Part II: Integrating HIV/AIDS in NEPAD
A. Cross Cutting Issues
There are five broad cross-cutting issues which have relevance for many
activities in NEPAD and it is worth identifying these separately precisely
because of their general importance in all sectors. These are: -
1. Human Capital
The importance of Human Capital for the achievement of sustainable
development is recognized by all developmentÝ practitioners. In part this
capital is the outcome of social processes undertaken privately, usually by
families, and in part it is the outcome of formal activities undertaken by
the state in the public education and training system, and private
institutions such as enterprises and churches. Whatever the source of the
investment in human capital it is essential for the processes of
development. Because the HIV epidemic is concentrated in the working age
population, both men and women, and may be affecting disproportionately
those with better education and skills, there is occurring in many African
countries an immense loss of human capital. Both the stock of human capital
is suffering attrition, but so isÝ the flow of those who are educated and
trained. These developments haveÝÝ consequences for all forms of social,
economic and political activity, and thus will have implications for the
totality of what is proposed by NEPAD.
2. Public Goods
The State in all countries plays a significant role in supporting the
processes of growth and development. It does this in part through regulatory
frameworks and systems of law and the judicial system, but also through the
direct provision of key services [such as the police, security, educational
and health provision, transport systems and telecommunications etc]. For
these services to function effectively there needs to be a system of public
administration which is appropriately staffed with relevant skills, and
managers and supervisors who are experienced and supported in their tasks.
But again the HIV epidemic is eroding public service capacity through the
losses of nurses, doctors, accountants, public administrators, teachers,
judges and so on. It follows that all of the NEPAD proposals that depend on
a functioning and effective public administration and on publicly provided
goods [such as those provided by utilities in the areas of energy, water
supply, telecommunications and transport] will only be feasible where
resources are devoted to sustaining public capacities.
3. Systems Approaches to Problem Solving
It needs to be noted that the economic and social system in all countries
consists of inter-dependent parts and that the efficiency of the whole
depends on the parts working more or less normally. In other words the
economic and social system has to a degree be conceptualised as "systemic"
if development plans are to be realized. It is clear from the foregoing that
because the impact of the HIV epidemic is generalized across different
productive sectors, social, political and economic, that policies and
programmes have to address the linkages ? or they will be less than
effective. For example, many children have been orphaned by the epidemic
[see above] and they and many other children are being increasingly
impoverished by the impact of the epidemic on families.
It follows that policies for educational expansion need to take into account
the changing needs of the school population, since many families will simply
not be able to send their children to schools [especially girl children].
Similarly, the educational system cannot carry on business as usual in that
employers are facing entirely new conditions because of HIV/AIDS in terms of
recruitment and retention of labour. NEPAD takes no account of the multiple
ways that HIV/AIDS has effects on system performance and what can be
achieved through new programmes for sustainable development.
It is also essential that the internal matrix of relationships be understood
if there is to be effective programming in any social and economic area. For
example within a productive sector there exist important economic and social
relations that need to be sustained for effective performance. Thus in
commercial agriculture because inputs are secured from external suppliers
[eg. the maintenance of equipment] then losses of skilled labour due to AIDS
in supplier organizations will adverse affect the productivity of commercial
farmers [who will face higher costs because of equipment failures]. Similar
consequences will affect performance in other sectors, such as education and
health, where the sectoral performance will be adversely affected because of
internal losses of capacity due to HIV/AIDS. Policies and programmes thus
need to address these intra-sectoral relationships if they are to mitigate
the impact of AIDS on economic and social performance.
4. Investment Strategies
There are issues relating to investment strategies. Raising levels of
investment in productive activities are seen as essential for the
achievement of the higher targeted rates of GDP growth and reaching the
various Millenium Goals [see above]. It is evident that raising rates of
investment in physical capital and importing embodied technology will in
themselves be less than successful unless human capital and organizational
capacity can be sustained in the face of HIV and AIDS.
There seems to be no realization in NEPAD of the fact that labour and capital inputs are both
essential for development in appropriate proportions, and therefore that
losses of human capital and erosion of public sector capacity will
significantly reduce the productivity of new investment. Nowhere in NEPAD is
there any analysis of the effects of the epidemic on new investment, whether
funded within the country or dependent on external flows of capital. There
are also related issues of the role of new investment in infrastructure in
positively increasing HIV transmission [and what might be done to mitigate
this], and of the role that technology can play in reducing some of the
adverse impacts of the epidemic on labour productivity [eg in agriculture].
5. Governance
NEPAD is premised on the statement and belief that Africa can and should
take responsibility for its current state and for the achievement of
sustainable development for all Africans. This is to be welcomed, although
it is recognized that its achievement will depend crucially on external
flows of resources, both ODA and private capital and technology. In the past
few years African leaders have begun to show leadership and commitment to
respond to HIV/AIDS, e.g. through involvement of political leaders in
National Coordination Bodies.
Further evidence of the changes underway is
the fact that the African Development Forum in 2000 demonstrated
significantly increased levels of concern about the effects of the epidemic
on social and economic development. It is, therefore, rather inexplicable
that the only mention of AIDS in NEPAD is in the context [very brief] of
communicable diseases, as if AIDS were indistinguishable from other diseases
such as malaria.Ý To address the issues in this way totally fails to note
the complex ways in which the HIV/AIDS epidemic undermines sustainable
development.
