Report No. 22046-NAM Namibia Selected Development Impact of HIV/AIDS April 10, 2001 Macroeconomic Technical Group Africa Region Document of the World Bank CURRENCY EQUIVALENT (April 10, 2001) Currency Unit = Namibia Dollar Namibia (N$) 1.00 = US$ 0.1242 US$ 1.00 = N$ 8.05 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Clinics CBO Community Based Organizations CGE Computable General Equilibrium DHS Demographic Health Survey GDP Gross Domestic Product HIV Human Immunodeficiency Syndrome IEC Information, Education and Communication MOHSS Ministry of Health and Social Services MTC Mother to Child Transmission NACP National AIDS Control Program NACOP National AIDS Coordinating Program NER Net Enrollment Rate NGO Non-Government Organizations PLWHA Persons Living With HIV/AIDS PROST Pension Reform Options Simulation Tool-Kit RON Republic of Namibia SSS Sentinel Surveillance System STD Sexually Transmitted Disease TB Tuberculosis UN United Nations UNAIDS United Nations AIDS Agency USAID United States Agency for International Development USBOC United States Bureau of Census WHO World Health Organization Vice President Callisto E. Madavo Country Director Fayez Omar Sector Manager Philippe Le Houerou Task Team Leader James Sackey Namibia: Selected Development Impact of HIV/AIDS Table of Contents Page No. Executive Summary ......................... ................................... v Chapter I Introduction: .............................................. I A. Nature of the Epidemic ............................................. 2 B. Likely Impact . .............................................. 3 C. Organization . .............................................. 5 Chapter II Status of HIV/AIDS in Namibia ...................... . 7 A. HIV Prevalence .............................. ................ 7 B. AIDS Cases and Deaths ............................................. 11 C. Sexual Practices and Knowledge .................................... 13 D. Need to Improve Monitoring ....................................... 15 Chapter III Demographic Impact of AIDS .......................................... 17 A. Impact on General Population .. .................................... 18 B. Implications for the Labor Force ................... ............... 21 C. Conclusions ...................... ........................ 22 Chapter IV HIV/AIDS and the Economy............................................ 23 A. Macroeconomic Impact .23 B. Impact on Selected Sectors .26 C. Conclusions .30 Chapter V Response to HIV/AIDS.............................................. 32 A. Control Strategies in Nanibia .33 B. Proposals to Strengthen Ongoing Initiatives .34 C. Some Lessons to Consider .42 Bibliography . .............................................................................. 44 Annex I: Modeling the Impact of HIV/AIDS in Namibia .46 Annex II: Namibia: Assumptions Used in Costing Selected HIV/AIDS Programs .56 List of Tables 2.1: HIV Prevalence Among Pregnant Women Attending ANC 1992- 1998 (In Percentage). 8 2.2: HIV Prevalence Among SDT Patients in 1998. 9 2.3: Regional Distribution of Reported HIV cases, HIV/AIDS Hospitalization and HIV/AIDS Deaths (Rate Per 1,000 Population) in 1998 .12 3.1: Summary of Selected Demographic Impact of AIDS .18 4.1: Indicators of Macroeconomic Impact of HIV/AIDS (in Percentage) .25 4.2: Summary of Long-term Demographic Indicators .27 .i.i 5.1: Strategies and Options .............................................. 35 5.2: Summary of Estimated Costs of Selected Policy Interventions .... 41 List of Figures 2.1: Age Specific HIV Prevalence in STD Patients .......... ............ 10 2.2: New and Cumulative AIDS Cases in Namibia .......... ............. 12 2.3: Adolescent Pregnancy .............................................. 14 2.4: Namibia - Percentage of Female Who Ever Used a Condom ....... 15 3.1: Population Growth With and Without AIDS ........... .............. 19 3.2: Population Profile in 2015, With and Without AIDS ........ ........ 21 3.3: Labor Force, With and Without AIDS ................. ................ 22 4.1: Namibia - Gross Domestic Product (With and Without AIDS)-- 25 4.2: A Young Through Rapidly Aging Population and the Uncertainty of AIDS .............................................. 28 5.1: Hospital Bed Days Needed for AIDS Patients ........................ 39 This report was prepared by James Sackey (Task Manager), Tejaswi Raparla, and Shashi Kolavalli based on a number of missions to Namibia during FYOO-0 1. The report team was supported by the staff of NEPRU, especially Hopolang Phororo. Anirudha Bonnerjee prepared the pension system projections. Valuable comments were received from colleagues at AFTMI, members of the Namibia Country Team, the peer-reviewers, Mead Over (DECRG) and Rene Bonnel (AFRHV). Secretarial assistance was provided by Felicidad Santos. This report was discussed extensively at the National Planning Commission in Namibia and by the UNAIDS Theme Group in Windhoek during March, 2001. Coniments from the participants are duly acknowledged. iv EXECUTIVE SUMMARY Since independence in 1990, Namibia's economy has grown moderately with real GDP growth averaging 4 percent annually in the early nineties. Nevertheless, it is estimated that close to one half of the population in 1993/94 could be considered to be poor, if they are defined as households with expenditure on food exceeding 60 percent of income. Poverty is also concentrated, with two-thirds of the poor living in northern parts of the country. The government has responded by developing a poverty reduction strategy in 1994 aimed at reducing the percentage of the poor and extremely poor from 47 and 13 in 1994 to 40 and 7 respectively by 2000. Population policy complements the poverty strategy with the following objectives: reduce the growth rate of population from 3.2 percent during 1991-96 to 3 percent by 2006 and to 2 percent by 2015; infant mortality from nearly 57 per 1,000 live births to 40 per 1,000 live births by 2006 and to 30 per 1,000 live births by 2015; and total fertility rate to 5 by year 2006 and to 3.5 by 2015. While modest improvements have taken place in Namibia's human development, as its social spending is one of the highest in the world, the onset of HIV/AID is likely to substantially weaken the government's ability to meet its development objectives. HIV/AIDS has emerged as the number one cause of death in 1996. It is estimated by the UNAIDS that 19.94 percent of adults (15 - 49 years) was living with HIV (excluding those with AIDS) in Namibia in 1999. The estimated prevalence rate among 15 to 24 year-olds was 18.8 to 20.8 percent for females and 7.9 to 10.4 percent for males. The estimated total number of individuals living with HIV/AIDS in 1999 was nearlyl60,000. Of them, about 150,000 are adults (15-49). Among adults, the estimated number of women was 85,000 (UNAIDS, 2000). These estimates, for obvious reasons, are nearly three times more than the number reported by the health directorate on the basis of testing in the health system which indicated the cumulative of infection to be 53,330 in 1999. Nevertheless the number of HIV positive cases reported annually by the system has exceeded 10,000 since 1996. All indications are that the epidemic is widespread in the country. The objective of this report is to provide an overview of selected likely development impact of HIV/AIDS in the light of existing data. It was initiated as an exercise to assist policy makers in Namibia in their effort to incorporate HIV/AIDS into the planning process on a regular basis. As such it is directed at officials at the agencies for planning and finance. Because of data limitations, the review at this stage does not provide detailed costing of the impact of HIV/AIDS on various sectors of the economy. Detailed costing and policy design alternatives should be the focus of subsequent analysis. Impact of HIV/AIDS Demographic: Examining the demographic consequences of the epidemic is the first step in making a comprehensive assessment of the likely impact on various sectors or the economy. Using the Spectrum Models (developed by the Futures Group International), with comparative reference to the results generated by other studies, it is concluded that the primary impact of the epidemic could be in the reduction of life expectancy at birth (LEB). The 1981 and 1991 censuses indicate that LEB has already fallen in Namibia from nearly 58 to 55 years. The decline is confirmed by current projections, which indicate that in the v absence of AIDS Namibians could have expected to achieve an LEB of nearly 70 years by 2015. As a result of AIDS related mortality of young adults, they might expect to live for 40 years. Comparable estimates by the US Census Bureau suggest that LEB would be reduced to nearly 40 by 2010, while the Ministry of Health and Social Services (MOHSS) estimates point to 40 years by 2005 before rising to about 45 by 2021. Although AIDS reduces the population growth, as sought in population and human development strategies of the country, it does so in perverse ways. In the desired form of demographic transition, the demand for children is brought down through improved education particularly of women and reduced infant and child mortality rates. The fewer children that are born receive greater investments in their development. In the case of AIDS-induced transition, on the other hand, child and infant mortality rates do not fall as much, crude birth rate does not fall significantly, but population growth rate is reduced by higher mortality of young adults. The demographic transition brought about by HIV/AIDS may have a number of consequences. A smaller economically active population may have to take care of the very young and the very old. Family and community structure may be affected significantly as more than 10,000 children are estimated would be orphaned annually and cumulative 115,000 by 2015. The labor force is also likely to be affected. Preliminary analysis suggests that AIDS deaths are likely to exacerbate the skill shortage in Namibia. While the existing data do not permit a detailed analysis of skill gap, the projected gap in the labor force as a result of AIDS related mortality is estimated to be nearly 20 percent by 2015. A substantial share of this gap could be in the skill category, made up of people with the means for greater mobility. Failure to deal with the skills shortage could exacerbate Namibia's growth constraints. HIV/AIDS and the Economy: From the macroeconomic perspective, HIV/AIDS is likely to affect the savings/investment relation. To the extent that AIDS leads to the reduction of savings, availability of skilled labor and profitability in the private sector, its impact on economic growth could be significant. Using a growth model, extended to incorporate the increase in morbidity and mortality resulting from HIV/AIDS, it is estimated that in the absence of AIDS, GDP