Assessing Impacts of HIV/AIDS on the education sector MTT Winter School, Durban, August 2004 Dr...

Assessing Impacts of HIV/AIDS on the education

sector

MTT Winter School, Durban, August 2004

Dr Anthony Kinghorn

Purpose

Understanding of:• Priority information for developing responses• Key issues around specific components of

information including potential pitfalls of assessments and interpreting information

• Impact assessment and monitoring options • How to improve effectiveness for mobilising

action

Reduce frustration and inefficient use of time and other resources

What are the objectives of impact assessment?

1. Fill information gaps for planning?– Susceptibility and vulnerability

– Types and size of impact – e.g. on employees, service needs, gender equity, access policies

– Response assessment

– Prioritisation

– Mainstreaming

2. Advocacy - which audiences?– Top leadership/ management

– Mainstreaming - intra- and inter-sectoral

Questions and objectives influence information needed and methodology

Scope (1)Internal impact/ impact on service

delivery

• Employee susceptibility to infection

• Employee infection, illness and death rates – Current and future

– Teacher training/staffing implications

• Costs– Absenteeism; training; pension, death or medical

benefits; vacancies; work disruption; other

• Critical posts/ processes and vulnerabilities

• Effects on quality and productivity

Scope (2)External impact/ impact on service

needs and demand

• Infection of learners– Risks and levels of infection among learners

– Illness among learners

• Affected learners– Orphans and other vulnerable children

– Indicators of vulnerability

• Implications– Access, enrollment and performance

– Loss of investment in education

Scope (3)Cross cutting issues

• Gender, rights• Option appraisal

– Priority, feasible, efficient and cost effective responses including eg effects of ARVs, prevention

– Guidance for initial, general strategy?– Guidance to refine strategy and planning/ fill gaps?

• Response analysis– HIV/AIDS programme – HR and other management and planning systems– Local and partner sectors’ responses and coping

strategies

• Recommendations– Prioritised– HIV/AIDS programme– Other programmes and sub-sectors

Scope and depthGeneral considerations

• Which education components? – Schooling, higher ed, teacher ed, management etc

• Developmental or HIV/AIDS specific focus?

• Current and future impact?

• Including analysis of interventions eg. ARV, BCC?

• Level of analysis – aggregated data or small samples may hide important impacts

• Academic vs systems/ action orientation?

• Finality and detail of recommendations?

• Time and resources available?

• Ability to provide “The answer”?

METHODOLOGY (1)

Projections

• Infection, death and illness rates; population size• Current and future estimates

– Possible effects of ARV; teacher supply and demand etc.• Calibrate against antenatal or other national surveys;

staff HIV or death/ attrition data • Challenges

– Many assumptions and uncertainties – Need to improve calibration and validation data– Process to ensure acceptability to key stakeholders,

coordination and limit duplication– Use of scenarios and sensitivity analysis to assess

the importance of uncertainties

May provide important guidance for action despite limitations

Projected levels of HIV infection among adults by region (Illustrative)

0%

5%

10%

15%

20%

25%

30%

35%

Caprivi Erongo Hardap

Karas Kavango Khomas

Khorixas Ohangwena Omusati

Total deaths as a percentage of teachers (Namibia)

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

No ARVS ARVs Actual pension data School survey

SOUTH AFRICA - TOTAL POPULATION

Total Population

44,000,000

46,000,000

48,000,000

50,000,000

52,000,000

54,000,000

56,000,000

58,000,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Year

Po

pu

lati

on

No Change Scenario

Change Scenario

No AIDS Scenario

Source: ASSA2000 Model

METHODOLOGY (2)

Routine data review/ monitoring

• EMIS

• Payroll, pension fund, other HR databases

• DEMMIS and informal district information

• Key information on eg. – enrolment trends and patterns– deaths, retirement, other attrition

• Can be lower cost than primary data collection and have ongoing benefits for systems, monitoring and management

• Challenges– Varying availability and reliability of data

METHODOLOGY (3)

Surveys

• Specific surveys of samples of schools

• Information on a range of impacts

• Challenges– Sample size and biases– Quality of certain data– Informed analysis to identify issues and

associations rigorously

• May use other surveys or their datasets– E.g. School surveys miss out-of-school

populations, so DHS or other population/ household can add to info e.g. OVC enrolment

ENROLLMENT RATES BY ORPHANHOOD STATUS - KENYA 1998

0

10

20

30

40

50

60

70

80

90

100

All children Poorest 40% Richest 20%

% o

f ch

ildre

n e

nro

lled

Both ParentsAlive

Paternal orphan

MaternalOrphan

Two- parentorphan

Source: Ainsworth M Filmer D 2002

** ** **

** = statistically significant P< 0.01

Erratic daily school attendance reported by Grade 10 learners

0%

5%

10%

15%

20%

25%

30%

Both parents alive Double orphans

Maternal orphans Paternal orphans

Recent paternal orphans Recent maternal orphans

Source: Schierhout et al 2004.

