Responding to the Socio-Economic Impact of the HIV Epidemic in Sub-Saharan Africa:
Why a Systems Approach is Needed

By Desmond Cohen
March 1999

What is the Problem ?

Analyses and responses to the HIV epidemic remain rooted in a mind set which while it was relevant 5 or more years ago may no longer be so. Or at least what is written, said, thought and done about the development implications of the HIV epidemic are no longer sufficient. There is still a lack of clarity about the ways in which development affects the course of the HIV epidemic, such as the role of poverty in transmission of the virus and how families cope with the poverty caused by illness and death. It follows that much analytical and empirical work remains to be done.

Similarly, we know very little about how to move from the language of multi-sectoralism to effective programmes which actively engage all relevant organizations and interests at national and community level. While there has been some progress in moving from processes reliant on experts and "normal professionalism", towards more inclusive and participatory approaches, we are still many years away from general acceptance of the need for changes in development practice within both the donor and recipient communities. Nevertheless, there is some limited evidence of a deeper perception of the need for new and better ways of working on development - including how best to respond to the HIV epidemic as a development issue.

At the same time as development organizations, such as UNDP and the World Bank, have been redefining their objectives - sustainable human development, eradication of poverty and sustainable livelihoods, within frameworks that ensure gender equality, better systems of governance and environmental protection - so the apparently inexorable march of the HIV epidemic has been eroding the development capacities for achieving these entirely reasonable and desirable targets. How did this come to pass ?

The HIV and Development Programme of UNDP, among others, have been arguing for almost a decade now that the epidemic will undermine development in high prevalence countries. So why is it that perceptions of what is feasible in terms of development in sub-Saharan Africa are still so unrealistic? For example, both policies and programmes in all of the key areas of UNDP priority concerns continue for the most part to be designed and implemented as if the HIV epidemic neither affects their achievability nor has any consequences for the continued spread of HIV.

There are many contributing factors to the state of affairs described above but this is not the place to analyse these factors in any detail. One contributing element has been the concentration of those working on the epidemic on matters of prediction. That if X is not done then Y will happen - specifically that at some point in time there will be severe damage to development possibilities because of the epidemic. Much effort has been expended by UNDP and others in raising awareness of the many ways in which the HIV epidemic diminishes what can be achieved through development programmes, irrespective of how these are financed and implemented. It is not being suggested that these advocacy activities have entirely failed in their objectives but, unfortunately, it is now the case that in many countries in Africa the effects of the epidemic are now systematically eroding development capacity. While past efforts have largely focused on predicting what might happen, the world and the epidemic have moved on and reality is now only too often worse than any prior predictions.

Thus in many parts of Eastern, Central and Southern Africa governments, the private sector, communities and households now face a day to day experience of falling standards of living, reduced capacities for personal and social achievement, worsening expectations of what the future holds for them (with important consequences for what can be achieved today), and a diminished capacity to maintain what has been secured over past decades in terms of social and economic development. In an important and significant way the problem has changed: i.e. perhaps the issue should no longer be defined as one of HIV and AIDS. This is in spite of the fact that many of the problems for sustainable development are causally related to the HIV epidemic, for the epidemic does not randomly erode developmental capacities because who gets infected, where they live and work, their spatial concentration, and their gender, are not random outcomes.

While there is general agreement that Africa is facing a set of constraints which must be addressed if development activities are to be successful - the fact that some of these constraints have their origins in the HIV epidemic, while very relevant to programme design and implementation, is in a real sense no longer the core of the problem. Causality is now a second order consideration; being able to ameliorate the social and economic consequences of the epidemic has now become the primary task facing many countries in sub-Saharan Africa.

In far too many African countries HIV surveillance is now registering infection rates in adults of 15-25% - higher in urban populations but increasingly being matched in rural areas. Prevalence continues to rise in most countries even beyond levels of infection that few predicted as probable a few years ago. Infection is concentrated on the working age population (15-45); with women infected at earlier ages then men, and rather more women infected than men. There is limited evidence that infection (and its consequences) are skewed in their distribution towards the better educated, managerial and skilled in the labour force, with effects which are now in some countries devastating the human resource base. Poverty is intensifying and deepening - even for households with apparently greater capacity to deal with shocks (through pressures on family resources caused by increased expenditures on health, the diversion of labour to caring and non-income earning/substituting activities, reductions in earnings, and so on). Productive capacity is being reduced in all sectors - both public and private - at the same time as demands are increasing, particularly for public goods such as health and education.

