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close this bookThe HIV Epidemic and Sustainable Human Development (UNDP, 1998, 13 p.)
close this folderB. WHAT IS THE RELATIONSHIP BETWEEN THE HIV EPIDEMIC AND SHD?
View the document(introduction...)
View the document1. POVERTY, INEQUALITY AND GENDER
View the document2. MEASURING THE IMPACT OF THE EPIDEMIC ON SHD - THE UNDP HUMAN DEVELOPMENT INDEX
View the document3. INCLUSIVE AND EXCLUSIVE PROCESSES

(introduction...)

This is a complex matter and the following represents a drastic simplification of what are little understood issues. It should be remembered that what we have is a bi-directional relationship; thus -
THE HIV EPIDEMIC HAS EFFECTS ON SUSTAINABLE HUMAN DEVELOPMENT and SUSTAINABLE HUMAN DEVELOPMENT HAS EFFECTS ON THE HIV EPIDEMIC

In what follows, I have selected only some aspects of the problem - those which seem to me to have the greatest policy and programme relevance. In no sense is this paper intended to be a complete analytical or empirical discussion - indeed I have been deliberately selective both in respect of the issues raised and in the marshalling of evidence in support of conclusions presented below.

1. POVERTY, INEQUALITY AND GENDER

There would be general agreement that the primary objective of SHD is to eradicate poverty for unless this is achieved there can be no way in which citizens can lead a full and productive life -able to support their children and to engage in those political, economic and social activities which are the hallmarks of a democratic society. In a region such as Asia and the Pacific this is a huge task - with perhaps 70% of those living in absolute poverty worldwide. Poverty on this scale is simply not going to be eradicated in the foreseeable future nor is the accompanying income and asset inequality. For many countries in the region have not only large numbers of men, women and children in deep poverty, but they also experience the consequences of observing the life-styles, and often being exploited by, those who are rich. Obviously there are differences in the incidence of poverty and inequality between countries and within countries, but the essential defining element of the Region as a whole is the size of the poverty problem and the consequent scale of the policy and programme problem in attempting to reduce it.

How does the HIV epidemic relate to this state of affairs and what are the implications of Poverty and Inequality for the achievement of SHD? Poverty and HIV transmission are obviously related but this is in no sense a simplistic relationship. The poor worldwide probably account for most of those who are infected and affected by HIV, but there are many of the non-poor who are also infected and affected. So it cannot be simply poverty which determines those behaviours which lead to HIV infection, for those who are not poor (the well off and the rich, the educated and the healthy) are also often infected with the virus in all countries - including the Asia and Pacific Region. It follows that the absence of income constraints and having knowledge of the risks of acquiring HIV can still lead to behaviours which lead to infection - those associated, for example, with young men taking the plane from Kuala Lumpur for Bangkok on a Friday evening for sexual entertainment.

So HIV infection is not confined to the poor, and the rich and better educated are also becoming infected, with important consequences for SHD since these groups possess precisely the skills, education, training and experience so critical for achieving SHD. They account for much of the accumulated investment in human resources in the Region, and if SHD is right in its assertion that the human factor is THE important input in its achievement then their growing infection with HIV threatens what is going to be feasible. This seems to me to be one of the key important conclusions:

· SHD as a target is threatened because a key input in the process of development - the educated, the experienced, the skilled are also becoming infected with HIV so reducing the human resources critical for development in the region. It will also reduce the capacity of this class to save - and savings are necessary for capital investment in agriculture and industry. The capacity of this class to save and invest, and to manage enterprises and public services is critical to achieving SHD.

What of the poor who are absolutely the largest group in the Region as they are also the supposed beneficiaries of SHD? The poor are not only income and asset poor they also lack those characteristics of education and good health so important for a modernising economy and society. Within the poor it is often women and women-headed households who are the poorest of the poor - often deprived of reasonable access to education, housing, health services and lacking anything that could be described as a "sustainable livelihood". It is scarcely surprising that in these circumstances the poor adopt survival strategies which expose increasing numbers to HIV. This seems to be true for women, and especially young women, who as noted above are everywhere subjected to social, economic and political discrimination, and often exploitation. It is scarcely surprising that the group experiencing the fastest rate of growth of HIV infection worldwide is women, with in many countries rates of infection in young women under the age of 20 some 5 to 6 times those of young men. The typical age and gender distribution in most countries, including Thailand as a good example, is for young women to outnumber men amongst those infected at earlier ages (so that women lose more years of life as a result of earlier infection and through their generally reduced access to treatment in almost all countries).

