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HIV prevalence by wealth status: MEN
0
5
10
15
20
25
1 2 3 4 5
Income Quintile
HIV
Pre
vale
nce
%
Burkina Faso
Ghana
Cameroon
Uganda
Kenya
Tanzania
Malawi
Lesotho
Mishra, Van Assche, Greener, Vaessen, Hong, Ghys, Boerma, Van Assche, Khan, Rutstein, 2007
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HIV prevalence by wealth status: WOMEN
0
5
10
15
20
25
30
35
1 2 3 4 5
Income Quintile
HIV
Pre
vale
nce
%
Burkina Faso
Ghana
Cameroon
Uganda
Kenya
Tanzania
Malawi
Lesotho
Mishra, Van Assche, Greener, Vaessen, Hong, Ghys, Boerma, Van Assche, Khan, Rutstein, 2007
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“Upstream” and “Downstream”
HIV Infection
“Downstream”“Upstream”
Poverty and Social Deprivation
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Economic Impacts of AIDS
• The macroeconomy
• Investment and FDI
• Firms and enterprises (workplace)
• The public sector
• Individual and household
• Human capital and long run impact
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Macroeconomic Impact
• Lower aggregate labour productivity
• Lower savings and investment
• Variations on neoclassical growth models project slower macroeconomic growth (as much as 1-2% reduction in growth in the worst affected countries)
• Empirical studies find little evidence for an impact on growth so far (in GDP terms)
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Investment Impacts
• Reduced savings and investment is a major channel for economic impact of AIDS in many countries– This is likely to result from household level
impacts and from slower population growth
• The potential impact on foreign direct investment due to loss of confidence may be more important than the labour impacts
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Impact on Firms and Enterprises
• Lower productivity from untreated HIV positive workers
• Higher medical expenses, where these are provided
• Replacing and training skilled employees who die
• Erosion of their customer base, as local customers and the local economy suffer.
• Positive publicity from positive action
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Estimates of Firm Level Impact
Sector Country SizeEstimated HIV prevalence
Cost per AIDS death or retirement
(multiple of annual compensation)
Aggregate annual costs
(% of labor costs)
Retail South Africa 500 10.50% 0.7 0.50%Agribusiness South Africa 7,000 23.70% 1.1 0.70%
Uganda 500 5.60% 1.9 1.20%Kenya 22,000 10.00% 1.1 1.00%Zambia 1,200 28.50% 0.9 1.30%
Manufacturing South Africa 1,300 14.00% 1.2 1.10%Uganda 300 14.40% 1.2 1.90%Ethiopia 1,500 5.30% 0.9 0.60%Ethiopia 1,300 6.20% 0.8 0.60%
Media South Africa 3600 10.20% 1.3 1.30%Utility South Africa >25,000 11.70% 4.7 2.20%Mining South Africa 600 23.60% 1.4 2.40%
Botswana 500 29.00% 4.4 8.40%Tourism Zambia 350 36.80% 3.6 10.80%
Source: Jonathon Simon, Sydney Rosen, Rich Feeley, Patrick Connelly, “The Private Sector and HIV/AIDS in Africa: Taking Stock of Six Years of Applied Research”
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Impact on Government
• Increased employment costs and falling productivity, as with the private sector
• Reduced revenue as economic growth slows, but increased expenditure demand as services must be scaled up
• Government’s role in providing an “enabling environment” may be compromised
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Individual and Household Impact
• Mortality and orphanhood• Lower productivity and wage earning• Loss of income from those who die• Higher costs of medical care• Higher costs of funerals
Deepening of poverty and malnutritionBarriers to treatment access
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Does AIDS Increase Poverty?
• It is difficult to attribute poverty changes to AIDS – there are many confounding factors
• Salinas and Haacker (2006) found that the impact on poverty in 4 African countries was likely to be greater than the impact on per-capita income– This is because HIV may be concentrated
among households close to (but just above) the income poverty line
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Long-run human capital effects
• Human capital is reduced directly through mortality and lower life expectancy
• Education outcomes are worse in areas with high HIV– Suggestion that investments are reduced
because the potential returns are lower
• Education and health outcomes are significantly worse for orphans, who are increasing in number
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Human capital and long-term impact
• Early work (Bell et al) suggested that accumulating human capital losses will cause a much greater macroeconomic impact in the long term
• Other methods (e.g. Solow growth models) incorporating human capital also expect much larger impact than current observation suggests
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The Impact of ART
• Most projections and empirical investigations of impact do not account for the impact of ART
• ART clearly mitigates impact, but by how much and with what other consequences?
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ART in Uganda
• ART offsets part of negative growth impact (1/3–1/2)
• ART provision does not pay for itself in economic terms, but can nonetheless be justified in social terms
• Extent of economic benefits of ART to a country depends on how programmes are funded– Domestic financing of ART is not sustainable and will
have an adverse economic impact due to tax/borrowing implications
– Budget impact is relatively small if HIV/AIDS programmes largely donor funded
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Does Poverty increase HIV vulnerability?
Data– Cross-sectional cross country analyses (DHS)– Longitudinal seroconversion studies– Longitudinal household surveys – Studies linking other interacting factors (mobility,
gender, malnutrition) with HIV risk
Outcomes– High risk behaviors– HIV prevalence (% of population estimated to be HIV +)
– HIV incidence (number of new infections/year)
– Prime age adult mortality (15-59 years of age)
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HIV Incidence and Wealth Status
• 3 prospective seroconversion studies– Lowest male HIV incidence among wealthiest
asset tercile (Lopman et al, Manicaland)
– Lowest incidence in middle tercile (Barnighausen et al, KZN)
– No association (Hargreaves et al, Limpopo)
– Limitation: High attrition rates
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Role of other socioeconomic factors
• Education associated with less risky behaviors and lower HIV incidence
• Age and economic asymmetries • Gender inequality• Low social cohesion (e.g. slums)• Mobility
• Women engaged in some form of self-employment less likely to die in prime age
(MSU and Kadiyala)
Positively associated with HIV +ve status
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Some Conclusions
• Economic status in itself is not a strong predictor of HIV status in Africa….– Prevention must cut across all socioeconomic strata of society
• No simple explanation– Poverty is part of the story, but not the key– Pathways and interactions are complex– Predisposing factors are different for different groups
• Tailor interventions to the specific drivers of transmission within different groups– Education; women’s economic independence
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Development and HIV
• Expanding treatment programmes is vital to maintain economic participation and mitigate economic impacts
• Development plans and projects must factor in the possible interactions with HIV
• AIDS is a long-wave event, and it is vital to sustain the financing for programmes in the long run.
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Vulnerability of Programmes
Congo, Dem. Rep.
Mozambique
Eritrea
Ethiopia
Comoros
RwandaZambia
Tanzania
South Africa
Swaziland
Angola
Lesotho
Botswana
Zimbabwe
Malawi
Uganda
Kenya
Djibouti
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
Higher Vulnerability to CrisisLower Vulnerability to Crisis
Higher Economic Share of HIV
Lower Economic Share of HIV
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AIDS and Development Planning
• Long term AIDS strategic plans need to be prioritised, evidence based and costed– Ambitious and feasible– Aligned with national development plans and
budgeting frameworks (PRSP and MTEF)– Coherent - focused on 3 ones principles– National level ownership and accountability – Meaningful participation of civil society