HIV/AIDS, children, education
and household survival
91. Prospects for development are inextricably linked
to the prospects for children in developing countries
their health, their education, their sense of social involvement.
In recent years, as we have seen above when discussing the international
development targets, there has been a renewed emphasis on children,
for example their universal right to education or to live a life
free from conflict. HIV/AIDS is undoubtedly a scourge blighting
the future of millions of children, denying them security, education,
health, and indeed life itself. In discussing the effects of HIV/AIDS
on children one is inevitably drawn into discussing the impact
on the household unit children are by their nature dependents.
It is impossible to understand their circumstances without examining
the household of which they form a vulnerable part.
92. The statistics on HIV/AIDS and children make
terrible reading. By the end of 1999 600,000 children (defined
as those under 15) were infected with HIV/AIDS. The cumulative
deaths to HIV/AIDS amongst children had reached 3.6 million. In
addition to the impact of HIV/AIDS through infection, illness
and mortality, there is the growing crisis of orphaning. By the
end of 1999 there were estimated to be 13 million orphans as a
result of HIV/AIDS, 95 per cent of them in sub-Saharan Africa
(an orphan being defined as someone under the age of 15 who had
lost their mother or both parents).
93. Witnesses emphasised discrimination and stigma
faced by young people, not only those infected with HIV/AIDS but
also those from households with HIV-positive adults, or those
orphaned by HIV/AIDS. Douglas Webb from Save The Children said
that "They have found that their biggest problem is with
their peers and the school environment. The amount of psychological
torment these children receive is quite horrendous in terms of
their ability to mix with peers, accepting their own family status.
Their self-esteem is completely ruined in many cases".
Children were not only stigmatised by their classmates and peers
but even by teachers who on occasion have chased from school "children
who are of unknown status, more than likely negative, whose parents
are ill or dying or dead".
Any illness suffered by such a child was assumed to be AIDS-related.
With such stigma comes a burden of shame and denial amongst children.
A survey amongst AIDS orphans in Rusinga Island, Uganda, discovered
that, whilst almost all knew about HIV/AIDS none of the 72 orphans
questioned in the study said that their parents had died of AIDS.
The 'handing down' of such attitudes does not bode well for countries
which need above all else an honest and open public discussion
of the issues surrounding HIV/AIDS.
94. The stigmatisation and exclusion of children
in some way connected with HIV-positive people is one immediate
and obvious way in which HIV/AIDS is having an impact on the education
sector. Such exclusion has an effect on any attempt to reach the
agreed target of universal primary education by 2015. The withdrawal
of children need not only be as a result of such overt discrimination.
In many instances it will be because children are called on either
to work or to take on part of the burden of care as income-generating
adults become ill. Moreover, as incomes are affected by the costs
associated with HIV/AIDS and as wage-earners themselves become
sick, children are withdrawn simply because school fees or associated
costs can no longer be afforded. Douglas Webb said, "you
are seeing a reduced demand for education from families who cannot
afford to send their children to schools or that child labour
is needed for other things as the children become producers in
the household economy before their time".
95. At the same time that demand is being constrained
by the epidemic there is an equally disastrous impact on the supply
of education. Alan Whiteside thought that education was "the
most important sector that has been affected, simply because it
holds in charge the next generation".
Similarly Douglas Webb said, "The impact of HIV/AIDS on the
education sector is probably the most critical sector that we
have to address".
He pointed to the effect of HIV/AIDS on teachers, "What we
are seeing is a contraction of education sectors. We are seeing
very high mortality rates of teachers. In the most heavily affected
of countries, you are looking at 20-30 per cent plus of teachers
HIV-positive ... if we are trying to increase the capacity of
the education sector to be an education tool for HIV/AIDS work,
teachers themselves are in no position to be educators. We are
seeing a decline in the health of teachers, the number of teachers
and also the ability of them to be effective educators around
HIV/AIDS issues as well as their normal curricular activities".
Experience in Zambia suggested that it was necessary to deal with
teachers' own insecurities about the disease and low morale as
a result of their own infection and the deaths of those around
96. Alan Whiteside mentioned another possible impact
of HIV/AIDS on the education sector. Teachers may not only be
lost to the epidemic itself. It was also likely that as mortality
across the workforce increased other sectors, which can pay better
than schools, may well poach teachers to go into the private sector
or other parts of the state sector. Thus there will be a further
contraction of the education sector.
Douglas Webb spoke of the effect on the quality of education provided,
with classes in Uganda on occasion of over 200 persons, "The
sectoral response is very difficult when you have such a high
infection rates within the sector of staff itself".