The behaviours which expose the poor to HIV infection also constrains their ability to cope with infection - their lack of assets/savings, the vulnerability and uncertainty of their sources of income, their lack of access to knowledge about infection processes including understanding of opportunistic illnesses, and their general lack of access to health and other support services. Access to even the least costly of drugs and to inexpensive material supplies for the care of the sick is denied to the poor in most places with important consequences for HIV progression rates. Those infected with HIV unnecessarily die from opportunistic infections which can be relatively cheaply treated with inexpensive drugs, and thus lose years of potentially productive life during which they could have supported both themselves and their families. Again the evidence is that for the poor, as for the rich but with more disastrous consequences for the poor, the experience of HIV infection deepens personal and family poverty and is often associated with forms of social and economic discrimination and isolation.

Three important conclusions follow from the foregoing:

· The HIV epidemic has its roots in the widespread poverty present in the region, although poverty is not the only factor driving the epidemic. But addressing through appropriate policies and programmes (SHD) the causes of poverty there is a chance that behaviours can be modified so as to reduce future HIV transmission.

· Since HIV infection and its costs are closely correlated with gender factors it follows that addressing sources of gender inequality through SHD holds out a possibility of reducing future HIV transmission and thus the costs of the epidemic. Gender inequity is a central objective of SHD and reducing this will make it easier to address the underlying causes of transmission. Improving access to sustainable livelihoods and to better social services will mitigate the impact of the epidemic on those affected.

· Sadly the HIV epidemic intensifies poverty and deprivation and increases social exclusion both for those infected and those affected. As such the epidemic makes the achievement of SHD that much more unlikely given that poverty in the region is already a major problem and the epidemic has the capacity to increase its level and incidence. The HIV epidemic makes the task of SHD greater than it would otherwise have been in the absence of HIV, and simultaneously reduces the human resource capacity in the region for undertaking those activities essential to poverty and gender focused programmes.

2. MEASURING THE IMPACT OF THE EPIDEMIC ON SHD - THE UNDP HUMAN DEVELOPMENT INDEX

The HDI of UNDP is widely used as an aggregate measure of progress with human development and is a useful proxy for assessing the performance of countries. It has some disadvantages as do all weighted indexes. In the usual from the HDI is an index which combines life expectancy, a measure of educational attainment and GDP per capita - all clearly important indicators of human development. There are obviously problems with the measurement of the different components of the index where there is a great deal of country variance in the coverage and quality of the basic data. There are other problems such as the absence of distribution indicators, most obviously in the use of GDP per capita which provides a poor indicator of the distribution of income (and no direct indication of the inequality of wealth which may be increasing). There are also major problems with setting the weights for such a index where there is an element of arbitrariness in their selection.

Nevertheless in spite of all of the caveats the HDI is probably the best general indicator we have of human development. Clearly no-one believes that SHD is achievable without rising per capita GDP - economic growth is a necessary if not sufficient requirement for reducing poverty and improving the standard of living. But unfortunately for a number of reasons the HIV epidemic is likely to reduce average rates of increase in GDP (in economic growth). This will happen through the effects of losses of human resources due to morbidity and death; to reduced national savings as resources are diverted away from productive uses and into consumption (especially rising expenditure on health and other social expenditure), and through losses of social capital (as society experiences the effects of changes in values and losses in the efficiency of institutions affected by the epidemic). The evidence from high prevalence countries in Africa who are experiencing more mature epidemics is that growth rates of GDP may be reduced by 0.5 to 1.0% per annum due to the epidemic. These losses may be much larger where the skilled, highly educated and experienced form a significant proportion of those infected with HIV, and when account is taken of the general effects of the epidemic on the efficient functioning of the economy.

· So the evidence is that rates of GDP growth are adversely affected by the HIV epidemic and that these losses can be very significant over time depending on the structure of economies, on the distribution of the infection in the population and its incidence, and on the aggregate effects of the losses of human resources on the efficiency of the production system - in both the formal and informal sectors.