could grow at about 3.5 percent during 2000- 15, approximately at the rate of population growth. With decreased investments, the rate of growth would be lower, projected at 2 percent by 2015, instead of the 3.5 percent that could have been expected in the absence of AIDS. Furthermore, the rate of per capita growth in GDP would have declined even in the absence of AIDS, as economic growth has not been keeping pace with population growth. With AIDS, it would decline much more. Depending on the nature of labor force employed in the sector, some sectors may be more affected by the epidemic than others. The key factors to consider are the skills level of the labor force in the particular sector, which highlights the difficulty associated with replacing those affected by AIDS, and the vulnerability of the sectoral labor force to HIV infection, which may be dependent on its socio-economic characteristics. As a case study a number of features of the civil service, for example, make it vulnerable to disruption through loss of manpower: vi * Based on a selected sample, it is estimated that about 80 percent of the civil service has less than five years in service experience, with less than one percent above 11 years. There is thus a missing middle level staff in the hierarchy. * Close to half of the civil service fall in the 25-40 years age category, which may account for the large number of staff with limited experience but fall into the high-risk age category of contracting HIV. Given the young age of the civil servants and their predisposition to contracting HIV, the service is likely to lose a significant number of its members in the near future, assuming that they have same risks as the rest of the population. As the skills gap would have led to a staffing crisis in any case in a few years, AIDS losses would worsen the situation. Namibia continues to have problems staffing its schools with trained teachers. It is noted that many of teaches in schools, especially in the north, do not have academic qualifications beyond secondary school and very few have undergone teacher training. As some estimates suggest that nearly 35 percent of teachers are likely to be HIV-positive, there would be dramatic losses in the education sector due to AIDS. Even taking into account a decrease in the overall demand for teachers, the loss of teachers would imply that teacher training institutions would have to double their yearly output over the next ten years. This implies that almost one in every six secondary school graduates would need to complete teacher-training college and enter teaching to keep up with the demand. The impact on the private sector is understudied and therefore little understood. AIDS may increase costs for local businesses. Cost increases may be both internal and external. Internal costs may include increased absenteeism, higher pension payouts, and breakdown in worker discipline and morale. There is no sufficient information available for firms in Namibia. Studies in other countries suggest that the costs may be as low as 1 percent of profit and as high as 9 percent, much of the cost deriving from increased absenteeism. External cost increases could be associated with wage increases resulting from likely skilled labor shortage. Response to HIV/AIDS Developing a response to the epidemic in Namibia requires cognizance of ongoing public, donor and private activities to mitigate its impact. In this context, the Government launched the National AIDS Control Program (NACP) in 1990 after independence. A short-term plan was implemented between 1990 and 1992 followed by a medium term plan between 1992-1997, which focused on prevention messages aimed at the general population, condom promotion, training of counselors and home based care providers, STD/HIV/AIDS case management issues for health workers, and epidemiological surveillance. An external review of NACP conducted in 1996 recommended that to improve program management NACP should include a broader range of actors from other sectors and should explore options for greater collaboration with NGOs. Non-health sectors had played limited role in responding to the epidemic. The review also found that high level support, commitment to action and sense of urgency which are critical to AIDS control programs were lacking as a result of which control was not effective despite the implementation of two plans. vii The strategic medium term plan II (MTP2) and the national AIDS Coordination Program (NACOP), which were launched in March 1999, focus on (i) social mobilization, (ii) prevention, (iii) access to services, (iv) reduction of discrimination, (v) policy and strategy development, (vi) program management, and (vii) capacity building through research and human resource development (HRD). The bulk of the resources mobilized would be allocated to information dissemination and condom promotion. In addition, greater attention would be paid in this plan to improve access to services for those affected. Available evidence suggests that efforts by the National AIDS Control Program (NACP), with the help of several NGOs and international agencies, has increased awareness of HIV/AIDS, its mode of transmission and consequences. However, there is little evidence to suggest that the average citizen considers herself/himself to be at risk of acquiring AIDS, has a good understanding of the asymptomatic nature of STD/HIV infection, or has altered her/his behavior to lower the risk of STD/HIV acquisition. Educational programs have turned out to be ineffective in controlling the spread of the epidemic. By the middle of the last decade it is estimated that more than 90 percent of the population had an adequate knowledge of HIV, but the information had not resulted in behavioral change. Building upon the Government's initiatives, this study provides an illustrative set of policy actions and costs a wide range of them with focus on reducing the transmission of HIV; prolonging life and reducing AIDS morbidity and mitigating the negative impact of HIV/AIDS on the economy. While the policies are not exhaustive, the preliminary estimates suggest that the cost of various individual elements of prevention could range between 0.1 to 1.3 percent of GDP per year, adding up to an average of 2.7 percent per year. In terms of mitigation, orphan care is estimated at about an average of 2.8 percent of GDP per year. The largest single cost element is hospital care, which is estimated at about 3.1 percent of GDP per annum. The latter points to the need for alternative programs for handling AIDS and terminal care. Although the estimates are preliminary, and merely for illustrative purposes, they point to the likely magnitude of the cost of response and suggest that the programs can be accommodated by existing resources. Compared to the estimated loss of GDP associated with HIV/AIDS (about 18 percent per year on average), the benefits of mitigation far outweigh the cost. Furthermore, since the costs of mitigation are substantially higher than those associated with prevention, it is prudent for Government to intensify preventive measures. Finally, international experience suggests that some of the features of effective national responses are: (a) political will and leadership, (b) societal openness and determination to fight against stigma, (c) strategic responses, (d) multi-sectoral and multilevel action, (e) community based responses, (f) social policy reform to reduce vulnerability, (g) sustained response and (h) learning from experience. To be strategic and to learn from past lessons, it is necessary to strengthen the information base. One of the difficulties in targeting behavioral modification strategies is the absence of behavior studies. Experience suggests that AIDS control programs that are not well focused on groups that are at risk are not effective. Standard prevention messages alone are not likely to effectively change behavior. Focused behavioral research is required to develop effective communication strategies. Therefore, an effective monitoring system is essential as part of a response program. viii CHAPTER I Introduction Since independence in 1990, Namibia's economy has grown moderately (largely on account of political stability), and there has been greater commitment to social development. Real GDP grew at an average of 4 percent annually in the early nineties reversing a decline in per capita income between 1981 and 1991. Nevertheless, it is estimated that close to one half of the population inI993/94 could be considered to be poor, if poverty is defined as household expenditure on food exceeding 60 percent of income (RON, 1998). Poverty is also concentrated, with two-thirds of the poor living in northern parts of the country. The government has responded to poverty by developing a poverty reduction strategy in 1994 aimed at reducing the percent of poor and extremely poor from 47 and 13 in 1994 to 40 and 7 respectively by 2000 (RON, 1997). Complementing the poverty strategy is a population policy whose objective is to reduce the growth rate from 3.2 during 1991-96 to 3 percent by 2006 and 2 percent by 2025; infant mortality from nearly 57 per 1,000 live births to 40 per 1,000 live births by 2006 and 30 per 1,000 live births by 2015; and total fertility rate to 5 by year 2006 and 3.5 by 2015. Some improvements have taken place in Namibia's human development, as its social spending is one of the highest in the world. Spending on social services is almost 50 percent more than South Africa, which has similar poverty and inequity profile. Health and education continue to receive increasing share of the budget up from nearly 38 percent in 1996/97 to 42 percent in 1997/98. There is a significant improvement in human development indicators, mainly on account of increases in enrolments at all levels of the education system. Improvements in education, in particular, have been significant. The number of schools increased from 1,171 in 1990 to 1,457 in 1997. The share of children aged 7 to 13 years attending school has increased from 87.5 percent to 95.2 percent between 1991 and 1995 (RON, 1998). Primary school enrolments increased from 60 percent in 1990 to 95 percent in 1997. By 1996, more than 90 percent of all the children of school-going age were enrolled in school and enrollment in grade 12 had increased from 3,000 in 1990 to 12,000 in 1996. Gender equality also may have improved. Female enrollment has increased and female literacy rates exceed that of males. Improvements in health indicators have not been as significant as in education largely because of the likely effect of HIV/AIDS on the population during the last decade. Under five mortality fell from 110 per 1,000 live births in 1977 to 87 in 1992, but life expectancy at birth may have declined from 58.8 in 1995 to 55.8 in 1998 (UNDP 1998).' Despite significant improvements in the last decade, HIV/AIDS epidemic is likely to