To give a few examples of the reality facing many families, communities and economic and social organizations.

• A lawyer in Gabarone (Botswana) complains that he can no longer count on the legal system to function because of absences of court officials - "what am I to do in the face of the legitimate demands from my clients for speedy redress through the courts?".

• In Kagera Region of Tanzania there is an observable and measurable decline in the productivity of the mattooki/coffee bean smallholdings system because of labour losses to households with effects on both farm incomes (with worsening child nutrition and falling school attendance - by girls especially, and a deepening of poverty) and reductions in export capacity (of coffee). Both food and non-food production in Kagera are no longer sustainable systems.

• In Uganda there is a process of decentralisation of government to Districts (a process underway in many parts of Africa) but because of deaths caused by HIV and AIDS in the Western Region there is effectively no local government - and public servants in Kampala are reluctant to have their families transferred to this area for perfectly understandable reasons - not least the risk of HIV to themselves and their families.

• In Kenya there have been HIV-related deaths amongst politicians, including ministers, although this is rarely admitted publicly. What effect is this having on the whole process of "democratisation" not only in Kenya but other countries where similar effects are experienced ?

• In Zambia a major international Bank (Barclays) has established an active workplace policy to deal with the persistent losses of labour caused directly and indirectly by the epidemic (absenteeism and the disruption of the flow of work caused by this and other factors; labour turnover caused by mortality, and women being also drawn out of the labour force to care for others with HIV-related infections and because of their own infection, and so on).

• In all of the countries with mature experience of the epidemic - and this is now many -there are disruptions to activities throughout the public service and public utility sectors. This seems to be most obviously true of public administration where absenteeism is commonplace and increasing, and where public servants with specific skills and experience are simply disappearing in large numbers. These effects are especially evident in Health where losses of doctors, nurses and administrators affects what services can be supplied in the face of health seeking behaviour which simply cannot be met. Wards - especially infectious diseases such as TB - are overflowing. Similarly, in the Education sector where teacher capacity is declining - not increasing - because of HIV infection and mortality. Yet improved access to better quality education, especially for girls, has been identified by everyone as critical for achieving economic and social objectives (vide the platforms of Cairo, Beijing and Copenhagen).

• In Tanzania it is reported that the military are suffering a daily attrition of soldiers of all ranks because of HIV infection. This seems to be common for militaries throughout Eastern, Central and Southern Africa. These losses are not only personal they also represent the loss of important social investments - the military have in Africa critical functions which often straddle public order, defence and economic roles.

• It is now reported that South Africa (RSA) has 3 million people infected with HIV - the highest of any country in Africa. Yet RSA is expected by many to exercise a continent-wide role as an engine of economic growth and source of technical capacity for the rest of Southern Africa. How will this be feasible? With HIV infection now rising at one of the fastest rates anywhere in the world and in a country where civil society is still deeply divided.

• An estimated 8 million African children have lost one or both parents to HIV and AIDS since the epidemic started, and projections are for this to rise to 40 million within the next 10-15 years. These numbers are staggering and have implications for Africa which extend far beyond matters of care, important though it is to ensure that children are effectively looked after. The issues raised are complex and require similarly complex programme responses that encompases care but extends to all areas of socio-economic and cultural support.

What the above examples demonstrate is the extent of the consequences of the HIV epidemic for the entire functioning of the economy and of civil society. Clearly there are differential impacts which are not felt equally everywhere. There is spatial, sectoral and social class differentiation in terms of the impact of the epidemic and it is important that these be identified and addressed through policies and programmes. But what the evidence reveals is the inter-dependence of the social, economic and political systems, and it is precisely this capacity to function normally which is being undermined by the epidemic.

Here is the crux of the problem as well as the challenge. The objective has to be the continued functioning of a complex and inter-dependent social and economic system. But this objective can only be achieved through policies and programmes which are themselves systemic and multisectoral. It means, furthermore, that programmes have to address the internal matrix of productive sectors in a similarly systemic way - for example, to respond to the issues facing the health sector through programmes which recognise the interdependence of the different parts. At the present time far too many interventions fail to take into account their systemic effects and as a result are a good deal less than fully effective.

What Should Be the Response ?

