House of Commons - International Development

Select Committee on International Development Third Report

Section 2 — The Impact of HIV/AIDS

HIV/AIDS and the health sector

111. Separate note should also be made of the impact of HIV/AIDS on the health sector. Professor Alan Whiteside considered it to be the worst affected sector, claiming that "HIV levels are the same in the health sector as in the general population. There is a whole question of morale among health staff. It must be absolutely soul-destroying to have to sit in a clinic in rural KwaZulu Natal and watch people die, and people you know. Probably the morale of the health sector is the worst affected".[151]

112. The UNAIDS June 2000 Report gives more information on the impact of HIV/AIDS on health service personnel, both in sickness and death, "Sickness and death due to AIDS is growing rapidly among health care personnel, but few countries have as yet fully understood the epidemic's impact on human resources in their health sector. A study in Zambia showed that in one hospital, deaths amongst healthcare workers increased 13-fold over the 10-year period from 1980 to 1990, largely because of HIV. As in other sectors of the economy, rising rates of HIV infection in health care workers will increase rates of absenteeism, reduce productivity, and lead to higher levels of spending for treatment, death benefits, additional staff recruitment and training for new personnel".[152]

113. Not only is there an effect on the morale and effectiveness of health personnel. There is also an impact on health budgets and on the health of those not infected with the virus. It has been estimated in the mid-1990s that 66 per cent of Rwanda's health budget and over a quarter of the health budget of Zimbabwe were spent on treatment for people with HIV. Given the small percentage of GDP dedicated to health spending in developing countries these amounts devoted to the care of those with HIV will inevitably be at the expense of other forms of health service delivery and care. HIV-positive patients are crowding out of hospital beds those uninfected with HIV but also ill. UNAIDS states that "The hospital sector in Kenya has seen increased mortality among HIV-negative patients, who are being admitted at later stages of illness".[153] Another effect of HIV on those uninfected is in the spread of tuberculosis. In Africa about 40 per cent of HIV-infected patients have TB. With a greater number of HIV-positive people developing active TB, this means there is a greater risk that the TB bacillus will be passed on to others in the community. The World Bank has estimated that 25 per cent of HIV-negative persons dying of TB in coming years would not have been infected in the absence of the HIV epidemic.[154]

114. Faced with the scale of the HIV/AIDS epidemic, developing countries, now more than ever, need effective health services. Instead, the health sector itself is becoming less and less able to meet the new demands arising from HIV/AIDS as skilled staff become ill and die, as scarce resources are overwhelmed, as sickness increases even amongst those uninfected as a result of the epidemic. DFID notes in its paper 'Better Health for Poor People' that "Health service staff are at particular risk from infection, and in some countries, staff are dying faster than can be trained".[155] The paper does not, however, expand on the particular stresses being borne by the health sectors in countries with high HIV/AIDS prevalence and what can be done to assist in terms of the training of staff and the provision of resources. We would welcome information from DFID on how best to remedy the staffing crisis in certain developing country health sectors. In general, we consider that 'Better Health for Poor People' could usefully have spelled out in more detail how health sector reform and development can be pursued in the context of high HIV/AIDS prevalence.

HIV/AIDS and the public sector

115. In considering the impact of HIV/AIDS we have noted the effect of the disease on a variety of government departments — agriculture, education, health. Many of the problems are the same. Decline in morale, loss of skilled staff, increase in sickness and resulting decline in productivity. One can only infer that a similar set of difficulties affect other government departments in those countries severely affected by the epidemic. In his memorandum Alan Whiteside thought that "Government inefficiency may result [from the epidemic]. The reason is that government tends to have generous conditions of employment and be less flexible. Thus people who fall ill will have extended periods of sick leave during which their posts will not be filled and their work not done".[156] He expanded on the point in oral evidence, "I think as a matter of urgency we need to look at the effect the epidemic is having on the state sector ... on the ability of the state to actually function. Unfortunately, nobody has done this. I wish I could come in and present you hard data, but I cannot".[157] There is an obvious problem when staff numbers and skills are declining whilst the State continues to pay out the same amounts in benefits to its employees. Alan Whiteside denied that he was arguing for a removal of civil service benefits and conditions from those ill as a result of HIV/AIDS. He argued instead against the slimming down of civil services, a point we have explored above, and for direct payments, presumably from donors, to central ministry finances so that they can afford to employ more people.[158]