The key challenge now facing African leaders is how to ensure that policies
and programmes are developed for the key strategic sectors identified by
NEPAD that integrate HIV/AIDS.Ý This is no simple task, and the evidence
from many countries that specific activities to mainstream AIDS across the
various sectors will take targeted resources and need to build on the
existing knowledge of what works and what does not.
B. Conditions for Sustainable Development
There is a section of NEPAD devoted to the conditions that
determine sustainable development [paras 71-95]. Under this rubric, three
separate but related areas are identified for brief analysis. These are
Peace and Security, Democracy and Political Governance, and Sub-Regional and
Regional Approaches to Development. These are all related. and in the final
analysis are likely to be achieved only under conditions where Africa
experiences over a period of years, probably decades, an end to instability
and wars. The pattern of recent history has, unfortunately, been one of wars
and crises which have undoubtedly contributed to the unfavourable
development experience of the continent. It is still the case that many
countries face armed conflict, and there are many governments that are far
from democratic, so there exist major problems with securing the essential
conditions for sustainable development.
It also follows that attempts to secure more balanced patterns of regional
and sub-regional development will in general be unsuccessful until peace and
security and democratic institutions can be achieved. For the moment it
seems better to think of these objectives as being dependent on the
achievement of peace and security in Africa as a whole, although clearly
there are possibilities to further integrate AIDS in existing institutions
such as ADB and SADC, where some HIV/AIDS-related activities already exist.
The primary area where opportunities exist for integrating HIV/AIDS in NEPAD
is in respect of what might be called the general underpinnings of
development, that is in relation to crisis avoidance and crisis management
[what NEPAD calls Peace and Security]. It is in this area that the OAU [now
the AU] has been active in trying to secure peace, and the leaders of the AU
have committed themselves to activities to secure conditions where conflict
is avoided. What NEPAD does not do is to provide any analysis of the
underlying determinants of crises, of which there are many. No typology of
crises is presented and yet they differ sharply in their causes and their
effects [ranging from armed conflict, natural disasters and economic and
social collapse].
What has been well established is that crises, especially those caused by
armed conflict, are precisely the conditions where HIV transmission is
accelerated and where programmes to respond to the needs of the population
[both HIV-specific and HIV- related] are disrupted and often destroyed.
Populations are often displaced in large numbers, and for many years have
their livelihoods removed. Now these are precisely the conditions in which
the HIV epidemic thrives, and even when the crisis is over there remains a
population, especially of women and girls, but also of ex-combatants, who
will need programmes that take account of the pattern and level of AIDS that
has resulted.
It follows that one of the most important ways of taking forward the
integration of AIDS in NEPAD in crises relates to programme development in
areas of prevention and care, and in the mitigation of economic and social
impacts of the epidemic. The need for such targeted activities is likely to
be greatest in post conflict situations where demobilized forces and
displaced populations will require programme support. The type of assistance
needed includes health infrastructure renewal, educational services,
employment generation, poverty alleviation, law and security, and so on.
There are also long-term problems of bringing services and support to
displaced populations who have for many years been stranded in refugee camps
in many parts of Africa as a result of previous conflict, for whom very
little has been done in terms of HIV prevention and care and support.
There exists in the UN system [ILO, WFP and UNHCR especially] and elsewhere
[NGOs especially] a great deal of experience in dealing with post conflict
situations.
None of these have taken very far the integration of AIDS in
their support of crisis- affected populations, but they all have experience
that is relevant to the integration of HIV/AIDS in NEPAD-related activities.
It is strongly recommended that the AU develop the capacity to address
issues of AIDS, most especially in respect of policies and programmes to
assist crisis-affected populations during periods of reconstruction. For
crises clearly lead to conditions where populations are exposed to HIV and
AIDS, and these populations require specific targeted programmes to address
their problems.
Part III. Integrating HIV/AIDS in NEPAD Sectoral Priorities
NEPAD focusses on six sectoral priorities, and since there are profound
implications for each of these stemming from the HIV/AIDS epidemic, it is
proposed to discuss these linkages sector by sector.
1. Infrastructure: including transport, information and communication
technologies, energy, and water and sanitation.
In the case of any capacity expansion in these subsectors, two initial
requirements are paramount: long term financing and human skills.
Subsequently it is essential that maintenance is undertaken, again involving
mechanisms for the financing of maintenance and the continuing availability
of a complex array of human skills and organizational capacity.
These requirements are all currently being undermined by the HIV/AIDS
epidemic. It is clear in many countries already facing shortages of highly
trained labour ? including engineers, technicians, scientists, managers ?
that HIV/AIDS is further reducing the numbers of such workers, reducing the
capacity both to construct new investment projects and to maintain existing
ones.