substantially weaken the government's ability to meet its development objectives. l The decline in life expectancy, as will be discussed in subsequent chapters, could be attributed to he impact of HIV/AIDS. 1 HIV/AIDS has emerged as the number one cause of death in 1996 (UNDP, 1998). Ministry of Health (MOH) statistics indicate that nearly 7,000 people have died from AIDS by 1998. An estimated 20 percent of the adult population may be living with HIV infection. The nature and magnitude of HIV/AIDS makes it in some ways unique among epidemics or other events that are sources of shocks to economic systems and societies. The objective of this chapter is to review the nature of the epidemic and its likely effect on the development prospects of affected countries. A. NATURE OF THE EPIDEMIC AIDS is caused by Human Immunodeficiency Virus (HIV), which is transmitted through body fluids.2 In Namibia, it is mainly a Pattern Two epidemic in which transmission is primarily through heterosexual contacts. The virus kills individuals by weakening the immune systems, and making them vulnerable to other infections and cancers. MOH statistics indicate that tuberculosis is one of the major opportunistic infections and cause of death of HIV-infected people. AIDS is also fatal, but it can be contained with a cocktail of antiviral drugs to extend productive life for a few years. Recent evidence suggests that these treatments may have significant side effects.3 However, such treatment is expensive and out of reach of the poor in low and medium income developing countries. The significant characteristic of HIV/AIDS is that it affects the most economically and socially active population that would otherwise be least likely to be seriously ill. As the epidemic spreads primarily through sexual contacts, it affects the population that is sexually active, which is in the age group 15 - 49 years. The period of illness could last for many years in the initial stages of which the effect may only be seen in terms of increased absenteeism. Ultimately the affected will withdraw from the workforce. The uniqueness of the epidemic comes from the unusual rate of severe illness and premature death of economically productive population. Some aspects of the epidemic limit individual action to prevent infection and also make public action to control its spread challenging. First, the epidemic is characterized by a long gap between infection and the onset of any signal of infection. Individuals infected with HIV may not experience any symptoms for as long as 5 to 7 years. During this period, infected individuals may continue their sexual activity, spreading the virus to their sexual partners. As infected individuals do not show any outward symptoms during this period, other individuals may not be able to take precaution against infection by avoiding unsafe sexual contact with infected individuals. 2 Like other sexually transmitted diseases (STDs), HIV is difficult to transmit except by sex or other direct contact with the bodily fluid of an infected person. The major modes of transmission are sexual intercourse, reuse of contaminated syringes by injecting drug users, infection via birth or nursing from mother to child, reuse of needles in medical settings, and transfusion of contaminated blood or blood products. 3 Toxic effects of drug therapy over extended periods are becoming apparent now. An important side effect is the redistribution of fat in the body resulting in humped back and distended bellies. The need to maintain a strict regimen of drugs also substantially reduces quality of life. 2 Second, there is stigma attached to those that are infected with HIV as it is considered to be acquired through 'immoral' behavior. Families may reject infected individuals and communities may ostracize affected families. In addition to the morality- related stigma, fear of being infected through association, and economic losses from debilitation and death of the infected individuals, also deny HIV/AIDS patients and their family members access to services and livelihood opportunities. They may not be able to get the usual services at health centers. Their children may be harassed at schools. They may be denied employment or terminated from employment under a pretext.4 Since public knowledge of one's infection brings emotional, social and economic consequences, individuals would not have the incentive to find out their status or to reveal the information to casual sex partners or spouses as it suggests that they have been unfaithful. Those that feel that they can do little about the disease except to wait for debilitation and death, would be particularly hesitant even to find out for themselves whether they are infected. HIV/AIDS affects, depending on the country and prevailing sexual practices, people at both ends of the socio-economic spectrum. At the upper end, they could include the rich, the educated and migrant workers (separated from family for long periods) with more than usual opportunities to engage in risky behavior. At the other end, the poor and the unemployed (especially the young women) who could engage in risky behavior for commercial purposes. B. Likely Impact The most likely impact of HIV/AIDS is a "shock to a existing system of livelihood at the national, regional, communal or household level which reduces the level and expectations of life and welfare" (UNAIDS, 2000). AIDS impacts livelihood through premature morbidity and mortality of labor. Some individuals, households, communities and economies may be able to cope with the virus better than others, but the epidemic can have significant effect at all levels of society. Impact at Household Level: The most significant effect of AIDS may be at the household level. Households may experience dramatic decrease in income, consumption and savings because of loss of income earners. Loss of income and substantial medical expenses could deplete family assets and could accentuate poverty. It may lead to food insecurity especially for children who may be taken out of school to save resources and to take care of ailing parents. The breakdown of family structure may have serious effect on how the children are taken care of. Elderly population living on meager retirement income may be burdened with bringing up children orphaned by the epidemic. 4 Reid (1993) characterized the HLIVAIDS epidemic as going through for phases: The first phase is felt as opportunistic infections occur, psychological trauma is experienced and there is increasing illness and death; the second phase is characterized by the change in demographic and societal structure, with many children and elderly without support; at the third phase, the depletion of labor is felt, especially in the productive and social service sectors; and the fourth phase is characterized by widespread destitution, social and economic disintegration and the possibility of social and political unrest. 3 The impact of the epidemic is often disproportionately higher on women as they tend to be more vulnerable to infection than male counterparts (World Bank, 1996). Women are physiologically more proned to sexual transmission of AIDS/AIDS. In addition, because of their perceived inferior status they are less able to take precaution as they also have less control over decisions relating to sex than their male counterparts. Women with limited economic opportunities, many of whom may also be raising children out of wedlock, are pressured into sexual relations that offer them economic security. They are likely to have sexual relations with older men who have had more exposure to infection in the past. Even when they are not affected, the burden of taking care of the sick often falls on women. Grandmothers also usually raise orphaned children. Demographic Impact: HIV/AIDS is likely to have substantial impact on the demographics of the country, which has implications for both households and the economy. The most important effect will be decreased life expectancy at birth as mortality rate increases. The population will grow at a slower rate than otherwise and there will be smaller labor force. The country may be left with a different population structure, with possibly increased burden. In addition to increasing numbers of orphans, family and community structures may be destroyed. Human Development: The impact of AIDS will be more significant on human development - life expectancy, education and economic opportunities - than on economic growth. Life expectancy has already fallen in many of the African countries. A worsening in the human development status of the country may have consequences for economic growth as well in the medium to long term. Economic Impact: Although AIDS causes considerable suffering to households and demographic changes could be dramatic, the estimates of the macroeconomic impact are sensitive to assumptions about how AIDS affects saving and investment rates, and whether AIDS affects skilled vis-a-vis unskilled/unemployed labor force. A likely economic impact is a reduction in savings as AIDS may require diversion of resources to uses that would not have been necessary in its absence. The costs of AIDS may be both direct (medical care) and indirect (labor productivity losses and training costs). Productivity loss measured in terms of weighted healthy years saved per case is higher for AIDS compared to common diseases such as TB and malaria, but less than that of sickle cell anemia, neonatal tetanus, and severe malnutrition (Becker, 1990). Macroeconomic effects are manifested through their impact on productivity, from changes in population growth, size of labor force and its skill composition. In addition to reduction in domestic savings, external capital flow may be affected because of reduced profitability, as well as reluctance of foreign labor to move into AIDS affected regions. The epidemic may also have substantial impact on government expenditures. It will be most apparent in expenditures at the health sector, where demand for services is likely to grow. Unless governments can expand services to meet increased demand, the access to and quality of services will decline. A study of the effect of the epidemic on health care services in a Nairobi hospital indicates that as the number of HIV infected patients grew, because of crowding out, the mortality of non-HIV infected people increased by 4 more than two-thirds (Over, 1998). The government is also likely to bear an increasing share of the health costs as private firns pass the burden to households and to government (Simon, 2000). All sectors of the economy may be affected, depending on the extent to which the relevant labor force is affected. The impact on the public sector itself may be substantial, affecting the ability of government to maintain critical services in health, education and defense, for example. Labor-intensive sectors, such as mining in Africa with disproportionate