It is unclear what the effects of the HIV epidemic will be on educational attainment which accounts for one-third of the HDI. What seems to be happening in many countries is that enrollment in formal education is reduced as households respond to the pressure on resources by withdrawing children from school. There is a clear gender bias to the response of many parents when making choices: girls are much more often taken out of school when family coping mechanisms are placed under pressure by the epidemic. There are many reasons for this gender bias - in part it is income related, where attendance at school has direct costs (fees and uniforms etc.) and in part it is opportunity costs (the labour of children - especially girls - becomes more valuable to the family as incomes are even more constrained by the epidemic, including also the diversion of women to caring roles, and/or the additional burdens on the household caused by greater expenditure on health, transport, etc., directly related to illness in the family).

Whatever the explanation it seems that one consequence of the epidemic will be a reduction in educational achievement, especially of girls and young women, which will impede the achievement of one of the main goals of SHD. That is the achievement of greater gender equality as both an end in itself and as a means for achieving higher living standards for all. Unfortunately the HIV epidemic has the potential for increasing gender inequality in many ways, not least in reducing the access of girls to education and also to better health where education is an important factor in understanding how to live a more healthy life.

· It follows that educational attainment which is already gender biased in the region will become more so as a result of the HIV epidemic rather than less. This will make it even more difficult to achieve greater gender equality for women in spite of this being a core objective of SHD.

Finally there is the effect on the HDI of changes in life expectancy directly and indirectly attributable to the HIV epidemic. Here the evidence is only too clear; the epidemic has the capacity to drastically increase adult mortality rates - raising these by factors of 5 or 6 times what they would be without AIDS. Since the epidemic is concentrated on the working age groups of 15-45 where mortality would generally be low the effects of HIV (and TB) are disastrous - these groups would otherwise tend to have low mortality rates. To give an example from Africa where the epidemic is more advanced; in Tanzania HIV and AIDS are now the largest causes of death for both men and women in the age group 15-59.

Figures 1 and 2 present data on life expectancy for a selected number of countries in sub-Saharan Africa where the epidemic is more mature than it is in the Asia and Pacific region. The projections for the year 2010 should be seen more as scenario predictions given the difficulties in estimating the likely trends in HIV over a period as long as 15 years. What is apparent is that the effects on life expectancy of the epidemic are already apparent in many countries in Africa, with highly significant falls in LE in many countries in the region. Thus in Zambia the Without AIDS LE in 1996 would have been approximately 60 years, whereas the With AIDS LE in 1996 is estimated to be about 35 years. The projected data on LE for 2010 represents an even more serious situation, with further declines in many countries in the Africa region. In some countries the situation is no less than disastrous. In Zimbabwe, to take one example, LE is predicted to be almost 70 years in the Without AIDS scenario, but declines to about 32 years in the With AIDS case.

FIGURE 1

LIFE EXPECTANCY RATE* WITH AND WITHOUT AIDS IN AFRICA: 1996

East Africa


Fig.

Southern Africa


Fig.

West and Central Africa


Fig.

B.F. - Burkina Faso
C.A.R. - Central African Republic
C.I. - Cd'Ivoire

* Life expectancy is the number of years an individual is expected to live.

Source: International Programs Center - Population Division U.S. Bureau of the Census, Washington, D.C.

FIGURE 2

LIFE EXPECTANCY RATE* WITH AND WITHOUT AIDS IN AFRICA: 2010

East Africa


Fig.

Southern Africa


Fig.

West and Central Africa


Fig.

B.F. - Burkina Faso
C.A.R. - Central African Republic
C.I. - Cd'Ivoire

* Life expectancy is the number of years an individual is expected to live.

Source: International Programs Center - Population Division U.S. Bureau of the Census, Washington, D.C.

The effects of HIV/AIDS on life expectancy are already apparent. Similar effects must already be underway in those countries in Asia and the Pacific with highest prevalence and most mature epidemics (such as Thailand and Myanmar).

· The effects on life expectancy of the HIV epidemic are potentially disastrous as the epidemic intensifies in the Asia and Pacific region and adult mortality rates increase. It is possible that life expectancy may over the next 25 years be reduced very significantly with enormous consequences on the potential for achieving SHD. A central objective of SHD is to increase life expectancy through improvements in the standard of living of the population, but the HIV epidemic has the potential for drastic reductions in this crucial indicator of human development.