The questions which need to be addressed include the following: in the
face of the morbidity and mortality resulting from HIV/AIDS, how are
countries responding in terms of sustaining necessary levels of skilled
labour? Is there a flexibility in terms of length of training periods,
without unacceptable losses of quality? To what extent can African countries
draw on skills from elsewhere in the region to bridge gaps in key categories
of skill? How feasible is this on a continent-wide basis? The reductions in
skilled labour affect not only those who are undertaking the tasks directly,
of overseeing the construction of new infrastructure projects for example,
but also the networks of training institutions which are losing capacity as
a result of HIV/AIDS, and the public sector's administrative capacity to
manage infrastructure development. Without serious consideration to the
relationship between the epidemic and the availability of skilled labour,
the plans laid out in NEPAD have little hope of being realised.
Financial capacity is also affected by the HIV/AIDS epidemic, in two main
ways. First, countries affected by the epidemic are experiencing declines in
levels of production and income, which are reducing both private savings and
government revenues. Whether national financing of infrastructure is to be
undertaken by the private or public sector, these constraints imposed by the
epidemic intensify already severe financial constraints. Secondly,
investment financed from overseas, whether from private sources or
multilateral institutions, will inevitably involve an examination of the
viability of projects taking into account the effects of the HIV/AIDS
epidemic on future flows of revenue.
Thus it is fundamental for national governments and intergovernmental bodies
to incorporate into their plans and programmes effective policies for
reducing the rate of transmission of the virus and for mitigating its impact
on the functioning of social and economic institutions, including most
importantly its impact on human capital. Otherwise, it may be difficult if
not impossible to secure overseas financing of major projects, the viability
of which may be undermined as a result of the HIV/AIDS epidemic.
Central to the proposals for infrastructure development are transport
improvements, which are clearly essential for the promotion of economic
activity. However, it is also essential to acknowledge the relationship
between mobility of people and the transmission of HIV. For example, it is
widely known that long-distance truck routes have been associated with high
levels of infection, and any programme to improve mobility via extensions of
inter-country road links must incorporate activities to effectively reduce
transmission and to protect the populations involved from infection.
All new infrastructure projects need to have built in from the outset a
programme for HIV prevention and care for workers and for communities
involved in the project, whether these are communities displaced or
communities whose lives are otherwise affected by the ongoing functioning of
the project. These HIV prevention and care strategies should be part of the
standard project design from the very beginning for all new investments, and
will need to involve NEPAD working groups cooperating with other agencies
and organizations, such as the AU, World Bank, African Development Bank,
bilateral and multilateral donor agencies, and private sector financial
institutions.
2. Human Resource Development: including reversing the brain drain,
poverty reduction, education and health.
The objectives enunciated by NEPAD represent a very great challenge indeed
if the impact on human resources of the HIV/AIDS epidemic is fully taken
into account. All areas included in this sector are severely affected by the
epidemic, and it must be acknowledged that, in many countries, current
trends are downward in indicators of poverty, and standards of health and
education provision. The reasons for this stem fundamentally from the impact
of HIV/AIDS on the working age population, where the greatest incidence of
morbidity and mortality is felt. Since the working age population is the
backbone of social and economic life in all societies, the greater
proportionate losses in this group have profound effects on all social and
economic functioning.
In the area of education, it has already been discussed above that losses of
highly skilled people have widespread systemic effects. It is not just that
there are losses of teachers ? even though this is serious enough; it is,
further, that there are losses at all levels of the education system: the
educational administrators and planners, the designers of curricula and
educational materials, the trainers of teachers and the trainers of
trainers, the librarians and translators, the examiners and inspectors. At
all levels and stages in the educational system, highly skilled and
experienced people are first unable to work and then dying prematurely as a
result of HIV/AIDS, people in whom very significantÝ resources have been
invested in order that they in turn will be able to increase the human
capital of society in some way.
The questions this raises for development strategies are similar to those
indicated above: how to attempt to maintain a functioning educational system
in the face of such losses of skilled people? How to reduce the length of
time taken to train teachers, teacher trainers, etc, without undermining
quality? Can increased cooperation among African countries fill some of the
gaps in the system? These kinds of questions need to be addressed with some
urgency in order first to halt the decline in the level of educational
provision and then perhaps to facilitate the improvements envisaged in
NEPAD.
There are further aspects of the impact of HIV/AIDS on levels of educational
achievement which also need to be examined: children who have lost one or
both parents as a result of the epidemic are less likely to be enrolled in
school, partly as a result of the greater poverty of the household because
of the illness and death of one or more parents, and partly because children
themselves are forced to become economically active at a much younger age.
In order that children in these circumstances are able to attend school, it
is imperative that programmes be developed to support households facing
losses of adults, so that the children are not confronted by the double
burden of losing parents and facing a future without the benefit of an
education.
In the health sector, skilled labour is being affected as severely as in
other sectors, with high levels of morbidity and mortality among nurses,
doctors, health administrators and all other workers. At a time when
intensified demands are being made on the health system for treatment and
care of people with HIV and AIDS, and for prevention programmes of health
education, the capacity of the health system to undertake these new demands,
in addition to meeting existing needs, is being eroded. In many countries,
levels of care for people living with HIV and AIDS are highly inadequate,
and this in turn means that other family members must devote their time to
looking after sick and dying relatives. This is having very significant
negative effects on levels of output in all sectors, further reinforcing the
overall effects of the epidemic on the economy.