number of both domestic and foreign migrants in the labor force, are particularly vulnerable. However, the evidence on whether the impacts are significant appears to be mixed (Simon, 2000). The impact of the epidemic on social and economic institutions is particularly difficult to anticipate. For example, high mortality, absence of public information, and uncertainty as to whether someone will be around and for how long may affect trust and willingness to enter into contractual relationships, which are essential for economic growth. Similarly, it is not clear what would be the social impact of a missing generation of adults on children that are neglected or even brought up in orphanages (home-based or otherwise). Despite harsh features of the epidemic - absence of sympathy for the affected, high costs of treatment and certain death - its impact in some countries may be no more significant than that of other catastrophic events. AIDS can balloon into something that can significantly erode the progress in human development made in recent years by many developing countries (Reid, 1993). Public action to control the spread of the disease and to monitor how the disease is affecting the society at various levels is therefore necessary. C. Organization The objective of this report is to provide an overview of selected likely development impact of HIV/AIDS for Namibia. The purpose is to use to the outcome of the analysis to engage in dialogue with Government, relevant stakeholders and the donor community on the appropriate actions to pursue in support of the Government's development strategy on the epidemic. This report examines the status and the likely impact of HIV/AIDS in Namibia, focusing on the likely impact on the demographics of the country and on the economy. It employs conventional demographic and economic models to analyze selected development impacts of the epidemic on the economy, thereby providing an illustration of how these impacts can be incorporated in the regular planning processes. The study was also initiated as an exercise to assist policy makers in Namibia in their effort to incorporate HIV/AIDS into the planning process on a regular basis. As such, it is directed at officials in the agencies of finance and development planning. The nature of public action required and challenges posed in responding to the epidemic are also examined. The review at this stage does not provide a detailed costing of the impact of the epidemic on various sectors of the economy because of data limitations. Detailed costing and policy design alternatives should be the focus of subsequent analysis. 5 The report is organized into five chapters. The second chapter examines status of the epidemic in Namibia, the sources of epidemiological information and the limitations of available information for examining the full range of impacts on the economy and for human resource planning. The demographic implications of the epidemic are presented in the third chapter. The impacts on the economy, focusing on likely sectoral implications are discussed in chapter four. The final chapter deals with the likely policy responses, providing some quantification of the costs associated with implementation over the next fifteen years. 6 Chapter II Status of HIV/AIDS in Namibia Monitoring the epidemic in order to understand how it is progressing and the factors that are contributing to its development is essential for the fornulation of effective strategies to control it. A key tool for doing this is the Sentinel Surveillance System (SSS), which was initiated in 1992 as the principal source of information for monitoring the epidemic in Namibia. The surveillance system entails survey of prevalence among pregnant women who visit antenatal clinics, and STD and TB patients who seek medical assistance. Antenatal clinics are usually chosen as they provide access to a cross section of healthy, sexually active women in the general population. Samples of all blood donors are also tested in Namibia, and this could also serves as sources of information.' The government also offers confidential testing; the results of which are also analyzed centrally by the MOHSS. In addition, many private firms including insurance companies test employees, job applicants or clients for HIV prevalence, but this information is not available to the public. Sentinel surveys have been conducted in Namibia at selected sites every two years since 1992. The number of sites has been increased from 8 in 1992 to 13 in 1998. A sample of 200 is taken at each selected ANC and STD clinic; the subjects enter the sample as they come until the desired number is reached. Unlike the ANC survey, the sample of STD patients includes both sexes and the sample can be stratified by the nature of sexual disease the participants suffer from. In this chapter, a review of prevalence rates observed in antenatal and STD clinics, and estimates for the general population is undertaken. This is followed by information on recorded cases of AIDS, hospitalization and deaths in the country. Information on sexual practices and knowledge of preventive measures is presented next. Finally, the last section explores the need for monitoring and discusses key features of the next- generation monitoring systems. A. HIV Prevalence Antenatal Clinics: HIV prevalence rates observed among pregnant women sampled at antenatal clinics (presented in Table 2.1) indicate that the simple mean has increased from 4.2 percent in 1992 to 17.4 percent in 1998. The median increased from 3 percent in 1992 to 15 percent in 1998. Prevalence among 15-19 year olds increased from 6 percent in 1994 to 12 percent in 1998. Among 20 to 24 year olds, it increased from llpercent in 1994 to 20 percent in 1998 (UNAIDS, 2000a). In 1998, prevalence rate ranged from 6 percent to 34 percent among various sites. ' Blood donor are representative of the general population. In 1998, 1.6 percent of blood donors was diagnosed to be HIV positive. Prevalence was 0.6 percent among regular donors and 5.5 percent among first time donors. 7 Table 2. 1: HIV Prevalence Among Pregnant Women Attending ANC 1992-1998 (In Percentage) Area Site 1992 1994 1996 1998 Rural Andara 2 11 16 Engela 7 18 17 Nankudu 13 Nyangana 6 5 10 Onandjokwe 8 17 21 Opuwo 3 1 4 6 Urban Katima Mulilo 14 25 24 29 Oshakati 4 14 22 34 Otjiwarongo 2 9 16 Rundu 8 8 14 Windhoek 4 7 16 23 District Gobabis 1 9 Keetmanshoop 3 8 7 Swakopmund 3 7 17 15 Walvis Bay 29 National 4.2 8.4 15.4 17.4 Source: Republic of Namibia: Report of the 1998 HIV Sentinel Sero Survey, Ministry of Health and Social Services, April 1999. There is wide variation among regions. In some of the urban sites such as Katima Mulilo and Oshakati fairly high levels of infection were observed in the early nineties itself. The wide variation in prevalence among regions may reflect regional differences in the timing of the first HIV incidence. At most locations, the observed prevalence among pregnant women showed an upward trend consistent with the hypothesis of an S-shaped progression in the epidemic.2 As has been observed in other parts of Sub-Saharan Africa, prevalence observed at sites in major urban areas and those outside major urban areas (rural)3 have converged, although it is difficult to distinguish between rural and urban areas as some of the survey sites serve both rural and urban residents. Extrapolation of HIV prevalence observed among pregnant women attending antenatal clinics to the general population is fairly robust particularly in populations in which virus transmission is primarily through heterosexual contacts, but attention needs to be paid to see if those who attend antenatal clinics are representative of the general population of pregnant women as well as the overall general population (UNAIDS, 2000b). The SSS excludes those who do not use public antenatal clinics. It also excludes those who use private facilities, typically those with higher incomes, and those who do not use any, typically poor rural residents without access to health facilities. Both these groups could potentially run higher risks of infection, the former because of mobility 2 HIV prevalence increases slowly during the first phase, sharply rises during the second phase, and levels off in the third phase as the number of newly infected persons equals the number of persons dying of HIV/AIDS. 3As urban usually refers to only metropolitan areas, rural areas may include some non-metropolitan urban areas. 8 afforded by their socio-economic status, and the latter because of limited access to information and lower ability to exercise control over their sexual partners or relations. Additionally, as the epidemic matures, fertility declines among those affected by the virus but this is not captured by surveys at antenatal clinics. Therefore, the observations from ANC may potentially distort the true extent of HIV/AIDS in the general population. Sampling methods adopted in Namibia also introduce biases in the ANC data. First, because of the dispersion of the population, several clinics are included in some sites (Table 2.1), thereby making it difficult to ascertain the catchments area for the site;4 second, surveys have not been done at all the sites consistently (notably, Gobabis, Nankudu, and Walvis Bay) thus making it impossible to identify trends and patterns in different communities; and finally, the sentinel sites do not necessarily correspond to the sampling frame used by the national population census, thereby making sub-national projections difficult. Table 2.2: HIV Prevalence Among STD Patients in 1998 le HIV ~~~~95% Area _S_t _ Samp 1 e Negative Positive Prvalencnc __________ ______Size_Prevalence Interval Rural Engela 96 50 46 48 38.58 Nankudu 65 47 18 28 17.39 Onandjokwe 193 125 68 35 28.42 Opuwo 58 52 6 10 3.18 Urban Katima Mulilo 178 70 108 61 53.68 Oshakati 173 108 65 38 30.45 Otjiwarongo 104 76 28 27 18.35 Rundu 199 107 92 46 39.53 Windhoek 222 123 99 45 38.51 District Gobabis 133 109 24 18 12.25 Keetmanshoop 84 61 23 27 18.37 Swakopmund 137 91 46 34 26.41 Walvis Bay 203 122 81 40 33.47 National 1,845 1,141 704 38A __ Source: Republic of Namibia: Report of the 1998 HIV Sentinel Sero Survey, Ministry of Health and Social Services, April 1999. STD Clinics: The observed prevalence rates among STD patients presented in Table 2.2 are substantially higher than observed among pregnant women. In 1998, a median of 42 percent of STD patients tested in Windhoek and Walvis Bay were HIV positive. Median prevalence from the 11 sites outside the major urban areas was 34 percent (UNAIDS, 2000a). As observed in antenatal clinics, differences in the rates among sites may be due to differences in the onset of the epidemic at different locations. However, they reflect largely the relative homogeneity of HIV prevalence rates at the 4 This is necessitated by Namibia's small population and limited coverage at each clinic, especially outside the main metropolitan areas. 