The foregoing makes it clear that in all of the main areas of development both what can be achieved and how it is achieved are both directly and indirectly affected by the ongoing reductions in human and institutional capacities caused by the HIV epidemic. Sustainable Human Development if it is about anything is about strengthening human and non-human resource capacities, both as "good things in themselves", and because these are critical for improving living standards in a sustained way.

What Are the Key Principles to Guide What to Do in Sub-Saharan Africa in the Light of the Foregoing?

1. There exist many issues which are regional, in the sense of common to many countries, relating to responding to the effects of the HIV epidemic on systems. These have to include gender relationships B women=s differential access to economic, social and political resources and decision making power as fundamental to effective responses in all countries.
   
2. Seven system areas seem to stand out in terms of their generality and in terms of their importance for the sustainability of development in Africa. These are:-

   - Public Administration

   - Legal Systems and the Judiciary

   - Education

   - Health

   - Economic Services (Private and Public - Banking, Insurance, Social Security, Transport/Communications, Water, etc)

   - Directly Productive Sectors (Commercial and Smallholder Agriculture, Mining, Formal and Informal Entreprises, etc.)

   - Civil Society Organizations

3. There are issues which are the outcome of factors which are common to many countries - perhaps more subregional than regional - where there are gains from common analysis and joint action. These are programme areas where there are economies of scale both in analysing the causal variables and in developing responsive activities. In part the support for common (regional/sub regional) action depends on synergy, i.e. that action taken by one country is less effective than action taken jointly by several countries. An example of a common factor which seems to be associated with HIV transmission and the spread of the virus beyond the borders of a single country is the mobility of labour, where regional/sub regional labour markets exist. Action to address the causes of inter-country labour mobility will require regional analysis of regional variables and the development of regional policies and programmes. Action by a single country is likely to be ineffective, and regional policies addressing common causes will be thus essential.
   
4. One priority area is to increase regional integration and trade where it is critical that policies and programmes be undertaken which limit the risks to populations through induced labour migration. The classical analysis of why trade is beneficial is in part based on the theoretical presumption that trade in goods and services substitutes for the movement of people, although in practice what one observes is a mixture of both. In a world of HIV it is thus even more essential that policies and programmes aimed at greater regional integration of economic activity be accompanied by policies to minimise induced labour flows. In so far as this is not achieved and poles of development act as magnets for labour from within a region then the benefits of greater economic integration will be offset in part (or wholly) by the costs of greater HIV infection in the population. To a degree this is already happening in Southern Africa as labour, especially skilled and professional, is migrating to RSA from "dependent" countries in the region (adding to the traditional migratory flows).
   
5. At the present time many countries and organizations are responding to common problems and are attempting to develop policies and programmes. But many organizations B both public and private, are lacking in substantive experience in these "new" areas and need a great deal of technical support. There are opportunities here for cross-learning so as to avoid some of the costs of individualized experimentation. This is a valid argument for a regional supply of technical expertise, because attempts to develop policies and programmes individually in the area of HIV and AIDS as in other areas (such as governance, sustainable livelihoods and poverty, and so on) is clearly sub-optimal.
   
6. So common objectives and common problems which can be addressed and supported through technical cooperation become an argument for supplying technical expertise through regional/sub regional activities. It follows that since the existence of the HIV epidemic now effects a wide swathe of development activities (see above), there is a generalised need for a regional capacity that can be accessed. A capacity that supports private organisations, communities, governments and others to respond to the epidemic through integrating HIV in their day-to-day activities. Strengthening regional/subregional capacities thus becomes an essential tool for more effectively responding to the epidemic. Now achieving this will be difficult at the best of times and will be doubly so under present conditions in SSA where the epidemic is systematically eroding human and institutional capacity.

    

   How Should It Be Done ?

   A number of important considerations are relevant. These are: -

1. First and foremost a deeper understanding of the systemic effects of the epidemic. For only if this is accepted will it be possible to develop and implement an effective response. There have been, and continue to be, many worthwhile activities that address both the causes and consequences of the epidemic. But these remain isolated and independent programmes and fail to address the fact that the HIV epidemic is systematically eroding development capacity across all sectors. Programmes need to be developed and implemented synergistically - they have to be planned and be undertaken in an integrated way. Mechanisms have to be established that ensure that activities of donors, governments and others are mutually supportive of the national response.
   