It therefore seems essential that, in order to support the functioning of
health systems and to improve levels of care for people affected by HIV and
AIDS, similar questions need to be raised as indicated above: how to sustain
numbers of health care workers? How to shorten training periods without
undermining quality? How to improve inter-regional and international
cooperation to fill gaps in trained personnel?Ý In terms of strategies to
improve support for carers, it is essential that mechanisms for learning
from best practice be intensified, as many countries have experience of the
establishment of systems of care at community level which enable family
members to continue to be economically active while their sick relatives are
provided with necessary support.
Programmes for reducing levels of transmission of HIV also need to be
included in the health sector, to protect health sector workers from
becoming infected. This is another area where there is much scope for
learning from best practice within a regional context.
Poverty reduction is a further objective of NEPAD, and this is another area
where HIV and AIDS is having widespread negative effects in large numbers of
countries. In fact it is astonishing that no mention of HIV/AIDS is made in
the discussion of poverty reduction, since the linkages between the epidemic
and levels of poverty are so clear. Already poor households are becoming
even poorer as a result of the loss of working-age adults, often leaving
children or elderly people as heads of households. Many households become
impoverished when adults become ill, by using savings or selling assets to
seek expensive treatment which may well be ineffective.
All households with HIV-infected people are affected by the resulting losses of labour and
therefore the losses of income, and those households on the margins of
survival are pushed into destitution. Furthermore, the necessity to care for
family members who become sick as a result of the epidemic leads to the
diversion of usually women's time from activities such as food production.
It also needs to be stressed that the poor ? and particularly poor women -
are also extremely vulnerable to becoming infected with the virus.
This is partly because many poor women engage in sex work as a result of the absence
of any other means of survival; it is also because poor women are frequently
unable to negotiate safe sex with partners because of their economic
dependence. The poorest in society in general have less flexibility and
fewer choices in their lives than the non-poor, both of which can be
associated with greater vulnerability to risks such as HIV infection.
Taken together, these linkages between poverty and HIV/AIDS have important
implications for programmes of poverty reduction. The provision of training
and employment opportunities especially for poor women is paramount, along
with micro-credit schemes to underpin economic activity and support for
households experiencing losses of adult members. In all of these areas there
is scope for learning from best practice elsewhere, especially from
countries where there has been some success in reducing the rate of
transmission of HIV.
It needs to be emphasised that all programmes and
projects with the objective of poverty reduction should incorporate from the
very outset the linkages between poverty and HIV/AIDS, otherwise there is
little likelihood of success, since any potential gains will be overwhelmed
by the negative effects of the epidemic.Ý
3. Agriculture:
NEPAD recognizes that the majority of Africa's people live in rural areas,
and that agrarian systems are generally weak and unproductive. However,
agriculture is another area where the impact of HIV and AIDS has been
profound, and where the absence of an analysis of the effects of the
epidemic will undermine any benefits the programme may achieve. The problems
associated with the epidemic are, as above, largely a consequence of the
high levels of morbidity and mortality among the working age population,
thus reducing the output of agriculture ? both food and non-food, in both
small scale and commercial units of production.
The problems of reduced labour supply in agriculture are further compounded
by the increased demands, especially on women, of caring for sick family
members. Rural women are already fully occupied, given the labour intensity
of all rural economic activity and household tasks, for example food
production and preparation, collection of firewood and water all involve
long hours of work, partly because of the lack of social investment in areas
such as water supply and energy.
The additional demands on women's labour resulting from the HIV/AIDS
epidemic mean that their time must be diverted away from other activities to
care for sick family members, resulting in many places in a decline in
agricultural production. There is also evidence of a shift in the
composition of agricultural output from commercial crops towards food for
local consumption. While this may be a means of ensuring household food
supplies in the short term, it lowers household income (because the crops
being produced in greater quantities are usually of lower value than those
being produced in reduced quantities), it reduces foreign exchange earnings
and therefore import capacity, it lowers tax revenues, and it lowers the
capacity of households to save and to afford non-food items (such as school
fees, medicines, etc).
The reduction in labour supply to the commercial agricultural sector (tea, coffee, cocoa etc) has similar consequences, of reducing levels of income to households in rural areas, and lowering total
foreign exchange earnings and government revenues. The problems arising from HIV/AIDS are also systemic, with mortality and morbidity increased among highly skilled and professional agricultural
workers ? extension workers in agriculture and veterinary services, trainers
of extension workers, government officials involved in agricultural
administration, technicians employed in areas such as tea and coffee
production. In all these areas, involving skills acquired over long periods
of training and at high resource cost, it is imperative that similar
questions be posed as above: how to sustain the functioning of the
agricultural administrative, technical support and training systems in the
face of significant losses of skilled people? Can intra-regional support
mechanisms be established to enable the gaps to be filled? Are there ways of
shortening training periods while not undermining quality? Are there
training institutions within subregions which can collaborate to sustain the
provision of training services?
A further set of questions arise for regional bodies to address, in the face
of the very significant declines in agricultural labour supply in many
countries, relating to agricultural technology: are there ways of increasing
levels of capital intensity in agriculture which can sustain output levels?
Are these changes in technology economically viable, crop by crop? Are there
cooperative mechanisms relating to equipment ownership and use, that may
remove some of the budget constraints facing smallholders? What can NEPAD do
to stimulate discussion of the options, to stimulate policy dialogue on such
issues, and help countries to explore alternative technologies?. Are there
changes in output mix which can help to overcome the losses of income and
production resulting from the epidemic ? eg greater concentration on animal
husbandry, which can often involve more labour by children?