It is possible to make calculations of the effect of the HIV epidemic on the HDI so as to assess the effect of the epidemic on human development - to measure the impact of the HIV epidemic on SHD. It is rather easier to assess the effects of changes in life expectancy on the HDI than the other two components of the index. Doing this can demonstrate how significant the effects of the epidemic will be on sustainable development in the region; and the evidence is that these can build-up to very significant effects indeed.

3. INCLUSIVE AND EXCLUSIVE PROCESSES

One of the objectives of SHD is to bring about a wider participation of civil society in the processes of decision making. Or, to put it differently, SHD aims to strengthen social capital through activities which build capacity in institutions and through changes in values that support wider participation by all groups in social decision making. Central to achieving this are policies for greater democracy, more open and accountable systems of governance, and increased authority for those who have responsibility for ensuring that human and legal rights are observed by all. Of course the gap between aim and actuality is presently huge, and many countries in the Asia Region are a long way from achieving the ideal in these respects. Indeed there is continuing dispute in some countries as to whether there are natural and intrinsic rights, with some leaders arguing that there is no such thing. Whether or not there is something that can be described as natural rights which are common to all is not central to our present concerns, important though it undoubtedly is to socio-economic progress in the Region.

What is central to our present concerns is whether the HIV epidemic has created conditions which have moved countries closer to the ideals of SHD or the opposite. The evidence here is, however, very mixed. In many countries in the Region the HIV epidemic continues to be seen as a health problem and responsibility resides still with Ministries of Health. It follows that the epidemic has continued in many places to be viewed as part of the normal response to infectious diseases - to be addressed within the traditional framework of laws and regulations, and utilising traditional health approaches. Indeed in many countries the initial response to the epidemic has been often to seek out ways of applying the law as if using the law as a threat was an appropriate response. Central to this approach is a conceptualisation of the epidemic which sees the problem as one of "core groups" who engage in anti-social and reprehensible behaviours. The aim of policy is to identify these "core groups" and to implement policies and programmes that will change their behaviour. Essentially the approach has been, and in many countries continues to be, one which is the opposite of inclusive - it defines a problem and then seeks to impose a solution.

The problem is perceived as being not the virus but people, and the processes followed are in most countries those traditional to public health programmes. Of course this is not true everywhere in the Region, and Australia is a remarkable example of how to develop a new consensus within society of what the problems are, how to build social capital, and how to develop policies and programmes which are genuinely participative and inclusive. Moreover such policy and programme development can, and should, involve those infected and affected by the HIV epidemic. To achieve these desirable objectives - of inclusion and participation - requires the development of an enabling framework of laws which are supportive of an effective response to the epidemic. It means establishing a set of principles of action for programme activities which ensure that these are based on collaborative processes and are not simply implemented and imposed by Government.

Paradoxically the HIV epidemic has the capacity to make the processes which are considered essential to the achievement of SHD more rather than less achievable. For while the initial response to the epidemic in most countries is, and continues to be, one which is inappropriate (to put it mildly) to what is required for an effective response, there has been in time in some countries a realisation that things have to be done differently. In a real sense the epidemic poses problems which cut across class and interest group identity. It threatens social and economic development, and may yet undermine political stability. Thus in an increasing number of countries, and also at a regional level, there now exist NGOs and networks of PLWHA, legal and ethical and human rights networks, and support groups for those affected - admittedly still too few but it is a start. Some Governments have come to a realisation that they have to broaden their response to the epidemic and this has to involve the rest of civil society - along the way understanding that strengthening the capacity of NGOs and CBOs and involving these in policy and programme development is the only way forward. There still remains a big distance to travel, but the road ahead has begun to look much clearer than it was even 5 years ago.

While policy and programme responses in the region have initially represented a retreat from the inclusive principles of SHD, in some countries there is now a gradual realisation that an effective response requires the active participation of civil society. Paradoxically the HIV epidemic has created a need and an opportunity for innovative approaches to governance which make the processes needed for SHD more attainable rather than less so. But there remains a large gap between those countries that have responded effectively through building social capital and those that have yet to do so.