2. What principles should guide the actions of UNAIDS and the Cosponsors in the region? The guiding principle in allocative decisions ought to be that institutions do those things which reflect their comparative advantage. It has become evident that the UNAIDS Secretariat will not have the expertise nor the capacity to address the myriad of development issues raised by the epidemic. Nor should it try to do so, for this would defeat the central purpose of the UN approach to the epidemic. That is, that the Cosponsors should undertake in accordance with their mandate those activities which reflect their competence and fundamental purpose. It is evident that while the World Bank has a lending programme for HIV and HIV-related activities, it has few intentions of developing the capacity in house (or indeed through its lending activities) that is needed for an effective response to the epidemic. While UNDP is presently the only organization with some capacity at HQ and in its Africa Regional HIV Project for addressing HIV and Development, this capacity is wholly inadequate to the task. Similarly with the other Cosponsors - all are capable and are engaged in limited activities that address sub-sets of the problems in SSA. But in the aggregate the activities are poorly focused and rarely integrated and are too limited in scale.
   
3. The objective of any activities has to be capacity development - providing technical cooperation in ways that lead to effective responses to the epidemic while simultaneously strengthening local/regional institutions and human resources. It cannot be said that in the past enough resources have been applied to capacity development. Analysis of the epidemic has been insufficiently complex, and the lessons from other areas of development have generally not been sufficiently applied to the design and implementation of HIV programmes. In deciding how to go forward it is crucial to learn the lessons of the past and to keep attention focused on capacity development in the region. This has to mean -

• a more explicit analysis of capacity needs in relation to the broad socio-economic and political situation in the region/subregion

• an initial mapping of the array of organizations, including networks, engaged in functions which relate to and can be drawn upon and strengthened by any proposed Africa Initiative

• an assessment of how to improve the organization and management of such organizations so as to raise their effectiveness, and

• the identification of people with expertise (including how to recognise relevant expertise, how to create it where it does not exist or is not recognised, how to manage its effective use, and so on).

Conclusions

The above more or less covers most of the factors which need to be taken into account in defining what to do and how to it. The details of what and how still need to be elaborated, but this ought to emerge from a discourse with partners in the Region and UNAIDS. It is unwise to be unduly prescriptive in these matters.

• It is almost certainly the case that some substantive presence in the Region will be necessary. This may not be a regional project(s) or inter-country team(s) as presently constituted - probably ought not to be since something much more substantive may be needed.

• Resources and activities will need to be reasonably close to the point of use (and in Africa - and perhaps in sub-regional locations), and be capable of a sustained and ongoing relationship with users of the services being supported.

• Ways of working will need to be quite different from in the past; the objective has to be to strengthen capacity and to engage in those activities required in order to achieve this target. It means identifying institutions and individuals who have a commitment to work with UNAIDS, the Cosponsors and others on development-related aspects of the epidemic. It means looking intensively at the possibilities of using existing institutional structures and networks, and undertaking a capacity assessment of their needs and potential.

• It may mean working specifically in some sub-regions and not others, and in some countries and not others. These limitations of coverage in terms of country and programme development need to be established as far as possible in advance so that resources are not frittered away.

The way forward with developing a detailed plan is perhaps to undertake an operational review of the existing activities in the region as a matter of great urgency. To use the Review -

• as a way of identifying some of the areas of concentration of activity (what is discussed above),

• for assessing what exists in terms of materials, skills etc (capacity generally both in UNAIDS and the Cosponsors, and in existing and potential partners) that can be drawn upon in the future, including ways of involving other key UN agencies such as ILO and FAO,

• for reviewing the status of existing activities, identifying those which should be continued and expanded, including an assessment of the capacity needs of existing resource networks that are being supported in the region,

• for the mapping out of new ways of operating in the future, including building resource networks, developing new partnerships within the region/sub-regions and how to work more closely with other donors, national and international NGOs, CBOs, and so on,

• as a way of identifying organizational structures: the way forward may be some mix of centre and periphery - centres of resource management and problem identification which are allied to networks of institutions/individuals who provide most (not all) of the substantive activities of any Africa Initiative,

• as a mechanism for mobilising the political commitment of governments in Africa to an expanded response to the epidemic.

Above all it means working in an integrated way - seeing the problems as being developmental and systemic, and seeking to find solutions which are themselves systemic rather than piecemeal and largely uncoordinated.

1. Paper prepared for UNAIDS discussions relating to an Africa Initiative on HIV and AIDS (December-January 1998/99).

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.