Finally attention needs to be given to the massive but unmeasured losses of
social learning which take place within families: how rural children learn
from their parents about farming, animals, house repair, drainage and
irrigation, herbal medicine, food preparation, basic hygiene, etc. All of
these areas involve continuous processes of learning within households which
enable children to become socially and economically productive members of
society ? and these informal learning processes are being destroyed as a
result of the HIV/AIDS epidemic. How to organize the informal transmission
of life-skills to rural children orphaned by the epidemic represents one of
the greatest development challenges.
4. Environment:
All aspects of environmental interventions discussed in NEPAD require for
their successful implementation a range of highly qualified skilled and
professional people, involved in networks of public, private and
non-governmental bodies, at national, sub-regional and regional levels. As
discussed above, the threat posed by HIV/AIDS to all such programmes must be
recognised, in terms of the premature death of people with high levels of
skill, training and experience, and the resulting collapse of systems and
networks.
It is therefore essential that all initiatives and programmes
should involve, from the very outset and integrated into the design of every
intervention, activities aimed at protecting the workers and communities
involved from HIV infection. For communities affected by the environmental
interventions, these activities should also include care for those living
with HIV and AIDS, and for households affected by the epidemic, particularly
households headed by children or elderly people.
In addition, similar questions need to be raised as indicated above,
concerning mechanisms for sustaining necessary levels of skilled people to
undertake the tasks, in the face of losses resulting from HIV and AIDS. The
scope for cooperation at regional and sub-regional level in terms of pooling
of skills and sharing of training capacity is immense, and will need to be
examined in detail in the light of the demand for specific categories of
skill created by the environmental initiatives.
5.Culture
NEPAD gives special attention to the protection and nurturing of indigenous
knowledge, which, along with other aspects of cultural life, are seen as an
integral part of development. As indicated above, the nurturing of
indigenous knowledge through the informal processes of learning within
households needs to be protected in the face of the effects of the HIV/AIDS
epidemic, which is depriving vast numbers of children of the normal
relationship with parents and of the learning which takes place as part of
daily life.
But there are further aspects of culture which need to be addressed if the
full effects of HIV/AIDS on African development are to be explored. These
include gender relations, norms of sexual behaviour, and
leadership/governance.
The relationship between the HIV/AIDS epidemic and
gender relations has been referred to briefly above: in societies where
women's access to education and training, employment and income generation
is much more limited than men's, women find themselves with fewer choices
then men. For some women, sex work represents one of the few ways of earning
a living, with all the attendant risks; for other women, marriage may be a
means of economic survival, in which women's relative power may be weak,
partly because women are often married at very young ages to men
significantly older than themselves, and partly because of men's relatively
greater economic power.
Women's relative weakness in negotiating sexual relationships may lead to
increased vulnerability to becoming infected with HIV, since they may be
unable to demand that their partners cease frequenting sex workers. In many
societies, it is considered normal for men to have sex with sex workers,
especially if they are away from home for any period. Such cultural norms
must be addressed in order for HIV transmission rates to be reduced, and
changes in such norms are only partly related to shifts in relative economic
strength. Clearly, if women have greater access to employment opportunities
and skill acquisition, this will increase their range of choice and their
bargaining strength; but changes in cultural norms concerning sexual
behaviour are still urgently needed.
Further aspects of gender relations may also be important in examining the
linkages between the HIV/AIDS epidemic and development: the gender division
of labour is often rigid and frequently has little basis in physical
differences in the capacities of men and women. As household members become
unable to work because of HIV and AIDS, it is important to support a shift
in attitudes towards the division of labour: in rural areas, for example,
the collection of water and firewood is "women's work", as is food
preparation and caring for family members; ploughing is "men's work"; such
rigidities will impede any capacity to adjust to the changing household
composition resulting from the epidemic.
The final aspect of culture which must be addressed in the context of NEPAD
relates to leadership and governance. Whatever criteria for leadership and
governance are adopted, one central requirement is that political leaders
have the courage to address vital issues of concern to society, however
difficult these issues may be. In part what is required is to broaden the
range of institutions that actively discuss and respond to the challenges of
AIDS, and a wider involvement of those groups and organizations that in many
countries have remained on the margins of the response. This means the
active involvement of parliamentarians, who would not only discuss the
issues but also establish processes for monitoring the national response. It
means the involvement of traditional leaders, faith organizations and other
elders.
To begin to tackle the problems resulting from the epidemic, NEPAD needs to
give prominence to HIV/AIDS, and to provide a forum in which leaderships
commit themselves publicly and collectively to the integration of HIV/AIDS
into all aspects of development policy and programming.
6.Science and Technology Platforms
As in the sectors discussed above, the objectives enunciated by NEPAD in
science and technology involve further investment in high level skilled and
professional people, the development of networks and the promotion of
greater intra-regional collaboration. The issues raised by the HIV/AIDS
epidemic are therefore similar to those raised above, which arise from the
high incidence of morbidity and mortality among the working age population,
including among the relatively small numbers of highly skilled and
experienced scientific and technological personnel.