116. Crown Agents state, "For our own part we have experienced reductions in staff resources in a counterpart government department in excess of 50 per cent in less than 12 months in one central southern African country, and between 25 and 50 per cent in other countries. It still depends on the willingness of the partner government to admit the scale of the problem as to whether the cause of staff losses and resources is faced up to by senior management. It is very noticeable that governments are finding it harder than ever to fill vacancies with trained staff. This will be exacerbated by the reduction in life expectancy figures from 59 over the last few years to 45 within 5 to 10 years".[159]

117. A decline in the efficiency of government departments in countries severely affected by HIV/AIDS will have a whole host of implications for development. Putting aside the examples given already from agriculture, education and health, one can think of the difficulties that might be experienced in, say, revenue collection, the management of the country's debt, the efficient regulation of industry, the preparation of necessary legislation. We have noted that DFID is involved in an inter-agency group on education matters, looking amongst other things at human resource issues in education. Such consideration needs to be extended so as to encompass human resource issues across the public service.

HIV/AIDS, conflict and security

118. As we stated earlier, there is good reason to believe that one significant contributor to the spread of HIV/AIDS is conflict. It is no coincidence that sub-Saharan Africa, disproportionately plagued by conflict in recent decades, is also terribly afflicted by HIV/AIDS. Speaking of Africa, Jacques du Guerny said, "It is certain that various conflicts, which are there, are creating the conditions for future epidemics ... One can see this in a country like Rwanda or Ethiopia. We are now seeing increases in the level of AIDS".[160] The reasons are clear. Families divided by war; the vulnerability of civilian populations and refugees; the impoverishment of conflict and the pressure for some to engage in sex work to make ends meet; the prevalence of rape; the instability and uncertainty leading to behaviour changes as past certainties no longer appear to apply.

119. But does it also work the other way round? A report produced by the National Intelligence Council of the United States entitled 'The Global Infectious Disease Threat and Its Implications for the United States' predicts, amongst other things, that —

- Infectious diseases are likely to slow socioeconomic development in the hardest-hit developing and former communist countries and regions. This will challenge democratic development and transitions and possibly contribute to humanitarian emergencies and civil countries."[161]

120. Professor Alan Whiteside warned of "Potential instability as middle ranking army officers, police and the security forces face increased illness and death. Social instability if there is not clear political leadership. Evidence suggests that in societies facing economic crisis and lack of clear political leadership the presence of AIDS with its associated stigma may cause instability. The citizens are aware of the increase in illness and death, the stigma associated with it; and the lack of leadership leads to blame and anomie in society".[162] Mark Stirling from UNICEF cited the estimate that 50 per cent of today's 15-year olds in Maputo, Mozambique, would be dead because of AIDS by the time they were 45 and questioned, given that statistic, whether "the leadership and economic progress, the security and stability" of Mozambique could be maintained.[163] Dr Peter Piot also saw HIV/AIDS as a question of national security, and indeed the very continuity of the nation, for many of these countries.[164]

121. It is obviously more difficult to demonstrate clear causal links between HIV/AIDS on the one hand and greater conflict and insecurity on the other. Our previous Report, however, on Conflict Prevention and Post-Conflict Reconstruction identified poverty as a major cause of conflict.[165] There is thus a prima facie argument, given all the evidence we have received that HIV/AIDS increases poverty, that there will be greater social insecurity and possibly conflict as a result of the HIV/AIDS epidemic.

122. There are obviously implications for UNHCR and refugee policy, for the deployment of peacekeeping forces, to give just two examples, in the close linkage between conflict and HIV/AIDS. There are also implications for those who think strategically about sub-Saharan Africa. Moreover, anyone tracking the epidemic in the region and concerned as to its spread can only be horrified at current events in the Democratic Republic of Congo, involving not only that country but nearly all its neighbours. There can be no doubt that that conflict is going to have a drastic and terrible effect on the prevalence of HIV/AIDS in central Africa. We request information from DFID and UNAIDS as to what representations have been made to all governments involved in the DRC conflict on the spread of HIV/AIDS amongst soldiers, refugees and civilian populations. We also wish to know what surveys of HIV/AIDS incidence have taken place in the region affected by the conflict. The area is obviously vast, difficult and extremely dangerous. But thought must be given, even in such circumstances, as to how the donors and NGOs can intervene and assist to limit the spread of HIV/AIDS.