Reasons for school interruptionn=165 (12% of learners) Source: Schierhout et al 2004

22%

13%

13%12%

9%

3%

3%

24%

Migration Uniform, books, transport

Death/ illness in household No school nearby

Other Working on farms

Pregnancy Fees.

Reasons for educators leaving the school in 2002

0.1% 0.2% 0.2%0.2%

0.3%

0.3%

0.4%0.4%

1.8%

Died after accident/violence Unknow n reason

Left because of illness Died after short illness

Early retirement Other

Died after long illness(> 3 months) Reached retirement age

Left to w ork elsew here

Source: Schierhout et al 2004. School Heads’ reports

Learner reports of teacher absenteeism by province*

0%

2%

4%

6%

8%

10%

12%

Absent 4-10 lessons Absent 10 or more lessons

Free State Limpopo* Teacher absent in previous 2 weeks with no substitute teacher

Source: Schierhout et al 2004.

METHOLDOGY (4)

Behavioural surveillance - KAPB

• Standardised questionnaires for staff and/or learners

• Generate indicators of Knowledge, Attitudes, Practices and Behaviour, and thus risk

• Can link to blood or saliva tests

• May miss unexpected issues, causes and suggestions for responses

METHODOLOGY (5)

Biological surveillance - sero-prevalence surveys

• Blood or saliva tests for HIV; STD rates

• Unlinked anonymous surveys

• Advantages– Plausible, accurate reflection of risk

• Challenges– May not be accurate or provide clear trends

– Costly and complex – employee buy-in and technical issues

– Response rates

HIV prevalence in a large company workforce (South Africa)

Category % HIV+ (95%

CI)

Sexual behaviours

Non-regular partner (last 3 months) 16.8 (14.5 – 19)

No non-regular partner (last 3 months) 6.9 (6.1 – 7.7)

Condom use

Used condom with last non-regular partner 14.4 (12 – 16.8)

No condom with last non-regular partner 11.8 (10 – 13.5)

No non-regular partners 4.5 (3.7 – 5.3)

Source: Colvin M Gouws E Kleinschmidt I Dlamini M. The prevalence of HIV in a South African working population. AIDS 2000 Conference poster, Durban 2000



Accommodation % HIV + and 95% CI

Construction camp 23.8 (17 – 30.3)

Hostels 16.9 (14.5 – 19)

Rented home 8.2 (6.3 – 10)

Own home 5.6 (4.8 – 6.4)



Job category % HIV + and 95% CI

Semi skilled 14.7 (13 – 16.4)

Skilled 5.8 (4.6 – 6.9)

Middle management 3.4 (2.4 – 4.4)

Senior management 3.2 (0.1 – 6.3)

METHODOLOGY (6)

Qualitative research

• Focus group discussions, key informant interviews

– Open ended

• Advantages– Refining questions, identifying priorities– Can alert planners to unexpected risks or needs – Can identify key/ critical posts and functions– Identification of impacts that are difficult to quantify

and assist interpretation of quantitative data – Information on response options and effectiveness

• Challenges– Technical skills– Lack of statistics

“I have a long term relationship now that I have been transferred away from my wife so that I am not tempted to sleep with many women. Some colleagues

have many short relationships to preserve their marriages. I don’t know who is more at risk, we may all be infected.”

“We feel protected by our HIV/AIDS knowledge when we are in our classroom. But when we are in the hostels or in town, we don’t know how to apply it. It is a

different world out there.”

“The greatest disruption occurs if a financial manager is absent or leaves. No-one else can do their job and they are hard to replace”

“ The HIV/AIDS programme has a vehicle but it is always being used by the

Regional Director”

“On the surface it may appear that their problems are as simple as inability to pay fees or discipline issues but you later discover that their problems have

deeper roots”

Understanding of practical problems

Components (7)

Costing and economic evaluation

• Size of costs?