In order to sustain scientific and technological capacity, let alone to
facilitate expansion, it is essential to raise questions of how to replace
skilled people as rapidly as possible; how to adapt training systems and
training periods to the changing situation created by the epidemic; how to
enhance regional cooperation to enable the most seriously affected countries
to continue to function in these areas. Further difficult questions need to
be addressed, concerning the viability of investing societies' scarce
resources in long periods of training in circumstances where working lives
are extremely short as a result of HIV and AIDS.
ÝIt is also essential that much more effective programmes to protect people
from infection are undertaken, and are built into all activities from the
very outset. Effective programmes of HIV prevention in the workplace are an
essential component of this, since most of the activities in the area of
science and technology are undertaken in the formal sector where workplace
programmes can more readily be implemented.Ý As stated above, in the absence
of more effective programmes to reduce rates of transmission of HIV, any
positive benefits resulting from NEPAD in the area of science and technology
will be undermined by the continuing negative effects on all aspects of
society of the HIV/AIDS epidemic.
Part IV. Technical Cooperation and the Integration of HIV/AIDS
A. Organisational Structures
Integrating HIV/AIDS is a complex problem and takes many forms but it is an
issue primarily of capacity development. It is also important for effective
technical cooperation, in that an important objective of the response to
HIV/AIDS is the integration of HIV in all relevant policy and programme
areas within organizations. Paradoxically the establishment of institutions
and units etc with a specific mandate for HIV/AIDS may have negative as well
as positive benefits.
It follows that an important objective for organizations involved in
technical cooperation is the strengthening of their own capacity. In doing
so they may choose to establish specific units and programmes with a remit
for HIV/AIDS and this may indeed in some cases be the appropriate
institutional response. However there are problems with this approach, in
that it may signal to the rest of the organization that HIV/AIDS need not
concern them and that they can continue with "business as usual". Herein
lies an important problem for donor and other organizations that seek to
meet the challenges to organizational needs through institutional structures
that may be perceived as removing the need for a more general response and
broader changes in ways of doing things.
There are thus two linked issues: setting up specific organizational responses to the epidemic may lead to general neglect of the issues facing the institution as a whole, and, secondarily, setting up a
unit etc. entails developing capacity within the programme itself if it is
to deliver in an effective manner the functions that have been determined
for it. It follows that one of the important tasks that a unit will have is
to ensure that elsewhere in the organization that HIV/AIDS is fully
integrated in core functions. Similarly, with tasks external to the
organization, technical cooperation will need to ensure that institutional
partners integrate HIV in their core activities, and do not simply see the
issues as peripheral to what they do.
B. Integration? Lessons of Experience
In this context the essential task is to bring about sustained
organizational change so that functions are aligned with a new set of tasks.
This is never easy, and is made doubly difficult in respect of the
integration of HIV/AIDS for a number of reasons ? all of which will need to
be addressed through specific activities.
Firstly, the epidemic raises many contentious issues and as such means
questioning deeply held moral, religious and often ideological beliefs.
Such, for example, that those injecting drugs are not deserving of
programmes to enable them to be supported [and rehabilitated] given that
they are seen as having "voluntarily" chosen this way of life. Thinking in
this way obviously misses the point, that whatever the personal culpability
there are major social benefits from programmes from which everyone gains.
Part of the task is to support the re-thinking that is necessary if
effective programmes are to be developed and implemented.
This is never easy, and requires sustained efforts if there are to be long-term changes.
Secondly, the HIV epidemic was originally defined as a problem
of public health and to a significant degree this remains true until today.
This in spite of the fact that research and experience over several decades
have resulted in a much deeper understanding of the epidemic, such that the
issues are now perceived as primarily developmental, in the sense that the
epidemic has its foundations in the structural conditions of societies, such
as poverty and gender relations, and that it has serious implications that
are severe for sustained social and economic development.
What follows from this observation is that efforts have to be made to
overcome what in the literature is often called "normal professionalism".
What this means is that problem definition and solution are seen as the sole
province of those with the "right" expertise, in this case public health
specialists. It follows that part of the problem of achieving integration of
HIV/AIDS in organizations and programme areas previously excluded requires
re-defining the issues so that they are seen as relevant. Overcoming this
constraint has often proved difficult, in part because those professionals
occupying the existing terrain have largely determined the approach to the
epidemic, and have strong reasons to prevent changes in existing resource
allocation.
Finally, it is now clear to many that involving a much greater
array of organizations, groups, levels of government and so on is essential
if there is to be an effective response to the epidemic. This follows from
the argument that the epidemic is developmental and undermines sustained
development. Bringing into the response a different set of actors requires
technical support to those organizations etc. that have previously not been
involved. Thus in most countries the response to AIDS has been largely
confined to Ministries of Health with the result that activities have been
largely limited to issues the ministry is familiar with. But a multisectoral
response requires a broader set of activities, and the involvement of both
the public and private sectors. It follows that technical support needs to
be re-focused to those organizations, and to political and community
structures, whose involvement is essential.
