1

HIV/AIDS and Education

IAEN Current Issues in the Economics of

HIV/AIDS by

Alan WhitesideDirector, Health Economics and

HIV/AIDS Research DivisionUniversity of Natal

Thanks to

• USAID• UNAIDS• DFID• Peter Badcock-Walters

• Tom Cobbley

2

Outline of Presentation

• The scale of the epidemic• Describe the dynamics• Demographics• A case study

HIV prevalence in adults in sub-Saharan Africa, end 2001

20 – 39%10 – 20%5 – 10%1 – 5%0 – 1%

No data unavailableoutside region

2001

Source: UNAIDS, 2002.

3

Number of people living with HIV/AIDS in sub-Saharan Africa, 1980-2001

0

5

10

15

20

25

30

1980 1983 1986 1989 1992 1995 1998 2001

Mill

ion

s

Source: UNAIDS, 2002

National trends in HIV prevalence

0

5

10

15

20

25

30

35

40

45

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

% H

IV p

osi

tive Botswana

Namibia

South Africa

Swaziland

4

Outline of Presentation

• The scale of the epidemic

•Describe the dynamics• Demographics• A case study

Epidemic Curves, HIV

27Aug01 - Report I: Epidem’gy & Lit. p. 27

T1 T2 Time

Numbers

A1

A2

HIV prevalence

A

B

5

Epidemic Curves, HIV and AIDS

27Aug01 -Report I: Epidem’gy & Lit. p. 27

T1 T2 Time

Numbers

A1

A2

HIV prevalence

AIDS - cumulative

B1

A

B

Epidemic Curves, HIV, AIDS & Impact

27Aug01 -Report I: Epidem’gy & Lit. p. 27

T1 T 2 Time

Numbers

A1

A2

HIV prevalence

B 1

A

B

AIDS- cumulative

Impact

6

0

10

20

30

40

50

60

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

Mill

ion

s

To

tal

po

pu

lati

on

0

1

2

3

4

5

6

7

8

9

Mill

ion

s

Nu

mb

ers

HIV

, A

IDS

sic

k an

d H

IV d

eath

s

Totalpopulation

Total HIV

TotalnumberAIDS sick

CumulativeHIVdeaths

Numbers infected, sick and dead, ASSA2000

A model of futureAIDS and non-AIDS Deaths

0

200000

400000

600000

800000

1000000

1200000

1995 2000 2005 2010 2015

year

num

ber

of d

eath

s

Other deaths AIDS Deaths

7

All orphans and orphans due to AIDS by HIV prevalence, Uganda, by year

1985 1990 1995 2000 2005 2010 Year0

0.5 million

1 million

1.5 million

2 million

Total Number

0

6%

12%

HIV Prevalence

Total OrphansAIDS OrphansHIV Prevalence

Outline of Presentation

• The scale of the epidemic• Describe the dynamics

•Demographics• What we know• What we are doing - the MTT

8

NYHQ HIV/AIDS Unit 1-May-03

Estimated increase in adult death rates relative to the 1985 rates

Women

0.000

0.500

1.000

1.500

2.000

2.500

3.000

3.500

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64

A g e

Rat

io

1994

1996

1997/8

1998/99

1999/2000

Declining life expectancy

Changes in life expectancy in selected African countries with high and low HIV prevalence: 1950-2005

Source: UNAIDS, 2002. Report on the global HIV/AIDS epidemic

9

Projected population structure with and without the AIDS epidemic, Botswana, 2020

80757065605550454035302520151050

020406080100120140 0 20 40 60 80 100 120 140

Males Females

Deficits due to AIDS

Projected population structure in 2020

Population (thousands)

Ag

e in

yea

rs

Source: US Census Bureau, World Population Profile 2000

Under Five Mortality 2000 and 2010

2000 2010

50

100

150

Botswana

02000 2010

50

100

150

Cote d’Ivoire

02000 2010

50

100

150

South Africa

0

With AIDS With AIDS With AIDS

Without AIDS

Without AIDS Without AIDS

Rate per 1000 live births

29

10

0

500000

1000000

1500000

2000000

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

AIDS orphans in South Africa

33

By 2010, orphans will account for 15-25% of all children in 12 countries in SSA

0 5 10 15 20 25

Lesotho

Swaziland

Botswana

Zimbabwe

Mozambique

Zambia

Namibia

Malawi

Rwanda

South Africa

Burundi

Central African Republic Non-AIDS

AIDS

11

Outline of Presentation

• The scale of the epidemic• Describe the dynamics• Demographics• A case study

HIV/AIDS Impact on Education

• The primary impact of HIV/AIDS is to explode the scale of existing systemic and management problems in education;

– Labour attrition, recruitment & training

– Access, enrolment & gender equity

– Increase orphaning & drop out rates

– Reduce household/school fee income

– Learner transition, graduation rates & quality

• AIDS makes dysfunctional systems worse.