• Which are the main contributors to costs?

• Which costs can be managed?

• What responses are “affordable”?

• Potential savings and cost–effectiveness?

• Methodological issues– Direct, quantifiable costs may be small

– Value judgments in methods

– Pension fund costs – actuarial valuation

– Medical care and other costs – available data; notional vs likely “cost savings”

Estimated Magnitude of Costs Estimated Magnitude of Costs of a New Infectionof a New Infection

Medical care4%

Turnover*22%

Productivity loss40%

Absenteeism34%

Company A- Heavy industry

Company B - agriculture

Artisans, Males 35-49

Actual Size

Turnover 17%

Absenteeism 14%

Productivity loss 7%

Retirement/ Disability 62%

Source: Rosen S Thea D Simon J et al. Estimating the Impact of HIV/AIDS in Businesses in Estimating the Impact of HIV/AIDS in Businesses in South Africa 2001South Africa 2001

Categories of HIV/AIDS costs to companies (Kenya)

trainingHealth care

20%

HIV absenteeism

21%AIDS absenteeism

14%Recruitment

2%

Burial costs14%

Funeral attendance

3%

Training20%

Labour turnover4%

Productivity loss after

2%

SOURCE: Forsythe et al 1996

Projected costs of risk benefits as % of salary (South Africa, non-ARV scenarios)

Source: Metropolitan Life Ltd 2000

1997 2007

Lump sum death or

disability benefit

1.5 4.5

Spouse’s pension 4.0 7.5

Disability pension 1.5 2.6

1. Pension fund Neutral

2. Medical Aid - ARVs N$ 146m to 2010 2% of school costs by 2010

3. Extra teacher training? N$ 35 m (ARV) N$ 135m (no ARV) to 2010

4. Absenteeism/ relief teachers < / = 1.7% of payroll

Projected sector costs of HIV/AIDS among education sector employees

(Costs at 2001 prices)

Costs are significant but potentially manageable

Total number of employees on ARV treatment

Mid scenario

0

20

40

60

80

100

120

140

160

180

200

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

HighSuccessARV, 20% Access HighSuccessARV, 100% Access

TOTAL EMPLOYEE HIV/AIDS COSTS TO GOVERNMENT (millions) Mid scenario – Mozambique Customs

sector

0

1,000

2,000

3,000

4,000

5,000

6,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

100% ARV Access No ARVs

AIDS costs by employee category

0

10

20

30

40

50

60

% of total

Support staff Manual labour Supervisors Tech. professional Seniormanagement

% employees

% costs

Source: Forsythe et al 1997

Dealing with uncertainty

All sources and methods tend to have limitations. Remaining uncertainty is inevitable

Decision makers need to be comfortable that responses are appropriate despite uncertainty

Approaches

• Sensitivity analyses and scenario planning– What options are high and low risk?

• Prioritise interventions in line with other priorities– HIV/AIDS as an opportunity not just a threat

• Increase flexibility to respond to hard hit institutions and functions

• Further analysis and better information in key areas

Trends in scope and methodology• More focus on:

– Specific impact areas and uncertainties likely to change planning decisions

– Specific intervention options: feasible, cost effective?

– Practical planning issues

– Primary data?

– Phased approaches to assess options?

• Improving routine data

• Where is exhaustive assessment cost effective?

• Is rapid appraisal, extrapolation of conventional wisdom enough for planning and buy-in?

Presentation and reporting

• Tailor presentation and reports to target audiences

• Use credible information and do not exaggerate• Identify more persuasive arguments

– Human impact? Costs? Cost effective responses

– Present impacts along with solutions?– Practical recommendations?– Interventions serving other organisational

priorities?

Key success factors

• Clear and prioritised objectives– What are the key information needs and uses?

• Methodology– Rigorous methodologies– Understand and manage limitations and implications

• Consider and link to general education challenges, context and strategy, not just HIV/AIDS

• Process– Buy-in and active involvement of MOE officials for

efficiency, quality and skills transfer

– Situate in clear process so study feeds into action• Part of the response; not a reason to delay action

– Dissemination and advocacy strategy

Assessing Impacts of HIV/AIDS on the education sector MTT Winter School, Durban, August 2004 Dr...

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