The evidence, in so far as it exists at all, is that achieving
integration is extremely difficult. Within many organizations it is still
the case that efforts focused on HIV/AIDS are largely confined at best to
specialized units. Thus many UN agencies have lagged in their response to
AIDS, in spite of the fact that it has been clear for many years that the
epidemic was undermining their purposes. For example, agencies such as IFAD,
ILO and FAO, have only recently begun to address the issues of AIDS although
it has been clear for a decade or more that their involvement was essential.
Progress has at best been slow in spite of research on the epidemic and in
spite of extensive advocacy and training with the staff of many agencies.
Achieving better outcomes has not been confined to donor organizations but
is also generally true of other institutions. There are exceptions to this
general statement but in practice increasing the involvement of non-health
based organizations in both the private and public sectors has proved to be
an uphill task. The reasons are complex, but whatever the specific causes of
the lack of policy and programme integration it is a fact of life in most
countries in Africa. It is not due to a lack of workshops on issues to do
with AIDS, for there have been huge numbers of these; staff at many levels
have been involved in study tours, where they have seen what other countries
are doing in the response to AIDS, but with very little practical outcome;
and consultants have produced a mountain of reports etc with little evident
effect.
The result is that national responses to HIV/AIDS continue to be largely
focused on health-related issues, with a neglect of the broader determinants
and consequences of the epidemic for sustained development. If this
conclusion is valid, then it follows that integration of AIDS in non-health
areas and the mobilization of new partners in the response to the epidemic
will continue to be a challenge. But it is one that donor technical
cooperation must meet, in spite of the poor record so far in achieving
integration. In part the problem is how to improve on the existing
performance, through more innovative approaches to what is undoubtedly an
issue of great importance.
V. Integrating HIV/AIDS in NEPAD: Next Steps
NEPAD represents an opportunity, but is at the same time an indicator of the
distance still to travel in persuading African leaders of the enormous
threat that HIV/AIDS poses for sustainable development. As is evident from
the foregoing discussion it is clear that an understanding of the issues is
more or less missing from NEPAD and that the first task facing UNAIDS has to
be that of increasing understanding at all levels of the bi-directional
relationship between AIDS and development [that the epidemic has its source
in the structural parameters of development such as poverty and gender
inequality, and that AIDS undermines sustainable development]. So the
primary and initial task for UNAIDS continues to be that of increasing
understanding of the AIDS and development nexus with key stakeholders in
Africa.
It is unfortunately the case, but nevertheless true, that NEPAD
is a flawed analysis of the development challenges facing Africa. It is not
grounded in the reality of what is feasible for Africa and is not based in
any serious way on an analysis of the constraints facing the region. As is
clear from the above discussion while there has been some progress in some
countries in achieving development goals during the past decade the general
performance has been disappointing. NEPAD needed to build on the experience
of what seems to have been achieved and to have then set its strategic focus
on moving forward in these areas of policy and programme development, within
realistic estimates of the likely resource flows that could be anticipated
from domestic and overseas sources [including debt relief].
So far the reception given to NEPAD by donors seems to have been
lukewarm at best, and at the worst has been negative. It follows that
resources are unlikely to be forthcoming to fund most of the activities etc.
set out in NEPAD. What seems more likely is that donor assistance will
continue at more or less present levels, which together with domestic
savings and debt relief will not match in any way the huge expenditures
required if the NEPAD target of GDP growth of 7% per annum is to be
achieved. Inevitably, therefore, what seems likely to happen is piecemeal
investment across many sectors reflecting the priorities to a large degree
of donors. This pattern of investment flows will in no real sense reflect
the totality of what is set out in NEPAD.
If this description is at all valid then what can UNAIDS do to
move forward its mandate that AIDS should and can be integrated into
development ? or more realistically perhaps into those sectoral and other
activities articulated by NEPAD which are actually funded by donors? One
activity that still seems to be needed is to support donors to integrate
AIDS into their projects in Africa, where as the above analysis demonstrates
HIV/AIDS permeates all areas of development activity. So the second task for
UNAIDS is to ensure through its advocacy, research and technical cooperation
activities that AIDS is integrated by bilateral and other donors in their
programmes for Africa. This is not a new task for UNAIDS but from the
evidence of NEPAD, and elsewhere, it is clear that much remains to be done
to ensure that the epidemic is seen as developmental and that programmes and
projects do in fact integrate AIDS.
For UNAIDS to be able to move forward the agenda of integration
of AIDS in development it has to have the capacity to supply the technical
support that is needed by countries. This is presently missing and is not
being provided by the cosponsors with primary interests in development [UNDP
and World Bank]. So the third task facing UNAIDS is to strengthen its own
capacity in the area of development as a pre-requisite for more effective
technical cooperation. Of course it would be desirable for UNAIDS, through
its ongoing relationships with its cosponsors, to ensure that they also
develop the capacity needed for integration of AIDS within their programme
activities. But this in part depends on internal allocation processes within
the cosponsors which UNAIDS can and should try to influence through its
machinery of government [the CCO and PCB].
One of the key issues is that of strengthening understanding and
capacity at country level. This is the critical constraint at present in
securing the integration of AIDS in development programmes and projects. In
part the problem arises from the fact that donors still do not in general
understand the issues [hence the second task noted above]. But there
continues to be very little capacity in National AIDS Programmes, and still
very few countries where HIV/AIDS has been integrated in non-health sectors.