12

Education MIS: The Need

• Need for EMIS to:

– providing system input, performance & output data moreregularly and efficiently

– capturing/monitoring key indicators of HIV/ AIDS impact regularly and efficiently

• Their key feature should be the capacity to capture

monthly time-series data.

HIV/AIDS Data Requirements

• Labour: Establishment and temporary & permanent loss by reason, age, gender, type and school (To inform recruitment & training, loss of contact time/quality – can link to payroll)

• Enrolment: Temporary & permanent loss by reason, age, gender, grade and school (To inform access, gender equity, orphaning & pregnancy rates)

• Transition & graduation rates: Ex-EMIS (To project output & tertiary supply)

• Orphaning: Incidence by month (trends)

• Fees: Loss through school exemptions

• Geographic variation: Analysis by school.

13

The Response

• A decentralised District Education Management and

Monitoring Information System (DEMMIS)* has been

developed to test viability of monthly data capture;

• The pilot system has been designed to capture key

indicators of HIV/AIDS impact on a monthly basis, to

guide response at the school, circuit and district levels;

The System

• The DEMMIS system captures monthly statistics on

teachers, learners, support staff and school governing

bodies;

• Provides time-series data on enrolment, absenteeism, attrition, contact time, drop-out, pregnancy, orphaning and fees – all by gender and grade;

• Copy to school, one to the Circuit and District;

• Indicators of HIV/AIDS impact can be quickly and easily derived from these;

• Linked to a District Managers Resource Kit with FactSheets and Management Response Checklist………

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The Pilot

• Pilot districts in the KwaZulu Natal Province,

South Africa’s worst affected, were selected on

the basis of their demographic mix;

• Pilot initiated in 95 schools in the Dannhauser

District, in February 2001;

• This illustrative sample, over 10 months, involved

32 schools: 20 Primary, 6 Secondary, 5 Combined

and 1 Pre-Primary;

The Geography

• KwaZulu Natal is South Africa’s most populous

province at around 8 million;

• It has a school enrolment of almost 2,7 million,

taught by about 75 000 teachers in almost 3 000

schools;

• It is also the worst affected by HIV/AIDS with an

antenatal HIV prevalence rate of over 36% in 2002;

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Change in enrolment figures

12700

12800

12900

13000

13100

13200

13300

Feb-01

Mar-01

Apr-01

May-01

Jun-01

Jul-01

Aug-01

Sep-01

Oct-01

Nov-01

+42

-21

-35

-29

-103

-13

-43

-33

-32

Annualized 2.6% decline

Absenteeism rates days lost as % of available time

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Feb-01

Mar-01

Apr-01

May-01

Jun-01

Jul-01

Aug-01

Sep-01

Oct-01

Nov-01

LearnersEducators

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Loss of contact time - educators

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Feb-01 Mar-01 Apr-01 May-01 Jun-01 Jul-01 Aug-01 Sep-01 Oct-01 Nov-01

Absent

Leave taken

Annualized 8.4% loss of time

Learners that left the system –cummulatively

517

29

0

100

200

300

400

500

600

Feb-01

Mar-01

Apr-01

May-01

Jun-01

Jul-01

Aug-01

Sep-01

Oct-01

Nov-01

13 177 learners in Feb 3.9% cumulative loss 5% annualized loss

17

1

16

0

5

10

15

20

Feb-01

Mar-01

Apr-01

May-01

Jun-01

Jul-01

Aug-01

Sep-01

Oct-01

Cumulative Loss of Educators

371 educators in Feb 4.3% cumulative loss 5% annualized loss

Teacher Attrition in KZN:A Case Study

Normal Attrition:

In 1999 6.79% of educators left the system according to payroll data analysis -

• Estimated that 0.69% left because of AIDS

• Around 6.1% could be considered ‘normal’ attrition

HIV/AIDS Attrition:

• Only the beginning: AIDS deaths are increasing sharply and will reach close to 5% a year by 2010

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Conclusions

• The total number of educators needed will

decrease

• The training requirement will, however,

increase as educators leave the system

faster than the decline in the need.