97. DFID has recently published its strategy paper
'The challenge of universal primary education' in which we were
pleased to see an attempt to tackle the impact of HIV/AIDS on
the education sector. The paper stresses the need to address teacher
supply and morale as well as the costs of HIV/AIDS to the educations
It concludes, "Responding to this challenge will require
new, decentralised planning models that allow schools and local
administrations sufficient flexibility to react quickly to changing
circumstances. At school level, a whole school approach to management
and development, which encourages community support to teaching
and allows for new staff to be quickly absorbed and trained on
the job, is likely to be vital".
The paper also concludes that education must be inclusive, "responding
flexibly to the needs and circumstances of all excluded children".
The means encouraging non-formal and complementary education provision
and addressing the needs of working children.
98. When DFID officials gave evidence to the Committee
at the beginning of the inquiry in June last year, they told us
that they were starting to look at the impact of HIV/AIDS on the
education sector - "it is a late stage, but we are now trying
to get more involved".
They were assisting in the preparation of guidance for South African
and looking at "human resource development and human resource
protection for ministries of education".
They had not then given much thought to informal and home education
as one way to mitigate the impact of HIV/AIDS.
The strategy paper 'The challenge of universal primary education'
is an encouraging example of how DFID can design its development
approach to take account of the impact of HIV/AIDS. Even within
the last few months, there has clearly been progress and further
thought in the Department on this issue.
99. We consider that all donors must agree on
an education strategy which both aims to achieve the international
development target of universal primary education by 2015 and
which also takes account of the new realities caused by HIV/AIDS.
Priorities in such a strategy must include:
- the provision of education for those unable
to attend formal schooling, in particular for those having to
work to provide for households;
- the protection of children stigmatised by
association with HIV/AIDS; and
- measures to maintain the supply of teachers,
perhaps involving the community, volunteers and the private sector,
as well as those formally trained and employed.
100. There is particular concern at the impact of
HIV/AIDS on household structures. The figures from the June 2000
UNAIDS Report on the global HIV/AIDS epidemic make appalling reading.
To date 3.8 million children have died of HIV/AIDS since the onset
of the epidemic, nearly 500,000 of them in 1999 alone. Another
1.3 million children are currently living with HIV and most will
die before they reach their teens. The vast majority of these
children were born to HIV-infected mothers.
UNAIDS estimates that 620,000 children were newly infected with
HIV in 1999.
There is thus an immediate developmental impact in terms of rates
of child mortality, with all the consequences of grief and trauma
for the surviving families. Before these effectively inevitable
early deaths the family or household will need to endure the burden
and additional trauma of dealing with the AIDS-related illnesses.
101. The impact of HIV/AIDS should not, however,
be seen solely in the context of the illness and deaths of children,
shocking though the statistics are. As working adults, parents
and carers die in the prime of life, there are immediate and inevitable
impacts on children. Of these the most discussed is the increase
in the number of orphans, particularly in sub-Saharan Africa.
UNAIDS reports that before HIV/AIDS 2 per cent of all in developing
countries were orphans. By 1997 the proportion of children with
one or both parents dead had increased to 7 per cent in many cases
and in some countries had reached 11 per cent.
This translates into a figure of 13.2 million orphans, 95 per
cent in sub-Saharan Africa, created by AIDS since the beginning
of the epidemic.
It is worth noting that this is a cumulative total and that many
of that number are no longer under 15 and others are no longer
alive. The result is of course an increase in the number of households
headed by a single parent (often women) and of households headed
by children. Such households are particularly vulnerable. Their
earning capacity is severely limited. They will often be the poorest
of the poor. Such economic weakness is then compounded by a vulnerability
to exploitation and abuse. Widows and orphans are often the subject
of sexual exploitation, are denied property and other legal rights,
stand to be dispossessed or defrauded of what is theirs.
102. Douglas Webb from Save The Children said that
his organisation preferred to speak of "vulnerable children"
rather than orphans. He said that "If you go into a community
looking for the orphans, you will suddenly find there are three
times as many as there were beforehand because you are implying
that there is some kind of assistance coming their way. The big
mistake that was made in sub-Saharan Africa is that enumerators
went in, counted orphans, disappeared and there was no follow
up support. The labelling of children and the categorisation of
children according to presupposed vulnerabilities can be very
counterproductive. We would encourage looking at the family support
structure, rather than the categories of children by orphan status".
103. There were some differences in evidence as to
the effect of HIV/AIDS on family structures and the household.
Alan Whiteside said, "There is a myth that the African extended
family absorbs the orphans that are left. I think the problem
is that the very few studies that have been done of the impact
on households have missed one glaringly obvious fact, and that
is the worst affected households have disappeared. You cannot
measure what is not there. Households which have collapsed, and
where the children are living under bushes (and there are those
households) are not being measured".
He made the point that in South Africa there had been a move to
a more nuclear family with the onset of rapid urbanisation. Thus
the extended family structures to cope with vulnerable children
were no longer in place. He strongly opposed the placing of such
children in residential care. Instead he advocated the transfer
of cash to support households and communities in distress, alongside
other social security benefits.