It follows that the final and most critical task for UNAIDS is to assist
countries in integrating AIDS across all sectors ? not an easy task, but one
which is crucial if development projects are to be sustainable and relevant
in a world characterised by AIDS.
The NEPAD secretariat is presently engaged in developing an
implementation programme, and this is exactly the time for UNAIDS, both
Secretariat and the cosponsors, to provide technical support for
integration. They can apply their experience in integration to the task
facing NEPAD at this time, so that detailed plans for the key sectors are
developed in ways that fully mainstream all aspects of HIV and AIDS. In
moving forward one important way to help would be through the secondment of
staff with experience of integrating AIDS in development to the NEPAD
secretariat in Pretoria. This could also be associated with technical
support to countries that are taking the lead in preparing detailed sectoral
plans.
Since human resources have been identified in the foregoing as
one of the key areas where development is being adversely affected by the
epidemic [see pages 14-16] it follows that an important area for NEPAD, and
for UNAIDS, is to assist the member states of the AU in assessing their
emerging gaps in key areas such as health and education. The problems are,
of course, broader and extend to more generally to issues of Human Capital.Ý
What is urgently needed is an assessment of the effects of the epidemic on
human capital, which lead to changes in public policy. NEPAD has a crucial
and important role to play, assisted by donors, in moving forward in this
crucial area for sustainable development.
Select References
The following is not a comprehensive list of references to
research etc. relevant to the issues of AIDS and Development, nor is it a
compendium of materials on how to integrate AIDS in development programmes
and projects. What it represents is a brief guide to relevant publications
which provide more detail about issues raised in this paper.
HIV/AIDS and Development
The HIV Epidemic and Sustainable Human Development [UNDP Issues Paper no.
29, 1998]
HIV/AIDS and Human Development in South Africa [UNAIDS/UNDP Human
Development Report, South Africa, 1998]
Responding to the Socio-Economic Impact of the HIV Epidemic in sub-Saharan
Africa: Why a Systems Approach is Needed [UNDP Issues Paper, 1999]
Towards an AIDS-Free Generation [Botswana Human Development Report, UNDP,
2000]
Gender, Development and the HIV Epidemic [UNDP Issues Paper, 2000]
The HIV Epidemic and other Crisis Response in sub-Saharan Africa [Working
Paper no.6, ILO InFocus Programme on Crisis Response and Reconstruction,
April 2002]
Integration of HIV/AIDS
Guidelines for Studies of the Social and Economic Impact of HIV/AIDS [UNAIDS
Best Practice Collection, 2000]
Mainstreaming the Policy and Programme Response to the HIV Epidemic [UNDP
Issues Paper 2000]
AIDS, Poverty and Debt Relief: A Toolkit for Mainstreaming HIV/AIDS
Programmes into Development Instruments [UNAIDS/World Bank, UNAIDS Best
Practice Collection, 2001]
Human Resources
Poverty and HIV/AIDS in sub-Saharan Africa [UNDP Issues Paper no.27, 1998]
An ILO Code of Practice on HIV/AIDS and the World of Work [ILO, Geneva, June
2001]
Young People and HIV/AIDS: Opportunity in Crisis [UNAIDS/UNICEF/WHO, 2002
Human Capital and the HIV Epidemic in sub-Saharan Africa [ILO Working Paper
no.2, June 2002]
Children on the Brink 2002: A Joint Report on Orphan Estimates and Program
Strategies [UNAIDS/UNICEF/USAID, July 2002]
Sectoral Impacts
AIDS and African Smallholder Agriculture, eds. Gladys Mutangadura, Helen
Jackson and Duduzile Mukurazita [Safaids, Harare, 1999]
Planning for Education in the Context of HIV/AIDS by M.J.Kelly [UNESCO
International Institute for Educational Planning, Paris 2000]
The Impact of AIDS on Agricultural Extension Organisation and Field
Operations in Selected Countries of SSA [UNDP/FAO, Malawi, 2001]
The Impact of HIV/AIDS on Human Resources in the Public Sector in Malawi
[UNDP/Malawi Institute of Management, Lilongwe, 2002]
The Impact of HIV/AIDS on the Health Sector in Botswana [Government of
Botswana/UNDP, Botswana 2000]The Health Sector Response to HIV/AIDS:
Coverage of Selected Services in 2001 [WHO, July 2002]
Data on Impact and the African Response
The Demographic Impact of HIV/AIDS [UNAIDS/Population Division, department
of Economic and Social Affairs, UN, NY November 1998]
AIDS in Africa: Country by Country [UNAIDS/ECA, African Development Forum
2000]
Lessons Africa has learnt in 15 years of responding to HIV/AIDS [African
development Forum 2000, ECA, Addis Ababa, 2000]
The International Partnership against AIDS in Africa [IPAA Progress report,
vol.2, UNAIDS, 2001]
AIDS Epidemic Update [UNAIDS, December 2001]
The Status and Trends of the HIV/AIDS Epidemics in the World [MAP,
Barcelona, July 2002]
International Goals and Commitments
Declaration of Commitment on HIV/AIDS [UN General Assembly Special Session
on HIV/AIDS, June 2001]
The Millennium Development Goals in Africa: Promises and Progress
[UNDP/UNICEF, June 2002
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