|AIDS in the Context of Development (UNAIDS - UNRISD, 2000, 77 p.)|
|An Agenda for Further Social Science Research|
There is no shortage of issues for research by social scientists seeking to improve understanding of, and response to, the HIV/AIDS pandemic. The following list grows out of our own work for this paper, and it is also shaped by our discussions with social scientists already actively involved in research and its application in this field.
Two overarching concerns are reflected in the list. The first is the need for greater differentiation in the analysis of who is affected by the epidemic (distinguishing by gender, age, social position, education, occupation, rural or urban setting, and so forth), greater ability to distinguish the reasons for any distribution and trends that appear to be occurring, and a more concrete understanding of how HIV/AIDS affects households and societies as a whole. Second, there is a need to appreciate the socioeconomic, cultural and political factors that both strengthen and inhibit the capacity of particular societies to deal with the epidemic.
The list is then divided into three broad categories: (i) contextual issues, research about which can help policy makers, programme planners and managers, social scientists and activists understand and respond better to the numerous factors that are driving the pandemic; (ii) impact issues that remain critical to understanding effective approaches to mitigation, support for affected households and communities, and realistic international responses; and (iii) programming issues, where research can aid in the design and implementation of prevention, care and mitigation efforts.
Findings from too many of the research projects undertaken to date have not been relevant for programme design or policy development. Thus, beginning at the conceptualization and design stage of any social science research activity that deals with HIV/AIDS, researchers must work closely with programme planners, policy makers and advocates to ensure that findings are relevant to their needs.
The global context for HIV/AIDS
1. It is obvious that rapid and equitable economic growth is an essential element in slowing the AIDS epidemic. What changes in global trade, debt relief and commodity price policies would be required to ensure that fairly distributed economic growth can be achieved in developing countries? And what global socioeconomic conditions and policies are heightening the susceptibility of people - especially of people in developing countries - to the HIV epidemic? To answer these questions requires integrating HIV/AIDS thinking into international debates on major development issues. Research on specific country cases can highlight the role played by various international policies and institutions (including multinational corporations) in affecting the capacity of governments and NGOs to conduct effective prevention, mitigation and care programmes.
2. It is also extremely important to evaluate global development goals, including those agreed by the OECD Development Assistance Committee and others set at international summits, in light of the worsening pandemic. It is likely that HIV/AIDS will be the biggest obstacle to achieving these goals - and in fact that it will not be possible to meet them at all unless there is a much more effective response to AIDS.
Country and local context
1. To gain a clearer picture of the socioeconomic, cultural and political factors affecting the course of the epidemic, case studies of the development of HIV/AIDS in similar kinds of environments - say commercial farming areas - in three or four different countries could be very useful. Work like this should trace the profile of the epidemic in each case and document, for each stage, how different groups were affected, how society responded and what social changes have occurred. If a study of this kind is well done, it might be possible to distil lessons of use in other contexts.
2. Specific public policy approaches in countries like Uganda or Thailand, which have been relatively successful in containing the epidemic, could also be compared with those of countries where little has been accomplished. A similar exercise could focus on regions within a single country (comparing, say, the situation in Kerala with that in another Indian state). The challenge in this kind of work is to explain the social, political and institutional factors that make for more or less effective responses to HIV/AIDS.
3. At the same time, it would be useful to assess the implications of HIV/AIDS for national poverty reduction strategies, carrying further the work that is already in progress. Many countries are setting time-bound targets for poverty reduction and for progress in such fields of human development as literacy, life expectancy, child mortality and gender equality. The epidemic must be factored into these plans, so that there will not be a bias in projections or a limitation to actions in Heavily Indebted Poor Countries (HIPCs) that are preparing Poverty Reduction Strategy Papers.
4. It is urgently necessary to improve debate on issues of health sector reform by relating them clearly to the challenge of HIV/AIDS. What are the essential elements of public and private health systems that can successfully confront a rapidly expanding pandemic? Here the holistic nature of health care must be highlighted through case studies. What kinds of counselling and testing services, for example, would have to be in place before sharp reductions in the cost of AIDS drugs could really benefit most people who must live with the disease in developing countries? How can needed laboratory systems and staff training services be provided?
5. In most countries, civic organizations have taken a lead in promoting prevention and care. How have responses to the epidemic strengthened or weakened civil society in different countries and regions? What are the practical implications for governance of different approaches to HIV/AIDS? Here the experiences of the Philippines and Myanmar might usefully be compared.
6. There is a broad scope for new research on AIDS and the workplace. For example, the organizational cultures of different kinds of companies affect HIV prevention programmes. Unions and workers groups also play an important role in determining whether HIV/AIDS is a workplace issue and how the epidemic is negotiated with management. In turn, the dynamics of labour/management relations affect the likelihood that people living with HIV/AIDS will be able to participate more broadly in the kinds of mobilization that can assert and protect their rights.
7. Labour migration is an essential element in the social and economic context of HIV/AIDS. It could be very useful to identify sites of labour migration where living conditions (privacy, the right for workers to be accompanied by their families, recreational facilities and opportunities, health services and so forth) are reasonable, and to analyse the costs and benefits of such situations from the perspective of AIDS prevention - as well as from the broader perspective of sustainable human development.