9 different sites. In general, at all major urban and sites near major transport corridors, HIV prevalence was higher than 30 percent. As STD patients carry higher risk of infection, prevalence among STD population is likely to be higher than prevalence among the general population for obvious reasons. Though it is not clear whether there was adequate sampling of sexes in different age groups5, the following tentative observations can be made: (i) there are no significant differences in HIV prevalence among men and women, the rates were close to 38 percent for both; (ii) and women are infected at an earlier age than males. For example, 24 percent of women under 20 years were infected compared to only 5 percent of men; 42 percent of women between 20-24 years were infected compared to 24 percent of men in the same age group (Figure 2.1). In general, at all sites, a higher percentage of younger women (under 24 years) was infected relative to their male counterparts.6 Figure 2.1: Age Specific HIV Prevalence in STD Patients 60t -'1 iZl~ ' " 40 WWWgg-g-W 30 El EFemale- - - - 20 > > *l | _ | _ _Ma 10 <20 20-24 25-29 30-34 35-39 40-44 45+ Source: Republic of Namibia: Report of the 1998 HIV Sentinel Sero Survey, Ministry of Health and Social Services, April 1999. The difference in HIV infection rates between men and women could be attributed to the difference in the age of the first onset of sexual activity and the age difference between partners. Since the data suggest that female STD patients, on average, were younger (median age of 26 years) than male patients (median age of 28 years), this may suggest (subject to improved data) the possibility of sexual contacts by younger women with substantially older men. National Estimates: The UNAIDS/WHO working group on Global HIV/AIDS Surveillance, in collaboration with regional and national experts, derives national HIV/AIDS prevalence rates by adopting the following approach: * Available data from SSS in Namibia are reviewed and median rates calculated for "major urban areas" and "outside major urban areas". The figures are then applied to the official urban-rural population distribution in Namibia to get national prevalence data for the year in which the survey is conducted. 5In the total sample, 51 percent were males and 49 percent were females. 6Higher prevalence among STD patients is not surprising as both HIV and STD are transmitted through unprotected sexual contacts. Moreover, those affected by STD are at higher risk of contracting HIV. 10 * The WHO Epimodel 27 is utilized to derive estimates of prevalence and incidence of AIDS and AIDS deaths, as well as the number of children infected through mother-to-child transmission of HIV, taking into account age-specific fertility rates, for other years. On the basis of the above, UNAIDS estimated that 19.94 percent of adults (15 - 49 years) was living with HIV (excluding those with AIDS) in Namibia in 1999. The estimated prevalence rate among 15 to 24 year olds was 18.78 percent to 20.82 percent for females and 7.89 percent to 10.38 percent for males. The estimated total number of individuals living with HIlV/AIDS in 1999 was nearlyl60,000.8 Of them, about 150,000 were adults (15-49) and 6,600 were children. Among adults, the estimated number of women was 85,000 (UNAIDS, 2000). These estimates, for obvious reasons, are nearly three times more than the number reported by the health directorate on the basis of testing in the health system which indicated the cumulative of infection to be 53,330 in 1999. The number of HIV positive cases reported annually by the health system has exceeded 10,000 since 1996. All indications are that the epidemic is widespread in the country, as it is established in the general population. One or more sub-populations may contribute disproportionately to the spread of the virus, but it appears that sexual networking in the general population is adequate to sustain the epidemic independent of high-risk sub populations (WHO&UNAIDS, 2000). B. AIDS Cases and Deaths According to the National AIDS Coordinating Program (NACOP), which maintains information on reported full-blown AIDS cases in Namibia, HIV/AIDS has become the leading cause of death in hospitals in 1996. In 1998, a reported 2,179 deaths due to HIV/AIDS accounted for 23 percent of all reported deaths and for 41 percent of deaths in the 15-49 years age group9. The total number of cumulative reported AIDS cases by end-December 1997 was 6,784 (Figure 2.2). UNAIDS estimated that the AIDS related deaths in 1999 alone were 19,000.10 The full extent of deaths due to AIDS may not be usually captured for the following reasons: (a) many deaths due to opportunistic diseases such as TB are not likely to attributed to AIDS; (b) AIDS patients in remote rural areas with limited access to health facilities may not seek hospital services; and (c) especially in early stages of the epidemic, there may have been poor reporting of AIDS cases by health units. ' Epimodel is a microcomputer program originally developed by the WHO Global Program on AIDS to make medium (under 5 years) terms estimates of the number of persons with HIV/AIDS. 8 The estimated total adult population in 1999 was 790,000 out of a total population of 1,689,000. 9 HIV related diseases are also an increasing cause of hospitalization, estimated to have increased from 355 hospitalizations in 1993 to 5155 in 1998 (Republic of Namibia, 1999). '° RON questions these estimates on the ground that they exceed the total reported deaths in the country. 11 Figure 2.2: New and Cumulative AIDS cases in Namibia 8000 l 7000 5000 m .00 WMW g 4000 Now 3000 SCumulative 2000 _ :f| 1000 0 No" ,KOob ,9 9p 69@\ NO 9 No s 99 92 o D o 4 6 o Source: UNAIDS: Namibia - Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Diseases, November 1999. Though official records are deficient, it is clear that the epidemic is growing exponentially. Based on 1998 data, the reported new HIV cases averaged 8.3 per 1,000 population, while the corresponding rate for hospitalization of HIV/AIDS is 3.4 per 1,000 population. The reported number of deaths due to HIV/AIDS is also estimated at 1.4 per 1,000 population. These figures suggest that the epidemic is at its infancy and in the absence of corrective measures, it is likely to have a devastating demographic effect in the near future. The regional distribution of reported HIV cases, HIV/AIDS related hospitalization and HIV/AIDS deaths also suggest that the crisis is widespread (Table 2.3). Table 2.3: Regional Distribution of Reported HIV Cases, HIV/AIDS Hospitalization and HIV/AIDS Deaths (Rate per 1,000 Population) in 1998 Region Estimated HIV/AIDS Reported RegiOn Population New HIV Cases Hospitalization HI V/AIDS Deaths Caprivi 107489 2.6 1.4 0.9 Erongo 99109 9.6 1.4 0.9 Hardap 61461 6.3 2.9 0.8 Karas 56447 12.3 2.4 1.4 Kavango 110313 6.1 5.2 2.4 Khomas 183155 20.3 5.0 1.6 Kunene 67480 2.6 0.7 0.2 Ohangwena 230023 4.3 2.2 0.9 Omaheke 52267 4.3 0.3 0.4 Omusati 193926 2.9 4.2 1.7 Oshana 171090 12.3 5.6 2.4 Oshikoto 111244 10.0 4.0 2.0 Otjozondjupa 92041 8.8 3.0 1.0 Total 1536045 8.3 3.4 1.4 Source: Government of Namibia - Epidemiological Report, 1998 (unpublished). 12 C. Sexual Practices and Knowledge As the epidemic is spread through certain sexual practices that expose individuals to risks of infection, information on sexual practices is a fairly good indicator of the course of the epidemic. The development of the epidemic cannot be effectively monitored based on prevalence rates alone, as they are not good indicators of recent trends in risky sexual behavior (UNAIDS, 2000b). Monitoring of sexual practices also helps in identifying risk groups and risk situations, which is essential for analyzing the epidemic using models that incorporate more realistic modes of transmission. Needless to say, such informnation is also essential for designing and targeting effective communication and other strategies to change the behavior of those that are at risk. In this context, this section focuses on two issues relevant for the spread of HIV: (a) sexual behavior and partnering practices; and (b) knowledge of preventive measures. Sexual Behavior and Partnering Practices: Existing studies suggest that the factors that have contributed to rapid spread of the epidemic in some Africa countries are: (a) high level of sex outside marriage, either through multiple partnership or prostitution, (b) high level of STDs and (c) low levels of condom use (Caldwell, 2000). One of the peculiarities of communities in Africa is that there are different degrees of commercialization of sexual relations, which may not be restricted to only a section of the population (typically sex workers) but widespread within the sexually active population. As these practices are likely to vary from one area to another, it is useful to have country/region specific inforrnation. The three key indicators of behavior are number of sexual partners, condom use especially in casual sex, and age of first sexual inception (UNAIDS, 2000b). Additional useful indicators are sexual coercion, age disparity, STD symptoms, alcohol consumption (precursor to risky behavior) and the number of sex acts, mobility and sexual partnership networks. There is limited information available for Namibia on these indicators. Two sources, the 1992 DHS and 1994 Census, suggest that the age at which first sexual experience takes place is decreasing. In the 1992 health survey, 20-24 year old females reported that the median age at which they had their first sexual experience was 18.7 years, while the 45-49 year olds indicated that it was 20.1 years. That is, in about 20 years, the age at which females had their first sexual experience had declined by 1.4 years. This result is also supported by the findings of the 1994 Census. The median age for first sexual intercourse was 19. However, 7 percent of women had become sexually active by 15 years and 37 percent by the age of 18 years. Women with no formal education became sexually active about 2 years earlier than women with secondary or higher education (Tjapepua and Magari, 1994). The above indicates that first sexual contacts are taking place at progressively younger age consistent with trends in other 13 African countries." A consequence of the early sexual contact among women is high level of adolescent pregnancy (Figure 2.3). The 1992 DHS indicated that about 36 percent of teenage girls aged 18 years and 26 percent of teenagers aged 15-17 years had already given birth or were pregnant with their first child. Early childbearing was found to be most common among teenagers with no formal education. Almost half of these teenagers had a child or was pregnant compared to 20 percent of teenagers with some formal education. The percentage of teenagers aged 15, 16, 17, 18 and 19 years, who were either mothers or pregnant with their first child, were 1.3, 6.3, 18.7, 36 and 45.4 (UNAIDS, 2000). Figure 2.3: Adolescent Pregnancy (Percentages of teenagers 15-19years who were mothers or pregnant with their first child) 501 -5-7i77 40- 20 15 16 17 18 19 Source: Namibia - DHS, 1992 Knowledge of Preventive Measures: Several studies indicate that knowledge of sexually transmitted diseases (STD), particularly AIDS, is widespread among the population in Namibia. Despite knowledge of the disease, many people continue to indulge in risky behavior (RON, 2000a). A survey to assess the impact of two major media campaigns showed that more than 80 percent of the respondents had heard or seen them. Nearly 60 percent of the respondents discussed with others about what they had seen or heard. More than 90 percent of the respondents considered AIDS to be a serious problem in the region. They also had knowledge of the level of prevalence, although men underestimated its impact. However, only 2 out of 3 men and 3 out of 4 women knew that infected persons would eventually die. Knowledge of preventive measures is also widespread. Nevertheless, a 1992 study of females indicated very limited use of condom. Only 5.5 percent of the adult females aged 15-49 indicated having ever used condoms, with the highest percentage use of 8.2 percent in the 25-29 years age group and the lowest of 1.7 in the 45-49 years age group l A KABP study for Lesotho for the same year (1998/90) found that the mean age at first sexual intercourse, by current age of respondent was 20.1 years for the 45-49 years age group, but 18.7 years for the 25-39 years age group, and 17.5 years for the 20-25 years age group (NACP/WHO, National KABP/PR Survey on AIDS, 1990. 14 (Figure 2.4). Though people are aware that AIDS is sexually transmitted and one is likely to get infected by maintaining multiple sex partners or participating in unsafe commercial sex, the awareness does not seem to have lead people to make realistic assessment of their own risk of contracting the disease. In a recent survey less than one half of the respondents felt that they ran the risk of contracting the disease. A significant portion of those who did not think that they had any risk of contracting the disease is believed to include those who usually engage in risky behavior (Ron, 2000a). Figure 2.4: Namibia - Percentage of Female who Ever Used a Condom 81, 2 - .:lo oM, * - ' - 6. 'A g; ...;,,. l W. '40W 1 1 h 1 - 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Source: Namibia - Demographic and Health Survey, 1992 D. Need to Improve Monitoring The present surveillance system provides basic information to monitor changes in the epidemic at the country level, but it is inadequate to understand why the epidemic is developing the way it is, and to design effective strategies to control its spread. An understanding of who is at most risk in the country and which behavior puts them at risk is fundamental to controlling the epidemic. A "second generation surveillance system" that focuses on getting information that is most useful to reduce the spread of HIV and provide care for those that are affected is needed (WHO&UNAIDS, 2000). The existing system does not track risk behaviors that provide warning signs of the spread of the disease as they record infections that have already taken place. Systems what provide early warning should record risk in addition to actual infection. Increasing emphasis needs to be placed on making surveillance useful for targeting and designing interventions and assessing their effectiveness. For improved monitoring, SSS needs to be combined with regular behavioral studies and population or sub-population based sero-surveys that also collect socio- economic information. There are significant benefits to be had from combining epidemiological data with behavioral and socio-economic data. Epidemiological data need to be combined with behavioral data to understand trends in prevalence in mature epidemics (WHO&UNAIDS, 2000). Population or sub-population based sero-surveys in combination with epidemiological and behavioral infornation provide useful information for assessing the likely impact of the epidemic on households and important sectors of the 15 economy. Monitoring systems using a combination of tools and sources of information can offer a multidisciplinary understanding of the causes and consequences of the epidemic that will place the government in a better position to anticipate consequences, assess its role, and take appropriate timely action. Repeated behavioral studies are central to second-generation surveillance systems, as they are useful to track changes in exposure to risk. Biological and behavioral data should be used to validate one another and to demonstrate which risk behaviors continue to drive the epidemic and identify possible areas of intervention to break the chain of transmission (WHO&UNAIDS, 2000). For example, stabilization of prevalence in generalized epidemics is not necessarily due to reduction in incidence. Second generation monitoring systems that include repeated behavioral surveys could help in better understanding as they offer information necessary to examine links between trends in behavior with trends in prevalence. Monitoring could also focus on lower age groups where HIV prevalence most reflects incidence. Cross section sero-surveys provide critical additional information. They can be useful in indicating sources of biases in sentinel populations. Therefore, they are integral aspects of research on biases in antenatal estimates. Their results should be used to calibrate the results of routine surveillance systems. Population based sero-surveys are also an important tool for estimating the relationship between HIV infection levels in men and women (WHO&UNAID, 2000). While they need informed consent, working through NGOs and other organizations engaged in prevention of HIV transmission and linking them with provision of services can reduce non-response rates. Surveillance can then become an integral part of control and mitigation, not just an independent exercise. Finally it is necessary to recognize the multi-sectoral and multi-disciplinary nature of the epidemic and develop multiple sources of information. For example, in generalized epidemic, monitoring mortality and morbidity is also important to help plan for services and orphan support. Information on mortality is critical for validating prediction models. It is, therefore, useful to put together an information system that goes beyond meeting merely the epidemiological needs. 16 Chapter III Demographic Impact of HIV/AIDS Examining demographic consequences of the epidemic is the first step in making a comprehensive assessment of its likely impact on various sectors of the economy. A number of models are available to examine the growth of the epidemic itself and its impact on demographics.' Common to all the models used in analyzing the demographic impact of HIV/AIDS is a two stage estimation framework: first, the models estimate the annual incidence of AIDS on the basis of recent estimates of HIV prevalence; second, by making assumptions about the probability of progress from HIV infection to AIDS and from AIDS to death, estimates of the annual number of deaths caused by AIDS are obtained. The growth of HIV infection is usually based on the hypothesis that many growth phenomena (especially of epidemics) in nature show an "S" shaped pattern, with initially slow growth speeding up before slowing down to approach a limit. The models that can be tailored to conditions in different countries by incorporating some of the unique features of transmission of the virus place more demands on the data requirements. The ASSA model, for example, requires classifying the population into various risk categories and specifying the nature of interactions and movements that may take place between them. Because of data limitations the discussion in this chapter is based on DemProj a sub-model of the Spectrum models2 with tentative results from the ASSA model, and compared with projections made by US Bureau of Census, and the Ministry of Health and Social Services (MOHSS) of the Govermment of Namibia.3 The projection model was initialized with 1981 population census data, and calibrated by comparing the projections for 1991 with the 1991 census. The prevalence is assumed to grow in proportion to HIV positive cases reported by the Directorate of Health, Namibia to reach 19.9 for 2000, and increase to 25 by 2015 (Annex I). The projections are based on a scenario in which the prevalence rate will reach 25 percent of the adult population in the absence of substantial action, not an unreasonable assumption given the experience of neighboring countries. Projections have been made for the period 1981-2015. This chapter focuses on the likely demographic effect of the epidemic and its implications for the overall availability of labor in the economy. The first section discusses the likely impact of HIV/AIDS on the general population and uses the result in the second section to evaluate the likely effect on human resource development in Namibia. The concluding section stresses that in the absence of timely intervention, the I Some of the models available are the Edelston's simple AIDS model, the Logistic curve model, UNAIDS' Epimodel, the Wilkie's Actuarial model, the IwgAIDS model, the Actuarial Society of Southern Africa (ASSA) model and a simplified blend models such as the Spectrum of the Futures group International. 2 The Spectrum Models were developed by the Policy Project, a United States Agency for International Development (USAID) funded project implemented by the Futures Group International. Two sub-routines, DemProj and the AIDS Impact Model (AIM), were used for the projections discussed in this study. 3 The US Census Board uses the IwgAIDS model and MOHSS estimates are made by using AIMS model. 17 public sector which is a major employer in Namibia would be unable to meet its development on account of staffing constraints. A. Impact on General population The following section assesses the impact of HIV/AIDS by considering the demographic variables such as total population size, additional deaths due to AIDS, crude death rate, infant mortality, and life expectancy at birth. The impact of HIV/AIDS on the demography of Namibia is assessed by comparing the projections that make allowance for the impact of AIDS with estimates and projections that hypothetically exclude AIDS. The discussion uses the information generated by the Spectrum Models, with comparative reference to the results generated by other studies. Two scenarios are provided, the With-AIDS scenario, which is the basis of discussion, and a hypothetical No-AIDS scenario, which is used for the purposes of comparison. Table 3.1 assembles the estimated indicators using the DemProj, with comparative estimates for the ASSA and other models. Table 3.1: Summary of Selected Demographic Impact of AIDS Indicator DemProj MOHSS ASSA Model USBOC 1991 2015 1991 2021 1999 2015 1998 2010 Population _ With AIDS 1.4 2.3 2.59 Without AIDS 1.4 2.9 1.41 3.49 Population growth rate With-AIDS 3.2 1.6 1.4 2.3 0.7 1.6 1.2 Without AIDS 3.3 3.0 2.1 2.9 2.8 Crude Death Rate _ With-AIDS 12.3 19.6 15 18.26 19.8 21.9 Without AIDS 11.9 7.4 5 11.67 6.54 7.5 5.2 Infant Mortality Rate With-AIDS 72.9 57.4 46 43.2 32.1 66.8 57.2 Without AIDS 72.9 54.6 29 29.6 17.7 44 28.3 Child Mortality Rate With-AIDS 115.6 98 75 125.5 118.8 Without AIDS 113.2 66.9 36 62.1 37.5 Life exp. At Birth _ I. With-AIDS 56.9 38.5 46 56.9 44 41.5 38.9 Without AIDS 58.4 65.6 . 