• Total decline by 2008 in demand 4 946

• Total educators leaving by 2008 64 418

• Training requirement 2000-2008 59 472

Number of learners orphanedreported month by month

Month 1 Parent 2 ParentFeb 33 9Mar 7 1Apr 7 0May 11 2Jun 3 0Jul 31 4Aug 17 1Sep 17 2Oct 10 0Nov 7 2Grand Total 143 21

Schools : 32Enrolment: 13177Annualized : 1.5%

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Cumulative rate of orphaning, excluding drop-outs

143

3321

90

20406080

100120140160

Feb-01

Mar-01

Apr-01

May-01

Jun-01

Jul-01 Aug-01

Sep-01

Oct-01

Nov-01

1 Parent

2 Parent

What goes around comes around part 1

20

What goes around comes around

Medical interventions for HIV-AIDS

ImmunisationMicrobicidesAnti-

retroviraltreatment

Individual Behaviour

Support

Incapacity & absenteeism inprivate sector &

civil service

cure

s exte

nds

reduces

Viral mutation

redu

ce pre

ven

t

Increaces ?decreases?

prev

ents

Sex industry interventions

Healthy lifestyle

Condom use

increaces

sustains

impr

ove

AIDS education & awareness

caus

es

redu

ces

prod

uctiv

ity

more orphans

Mores & customs (multiple sets of these) Education

Diet &nutrition

affect

Migrant & mobile workers

Stable & settled workers

brings better

Govtpolicies

Funding for health care, infrastructure, sanitation

scarce educators die

challenges

& influences provides skilled people

Re

du

ces

dem

and

sustains

creates vacancies

inhibits

support Drain on

Shareholderexpectations

& values

drive

risk taking &risk avoidance

Role of women

NGOinvolvement

Circumcision

Notions of masculinity

Social cohesion

Spiritual & political authorityReligion challenges

& influences

Beliefs

Above average survivors:chaste & faithful,

long term thinkers,tertiary educated,

non-migrant families,settled LT employees,high income, cohesive

& candid societies, grandparents

Aboveaverage survivors

Above average mortality :unemployed, orphans,soldiers, sex workers,

hazardous occupations, migrants, temps, contract

workers, newly prosperous, young women,

uncircumcised men, & partners of all the above

Population stops

growing, and ages

Businesssector

involvement

Autonomy of HIV in Complex Societies - A systems model of the S’n Africa AIDS epidemic

TreatingSTD’s

HIVEpidemic

(prevalence)

HIV Transmission

LatencyPeriod

(avg8 yrs)

AIDS related Disease & Deaths

(death rate)

Motherto child

treatment

ham

pers

prev

ents

Treatingopportunistic

diseases

Africantraditional

healers

promiscuity

incr

ea

ss

Economicorganisation

Personal responsibility

Self-confidence

Chastity,Fidelity

reduces

Business sector involvement

Migration & mobility

Impr

oves

we

ake

ns

changes

Tension of two worlds

Life force,procreation,

sex urge

Drives

affects

affects uptake of

AIDS testing & counselling

impr

oves

Promote / hamper

increa

ses

Leadershipin society

Bus

ines

s se

ctor

invo

lvem

ent

reduces

Promote / hamper

G i v e s r i s e t o

Global competition &

economy

Weather & climate change

Jobs

Economy

Cost of hiring &

retraining

affe

ctaffe

ct

affect

skilledworkers

die

Who dies & who survives:

(population. Demographics &

particularities)

values, profits, patents, prices, research

Determinesnature of

influ

ence

s

create

provides

prov

ides

prov

ides

promote

s

increases

create

incr

ease

s

perceptionsof risk Hazardous

occupations

crea

te

affects

Housing & land Urbanisation

affect

Safety, crime & war

I n f l u e n c e

Cost toindividuals & households :

medication, care, burial,& orphans

reduces

affects

extends

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Conclusion

• We are only beginning to track the effects of AIDS in education.

• We have not tracked the financial cost

• We have not tracked the development cost

• Human capital • ‘Manpower’ planning