8. In a similar vein, case studies of the relation between construction projects and HIV/AIDS - and the way this symbiosis affects both workers and host communities - have immediate policy relevance. What factors seem to reduce susceptibility to HIV/AIDS? Projects that supposedly have taken steps to reduce susceptibility of workers and host communities - if there are such - should be included in the research.
In their review of HIV/AIDS impact studies, commissioned by UNAIDS in 1999, Barnett and Whiteside (2000b) note that most of these studies have been done by demographers and economists. The former have modelled effects of the epidemic on population structure and size, and the latter have focused on the estimation of costs (usually only direct costs) - for various sectors of the economy, for government programmes (particularly in the health sector), and for businesses and communities. The authors conclude that social scientists other than economists and demographers now need to make their contribution to our understanding of impact issues.
This is certainly true; and we would suggest that a useful way to frame this contribution is by giving special attention to the complex processes of socioeconomic differentiation associated with the spread of HIV/AIDS in different countries and regions. The epidemic worsens poverty and deepens income inequality. But it does so in various ways, and these are often poorly understood. If public policy is to deal more effectively with the crisis, it is important to understand not only who is most vulnerable, but also why this is the case and how the impact of disease is transmitted to different members of society.
1. How, for example, does HIV/AIDS affect the life chances and livelihood of women in specific cultures and localities? This is more than a timely question for comparative social science research. It is an extremely practical subject of investigation, which must be linked to strategies for mitigating the impact of the epidemic on women themselves, and on households and communities. Practitioners dealing with HIV/AIDS in specific localities need the help of social scientists to gain insight into the mechanisms of differentiation that affect women.
2. Legal and institutional questions deserve greater attention - including elements of customary law and tradition. For example, there is the issue of survivor rights. Some countries, like Tanzania, have made specific reforms to these rights. Who do these favour in practice, and how effective have they been in protecting women and children?
3. How do people - again, in specific social settings - finance care for those living with HIV/AIDS? Are shifts in land ownership occurring, as households give up access to land in return for needed resources? What are the conditions for such transfers? Are other fixed assets (including livestock in rural areas) changing hands? It is important to remember that increasing maldistribution of resources implies not only that some people lose, but also that other people win.
4. The impact of HIV/AIDS on the labour force must also be better understood. This is an essential element in analysing the impact of the epidemic on subsistence farming systems in various parts of the world. Household provisioning depends on unpaid labour. When family members are no longer able to carry out subsistence activities by themselves, are old and new forms of unpaid labour exchange filling the gap? And when this is not possible, are subsistence farmers becoming agricultural labourers? What are the implications of this for food security in the villages and regions under study?
5. In more general terms, how are rural economies coping with changes in the labour force? Is the lack of hands great enough at peak seasons to weaken or destroy local agriculture or change cropping patterns? How are rural wages evolving? Are more children involved in agricultural labour? More old people? More women? Specific case studies could highlight policy choices that should be considered by institutions ranging from agricultural ministries to social service providers.
6. It is also important to explore a number of issues related to human capital formation. What is happening, for example, to the capacity of key educational and training institutions, as they suffer the loss (through absence or death) of teachers and administrators? How are specific educational systems attempting to carry out their mandates despite the ravages of AIDS? And how are communities and households dealing with the loss of adults who play a key role in the informal process of education, imparting knowledge about certain trades or teaching skills gained over years of practical experience?
7. Human capital encompasses the capabilities and knowledge of both skilled and unskilled workers - neither of which can be costlessly replaced. Researchers should be involved in assessing the implications of human capital loss for the functioning of developing country economies - evaluating both the direct impact of HIV/AIDS on particular sectors and industries, and the systemic effects of changes in one sector on others. The assessment should also describe and evaluate the way these sectors and industries are attempting to respond to the loss of people with different skills and training.
1. NGOs have led the way in responding to the epidemic with pilot projects and effective small-scale initiatives. They often run into difficulties, however, if they attempt to scale up their efforts. By working closely with some of these groups, researchers could help them analyse the structural and resource limitations that arise when they try to expand their reach. Their ideas and experience could provide very useful lessons for others.
2. Case studies of attempts by governments to mainstream HIV/AIDS should also be prepared, so that the strengths and weaknesses of different approaches become clearer. A fuller examination of where, why and how mainstreaming has occurred would provide guidelines for other countries.
3. There are examples of large, internationally financed infrastructure projects that have incorporated an assessment of their potential impact on STDs (including HIV/AIDS) in their project design. The Chad/Cameroon oil pipeline is the first of these. It would be instructive to conduct a follow-up study of the project.
4. The European Commission has designed a toolkit to promote multisectoral assessments of HIV/AIDS impacts and appropriate programme responses. Researchers could identify projects in which the toolkit has been used and explore the strengths and weaknesses of this approach in different institutional settings. Work could also be done to evaluate other instruments that are designed to promote multisectoral responses to the epidemic; or to test new proposals, such as the Guidelines for Studies of the Social and Economic Impact of HIV/AIDS (UNAIDS, 2000b).
5. Finally, there is room for research on the issue of how funds freed up by debt relief can be channelled into innovative development strategies that make a real contribution to the fight against HIV/AIDS - creating an overall economic and social context in which peoples vulnerability is reduced and their chances of leading full and productive lives are greatly increased.