70 61.6 65 65.3 70.1 AIDS Deaths (annual) 392 28,213 . 20,000 3,686 25,811 _ Orphans 15,432 . 190,000 Sources: DemProj & ASSA: (Annexes I and II); MOHSS: Projecting the impact of HIV/AIDS in Namibia (October 2000); USBOC: World Population Profile: 1998. Life Expectancy: The primary demographic impact is a reduction in life expectancy at birth (LEB), an indicator of human development as it reflects higher chances of surviving childhood and a longer, and possibly, a healthier adult life. The 1981 & 1991 census indicate that LEB has already fallen in Namibia from nearly 58 to 55. According to MOHSS projections, in the absence of AIDS, Namibians could have 18 expected to achieve an LEB of nearly 70 years by 2021. As a result of AIDS related mortality of young adults, they can expect to live for 46 years (Table 3.1). There is a reasonable consistency by all four estimates that LEB will decline substantially in Namibia in the absence of policy to deal with the impact of HIV/AIDS. Population size and growth: The rate of population growth was expected to fall to about 3 percent by 2015, only a marginal decline from the observed rate of around 3.2 percent in 2000. Because of increased AIDS related mortality, the rate is projected to decline to 1.6 percent by 2015 (Fig. 3.1). The size of population is therefore projected to be 0.6 million smaller. In comparison, estimates by MOHSS indicate that Namibia in 2021 will have nearly 0.9 million people less in 2021 than it would otherwise have (RON, 2000). As growth in population continues to be positive, the population will not shrink. The decline in growth rate takes place as a result of significant changes in mortality indicators and marginal changes in fertility. Figure 3.1: Population Growth With and Without AIDS Annual Population Growth Rate 3.5% .............. 30% Wth AIDS 2.5% o 2.0% 1 .5% 5 =e. 1.0% 't': S 'S ' ! Xe ^- t Mortality Indicators: The annual number of Namibians expected to die from AIDS is projected to reach nearly 28,000 by 2015. The cumulative number of deaths due to AIDS will reach nearly 335,000 by 2015. Similarly, MOHSS estimates that annual AIDS death number would reach half million by 2020. The Crude Death Rate (CDR), which was projected to decline to about 7 per 1,000, may decline to only 20 per 1,000 by 2015, about three fold higher. The bulk of the deaths would be young adults (15-49 years old). The number of young adults projected to die due to AIDS in 2015 would be nearly 27,500 compared to about 4,500 in the absence of AIDS. Both infant and child mortality rates are expected to decline at a lower rate than without AIDS (Table 3.1). It is estimated that approximately one-fourth to one-third of the children born to HIV-positive mothers are likely to acquire infection from their mothers. A significant proportion of them would die in the first year of birth. With 19 improved access to health care, infant mortality could have been expected to decline to 55 in the absence of AIDS, but with AIDS it would fall to about 57 per 1,000. Similarly, child mortality rate is projected to fall to only 100 per 100,000 with AIDS instead of nearly 70 per 1,000 without AIDS. The magnitude of the impact of AIDS on both child and infant mortality would depend on the extent to which Namibia would have succeeded in reducing new infection of HIV. In addition to significantly increasing mortality particularly for young adults, AIDS reduces population growth rate by lowering fertility as well. The crude birth rate (CBR) could have been expected to fall to 36.2 per 1,000 by 2015. It would instead fall to 35.2. Fertility may come down for a number of reasons: (i) because of higher death among young adults, many women would die before they complete their childbearing age; (ii) fertility is also reduced among women who are affected by AIDS; and (iii) wider use of condoms to prevent transmission of the virus could also reduce a significant portion of unplanned pregnancies. Population Structure: Although AIDS reduces the population growth as sought in population and human development strategies of the country, it does so in perverse ways. In the desired form of demographic transition, the demand for children is brought down through improved education, particularly of women, and reduced infant and child mortality rates. Fewer children that are born receive greater investments in their development. As the adults also live longer the size of the older population also increases. The population profile begins to look more like a column than a pyramid as the number of children in the population is reduced and the number of very old people is increased. In the case of AIDS-induced transition, on the other hand, child and infant mortality rates do not fall as much, crude birth rate does not fall significantly, but population growth rate is reduced by higher mortality of young adults. With a small decline in fertility, the base of the population pyramid tends to shrink making the profile look like a chimney (Fig. 3.2). The middle of the pyramid may also shrink substantially depending on the extent of adult deaths. The demographic transition brought about by HIV/AIDS may have a number of consequences. A smaller economically active population may have to take care of the very young and the very old (UNAIDS, 2000) and may have profound effect on pension schemes (Chapter IV). Family and community structure may be affected significantly. More than 10,000 children will be orphaned annually, an estimated 15,000 in 2015. Another possible outcome is that men may outnumber women. A more serious consequence is what the change in population structure does to individual expectations. A fifteen-year male or female would face almost 90 percent chances of dying of AIDS by the time he/she is 40 years old. 20 Figure 3.2: Population Profile in 2015, With and Without AIDS 75-79 60-64 45-49 *.WAIDS l 5 ,,. ..........-.... - .jJ .*WOIDS 30-34 _ 15-19. ^ - -A---: 0 10000 20000 30000 40000 50000 60000 0 0 0 0 0 0 B. Implications for the Labor Force In 1991, 58 percent of the population 15 years and above was economically active and about 47 percent was employed. Unemployment, which also includes underemployment, has been growing since independence from less than 33 percent in 1994 to almost 35 percent in 1997, and continues to be a problem. This is mainly because manufacturing employment has been growing slowly, while agriculture, mining and fishery are actually shedding labor rapidly. Employment in the mining industry, which contributes 12.5 percent of the GDP, fell during the 1990s. In general the number employed fell from 12,000 in 1990 to 5,000 in 1999. Skill shortage is also a major problem. An estimated 10 percent of all the positions are filled with people less skilled than the positions require, or not filled at all. Businesses indicate that after lack of capital and inadequate market, the lack of skills is a key reason for not expanding their operations. As a result, the country depends on imported labor: nearly 18 percent of senior officials and 14 percent of professionals are non-Namibians (World Bank, 1999). The skill shortage is expected to continue particularly in science and technology and engineering. Though substantial investments have been made in education in recent years, there is concern that the system is not designed to strengthen industrial and entrepreneurial skills and also instill work culture. Given that the economy can barely keep up with the growth in labor force and high levels of unemployment, a shrinking of the labor should not affect the economy. But the present skill shortage and prevalence of the virus among the skilled and the educated is likely to affect the economy despite the large number of people in the labor force. The projected gap in the labor force as a result of AIDS related mortality is estimated to be 21 nearly 20 percent by 2015. Those lost by the labor force are likely to include both skilled and unskilled exacerbating the prevailing skill shortage and high wages (Figure 3.3). Figure 3.3: Labor Force, With and Without AIDS Size of Labor Force 8 50,00 0 750,000 650O000 0 With AIDS 550,000 -u-N D 450,000 350,000 250,000 14; e'b eR6 Nb7 loO ,4O le,0 4`0X ip0 5 lo') C. Conclusions Although it is not possible with existing data to analyze the likely magnitude of the skill gap that would emerge in the presence of HIV/AIDS, the impact of the epidemic on the demography of Namibia appears to be substantial: * It is estimated that by 2015, Namibia's population would be around 2.3 million, about 21 percent lower than it would have been in the absence of AIDS. The results indicate annual AIDS deaths increasing from 329 in 1991 to over 28,000 in 2015. Closer examination of the data reveals that by the 2015, the number of adult (15 - 49 years) AIDS deaths may far exceed the number of normal deaths (without AIDS). Majority of the AIDS deaths is expected to fall on the 15-49 years age group, the most sexually active and in the prime of their productive years. As a result of the increasing mortality due to AIDS, life expectancy at birth has already stagnated in Namibia and the trend is likely to continue through 2015. Life expectancy is estimated at 43.1 years for 2001, instead of 61.4 years in the absence of AIDS, a loss of almost 18.3 years over the past decade. By 2015, the difference in life expectancy, with and without AIDS, is projected to reach a staggering 27.1 years in the absence of preventive programs. * Preliminary analysis of the impact of HIV/AIDS on the labor force suggests that AIDS death is likely to exacerbate the skill shortage in Namibia. While the existing data did not permit a detailed analysis of skill gap, the projected gap in the labor force as a result of AIDS related mortality is estimated to be nearly 20 percent by 2015. A substantial share of this gap could be in the skill category. Failure to deal with the skills shortage could exacerbate Namibia's growth constraints. 