123. In our Report on Conflict Prevention and Post-Conflict Reconstruction we also welcomed work by DFID, the FCO and MoD in security sector reform.[166] Discussion between the departments on security sector reform issues takes place in the forum of the Whitehall Conflict Network. We recommend that DFID, the FCO and MoD discuss the implications of HIV/AIDS for their security sector reform activity. We would expect any such discussion to include consideration of how to establish good morale in forces with high HIV/AIDS prevalence; the need for training in the rights and proper treatment of civilians, and of women in particular; HIV/AIDS prevention in the armed and security services, both in terms of sexual behaviour and also other risky contacts such as open wounds; the training and 'skilling' of personnel given the likelihood of high mortality and morbidity rates.

The Impact of HIV/AIDS — Some Conclusions

124. We have looked at the impact of HIV/AIDS across a number of sectors. There are other aspects to the impact of the disease which we simply do not have space to go into. But the main thrust of our findings has emerged clearly. HIV/AIDS will further and profoundly impoverish those who are already poor. In those countries, particularly in sub-Saharan Africa, with high prevalence rates, its effect could well be to reverse past development gains and destroy state, social and household systems which have previously been extremely resilient to shocks. This means that development may well have to be done in a different way. Donors are now generally aware that HIV/AIDS is not merely a medical problem but a developmental one — and by this they mean it is having a pervasive and destructive effect on the poor, thus making its prevention one of the main developmental challenges. What is still lacking amongst donors is a real and determined attempt to examine how HIV/AIDS affects all aspects of development activity. Support for education, the private sector, agriculture extension and rural livelihoods, developing country government departments, to give just a few examples, must not only be increased but, more importantly, redesigned. We have on a number of occasions in this Report commented on DFID publications which ignore the impact of HIV/AIDS and how the epidemic should change the way development is done. We single out DFID because it is the donor we have a responsibility to scrutinise. But this failure is a general one, and certainly not confined to DFID.

125. We have been impressed in this Parliament by the role DFID has played internationally as an advocate for the international development targets and for a development strategy genuinely committed to the elimination of poverty. Does DFID have a similar advocacy role with regard to HIV/AIDS? Evidence from the Secretary of State at the conclusion of our inquiry gave no hint that she saw DFID in such a role. She began her comments by stating "that we at our very best are only part of an international system. Sometimes when people get emotional about things like AIDS they say, 'What is the United Kingdom do more?' as though we can do it, and we cannot. We are not the whole of the international system. We do not operate everywhere. We can try to be a leading force both in influencing the international system to operate better and to do good work from which we learn and which drives forward our understanding of what can be done. But sometimes the discussion is as though a Government like ours can lead the whole world effort, and of course we cannot".[167]

126. Clare Short's warning is true and important. DFID is only one player in what must be an international and coordinated effort, headed by the national governments of those countries most severely affected by HIV/AIDS. We will return later in this Report to the responsibilities of the various actors in combatting the epidemic. However, we do believe that one aspect of an effective HIV/AIDS strategy for DFID must be an identification of its 'added value' on the international stage. We have no doubt that one great asset of DFID is its intellectual capital and expertise. It is in our view particularly well placed to do the sort of rethinking and redesign necessary to ensure development programmes regain their relevance and effectiveness in countries with severe HIV/AIDS epidemics.

127. Mainstreaming HIV/AIDS is a two-way process. It means ensuring that all aspects both of development policy, and of government policy more generally, conspire to reduce the incidence of HIV/AIDS and reduce its impact. But it also means ensuring that HIV/AIDS is taken into account when working out development policies which are genuinely going to tackle and reduce poverty. We recommend that DFID conduct an audit of all aspects of its development programmes, particularly as they are applied in sub-Saharan Africa, to ascertain the extent to which they are prepared to withstand current and likely future impacts of HIV/AIDS. We also recommend that where they are found wanting, DFID should research how best to redesign programmes, sharing conclusions with other donors and developing country representatives.

128. Reducing the impact of HIV/AIDS through appropriate development is, we must remember, itself a preventive measure of fundamental importance. In the successful reduction of poverty we target that environment in which HIV/AIDS thrives and devastates. Conversely, if we do not act to reduce the impact of HIV/AIDS we entrench further that poverty which fosters the epidemic and we allow a vicious circle of poverty and infection to develop.

151 Q.124 Back

152 UNAIDS June 2000 Report pp.31-32 Back

153 UNAIDS June 2000 Report p.31 Back

154 UNAIDS June 2000 Report p.31 Back

155 DFID 'Better Health for Poor People' para.2.1.6 Back

156 'The challenge of universal primary education'75 Back

157 Q.120 Back

158 Q.121 Back

159 Evidence, p.268 Back

160 Q.426 Back

161 'The Global Infectious Disease Threat and Its Implications for the United States' January 2000 Back

162 Evidence, p.75 Back