104. A slightly different perspective was provided
by other witnesses. Douglas Webb emphasised that Professor Whiteside
was speaking from a South African perspective, "Going off
the Limpopo, you do find that extended families are coping to
a very limited extent. You are not finding hordes of children
wandering around aimlessly. You are seeing increasing numbers
of street children, yes, but we have done surveys of those street
children. Only between a third and a half are orphans and that
is massively more than the background child population. Poverty
is the cause of that kind of thing".
Mark Gorman of HelpAge International considered that "even
in South Africa, even in urban situations in the townships, you
do find very well developed family and community networks".
Such coping strategies in South Africa were assisted by the fact
that South Africa paid an almost universal old age pension.
105. Mark Gorman claimed that "the family and
the household has remained immensely strong. It has not existed
for hundreds of thousands of years in African and Asian communities
without being very strong. We should be careful not to write it
off too early, but what it needs above all is support from outside.
Family structures, older people, young people, cannot do without
that external support and that is where, for example, education
programmes can be immensely helpful and supportive if they are
sensitive and appropriate".
Francesca Simms agreed, "Research suggests the extended family
is not breaking down. What is happening is that there is less
transmission of money between the extended family, so you are
getting an increasing number of families without the means to
support the basic needs of their children, but the carers are
still there and the relationships are still there. There is a
lack of money to provide for that care and that is what is needed.
Unless we provide that, we are going to see the destruction of
an extended family system which has gone on for generations in
Africa and has very successfully provided for the needs of all,
children, old people and disabled in a very cost effective way".
106. The differences amongst witnesses are then ones
of degree rather than basic message. There will of course be variations
amongst countries as to the nature and strength of the extended
family. Witnesses differ as to how severely the extended family
system has been affected by HIV/AIDS has it already broken
down or is it still functioning? There is a consensus that the
"traditional coping mechanism, which was the extended family,
is being stretched beyond capacity now", to use the words
of Carol Bellamy.
In other words, HIV/AIDS threatens to unravel what has been for
generations a remarkably robust and effective social security
system, the extended family, leaving the old uncared for, children
vulnerable to abuse, uneducated and deeply traumatised.
107. Alan Whiteside recommended the transfer of funds,
managed by town councils, NGOs or churches, to those with caring
responsibilities for the poorest families and orphans.
He admitted that this went contrary to accepted development practice
and there would have to be a willingness to see some percentage
of the funds diverted but added, "I do not think we have
a choice. I think we either have to be imaginative and look at
some of these options". Such interventions would "be
immeasurably cheaper than putting that person in an institution".
He emphasised that such payments would have to be for all children
in distress, not only those orphaned as a result of HIV/AIDS.
108. Douglas Webb said that studies a few years ago
in Zambia suggested that 90 to 95 per cent of orphans were absorbed
by extended family members.
What was needed was extra resources to assist in the care of the
children, child care training, income generation opportunities.
Francesca Simms said that "there are carers for these children
... but they must have support ... which could be income generating,
for material aid, and psychological support as well".
All witnesses spoke strongly against putting such vulnerable children
in institutions, it being both damaging and expensive. Douglas
Webb gave the example of Save The Children's work in Cambodia
where they noted a high incidence of migration to and from cities
amongst children and young people from affected households. He
explained, "What we have to do is not say 'Here is some money';
what we need to say is, 'Here are some skills. Here are some opportunities
for you to make money', which is a totally different thing. We
are working with organisations to look at vocational training.
We use market gardening quite a lot, bringing in skills from outside
to get some basic skills in marketing ...".
109. What is clearly needed is "the work in
the communities to identify these children and strengthen the
capacity to cope and keep the children in the communities".
Francesca Simms argued for the mobilisation and scaling up of
those community projects which had been seen to work, workers
mobilising community structures, through village chiefs, so that
every child in need has a named volunteer and care plan.
Douglas Webb, however, warned that there was real problem of replication,
"this problem of taking things forward is far more difficult
because the central authorities are not taking that lead role
in taking these small scale projects, saying, 'They work. Let
us take them to another place'. ... The lack of central capacity
in government to do that is probably the critical barrier".
110. The needs of orphaned and vulnerable children
must be a priority in the international response to the epidemic.
We have already mentioned the importance of education, training
and the protection of their legal and human rights. It is also
clear that households must be supported as they take in and care
for such children. Much good work is being done in individual
projects and programmes. But this is not enough. Support to
households caring for vulnerable children needs to be extended
and replicated on a national scale in high-prevalence countries.
This is a significant challenge, particularly for public sectors
already weakened by poverty. It requires determined coordination
amongst national governments, donors and civil society. Consideration
should be given as to whether cash payments or other forms of
support are most appropriate. We recommend DFID in its response
to this Report provide further details of how it plans to support
the identification and care of vulnerable children in the community.