22 Chapter IV HIV/AIDS and the Economy Attaining high growth is the fundamental challenge for Namibia as nearly one half of the population lives at or near the poverty line and over 35 percent of the labor force is unemployed (World Bank, 1999). But the performance of GDP has been disappointing since 1994 as it grew at 2.6 and 1.8 percent in 1996 and 1997 and dropped to 1.5 percent in 1998, rates much lower than 3.1 percent at which the population is increasing. Unlike the 4.4 percent growth in the first half of the decade, average annual growth rate was 2.8 percent during 1995-99. While growth increased to nearly 6 percent in 2000 because of a surge in the mining sector from a discovery of new mineral deposits, Namibia needs to maintain a growth rate of 4.5 percent per year to maintain current unemployment levels. With recent levels of growth, the average Namibian is becoming worse off. It is within this background that likely impact of HIV/AIDS on the economy in the next decade or so could be so devastating. This chapter examines the likely economic impact of HIV/AIDS in Namibia. The AIM model is used to demonstrate how AIDS could potentially affect the growth of GDP and impact on the performance of selected productive sectors. The impact of HIV/AIDS on the key macroeconomic fundamentals are analyzed along with discussion on likely factor that need to be monitored. A. Macroeconomic Impact Modeling the Macroeconomic Impact: The impact of HIV/AIDS on macroeconomic fundamentals is much more complex than that of the demography. Because HIV/AIDS is associated with major transformation of the demographics of a country, including skilled labor configuration, it may be concluded that high and rising HIV prevalence rates and AIDS deaths are likely to have significant effect on production and productivity in the productive sectors and subsequently on growth (Anderson, 1991 and others). However, because of the presence of surplus labor and differential wage rate changes, in various labor categories as a result of the epidemic, the choice of techniques in production may likely shift the relative prices of the factor of production and thus the effect on growth becomes ambivalent. From the macroeconomic perspective, HIV/AIDS is likely to affect the savings/investment relations. Since expenditures for mitigating the impact of HIV/AIDS at both the household and public sector are likely to reduce the amount of capital (both public and private) available for more productive investment, in the absence of external inflows, the higher the proportion of care financed from savings, the larger the reduction in growth resulting from the epidemic. In recognition to the above, two approaches have been adopted in the literature. The first uses a growth model extended to incorporate the increase in morbidity and mortality resulting from HIV/AIDS (Cuddington, 1992; Over, 1992, and others). The model incorporates, among other parameters, labor productivity losses and AIDS costs met from reduced savings. The second uses a Computable General Equilibrium (CGE) model 23 in which the labor market incorporates various labor skill categories (Kambou, Devarajan and Over, 1992). Adopting the growth model approach for Namibia', the following issues are discussed. Savings, Investment and Growth: Namibia's growth depends on investments and higher productivity. Namibia has a positive national savings/investment balance. Savings are satisfactory at about 25 percent of GDP, but investments lag behind savings. Private savings cannot find profitable domestic investment opportunities; thereby the bulk of the savings move out of the country. Much of the investment goes into replacing existing capacity. Both public and private investments have fallen since 1997. There is complimentarity between government and private investments although Namibia has fairly well developed infrastructure. Further decline in government investments may discourage private investments as well. Government spending is already at the level of the OECD countries, and much higher than those of neighboring countries. Much of the spending is on consumption, mostly in terns of wages to the relatively large public sector. The country has one of the largest civil services in the world, supported by Government expenditure of nearly 40 percent of GDP. Relatively low returns to investments caused by low productivity in certain sectors may be a factor in driving savings out of the country. This is so despite the fact that the economy is competitive in terms of infrastructure, investment regulation and tax incentives. But high wages make Namibian labor uncompetitive, with wages in the formal sector growing much faster than inflation. A 1994 survey indicated that the wages in Namibia are higher than in comparable neighboring countries except for South Africa (World Bank, 1999). But the level of skills may be somewhat higher in South Africa. The same survey indicated that unit costs were higher too, as much as they are on South Africa. Loss of skilled labor force on account of HIV/AIDS could further increase costs affecting profitability in the private sector. To the extent that AIDS has impact on savings, availability and skilled labor and profitability in the private sector, the impact on economic growth would be significant. Private and public expenses on control and mitigation are likely to reduce investments. Using the AIM model, it is estimated that the gap in investment/GDP ratio is likely to increase from 0.1 percentage point in 2000 to 0.7 percentage point in 2015. In 2015 for example, the ratio will be 22.8 percent of GDP instead of the 23.5 percent it would have been in the absence of AIDS (Table 4.1). GDP growth rate. Based on an optimistic assumption about the medium to long- term (World Bank, 1999), it is estimated that in the absence of AIDS, GDP would grow at about 3.5 percent, approximately at the rate of population growth. Over the recent past, it was only in 2000 that the rate of actual growth has exceeded 3 percent. With decreased investments and productivity on account of HIV/AIDS, the rate of growth is projected to be lower (Figure 4.1). By 2015, the rate of growth would be 2 percent instead of the 3.5 percent that could have been expected in the absence of AIDS. 1It is not possible to construct a CGE model for Swaziland because of data limitations. 24 Figure 4.1: Namibia - Gross Domestic Product (With and Without AIDS) Gross Domestic Product 36,000 , -e 32,000 _ 28,000 _ 2 24,000 F . ~~~~. ~~~~~~~~ *A4 ~ ~ ~ ~ ~ WthAD 20,000 16,000 jM--4;j..;f o>-0e 12,000 - 9¢ ',,''.' . ,', .'.,s..r9 , Finally, the rate of per capita growth in GDP would have declined even in the absence of AIDS as economic growth has not in the past kept pace with population growth. With AIDS, it would decline further. However, there is the possibility of some upward adjustment in per capita GDP at the end of the projection period if the population growth declines at the anticipated rate. Table 4.1: Indicators of Macroeconomic Impact of HIV/AIDS (in Percentage) 2001 2005 2010 GDP Growth Rate With_AIDS 3.5 3.1 2.6 2 NoAIDS 4.3 4.2 3.9 3 Investment/GDP With_-AIDS__ 23.3 23.2 23.1 22.8 No-ATDS 23.5 2935 23.5 23.5 GDP Per capita Growth With-AIDS 1.2 1.3 0.8 0.4 Rate I__ _ _ _ _ _ No-AIDS 3.0 1.1 0.8 0.5 Comparable estimates for Tanzania suggest that the economy would be between 15 to 25 percent smaller in 2010 because of the epidemic (Cuddington, 1992). Furthermore, a study of 30 sub-Saharan countries (Over, 1992) concluded that the net effect of the HIV/AIDS epidemic is likely to be a reduction of the annual growth rate of GDP of 0.8 to 1.4 percentage points per year and a 0.3 percentage reduction in the annual growth rate of GDP per capita. Table 4.1 summarizes the net effect of HIV/AIDS in Namibia with respect to GDP growth, per capita income, and investment rates for both the With-AIDS and No- AIDS scenarios. 25 Although the macroeconomic effects of HIV/AIDS do not appear devastating, the impact is not uniformly felt across households. At the household level, HIV/AIDS morbidity and death exacerbates poverty and social inequality. Lower income households will be less able than others to cope with the medical expenses and other impacts, including loss of income. The loss of social capital and the resilience level of the house are two key areas requiring policy focus. B. Impact on Selected Sectors Depending on the nature of labor force employed in the sector, some sectors may be more affected by the epidemic than others. The key factors are the skill level of the labor force in the sector, which suggests the difficulty associated with replacing those affected by AIDS, and the vulnerability of the sectoral labor force to HIV infection which may be indicated by the socio-economic characteristics. In this section, we examine the impact on the pension sector, civil service and review information on potential impact on other sectors. This study uses age-based prevalence information to examine the likely impact on the pension system, civil service, education and private sectors.2 It is important to note that it is necessary to have information on how the risk of acquiring HIV do vary among population working in different sectors based either on behavioral or sero-surveys. In the absence of such information, it is assumed, for example, that prevalence among civil servants is no different from the general population, although in reality there could be substantial differences. Selective testing in South Africa, for example, has indicated that prevalence in the mining industry is estimated at 40 percent while for the general population it is slightly above 20 percent (Elias, 2000). Assumptions on the basis of widely held beliefs that AIDS is restricted largely to migrants, truck drivers and prostitutes, may therefore lead to serious errors. Pension Schemes: Namibia's social security and welfare system includes a universal, non-contributory social pension scheme (SPS); a pension fund industry, which caters primarily to voluntary participants and civil servants; the maternity, sickness and death (MSD) insurance for registered employees; and a host of family allowances, work related transfers and housing programs. Besides the formal arrangements, the extended family in Namibia provides an informal safety net, which plays an important residual role. The formal contributory system has limited coverage: only about 120,000 of an estimated 500,000 economically active Namibians are covered by contributory schemes. The rest of the population relies on the SPS, which is currently assessed by about 125,000 individuals. Recent studies indicate that the SPS is poorly targeted and is associated with prohibitive administrative costs. About half of the existing beneficiaries cannot be considered poor as most live in the urban areas, while majority of the poor in Namibia live in the North where coverage is limited. The proposed 1999 pension scheme envisages a pay-as-you-go (PAYG) system where a contributor could retire with 15 years of contributions at the age of 60 years. The objective is to redistribute income by providing benefits that account for a large share of the wages of the low income compared to that of high income workers. Initial calculations 2 These sectors were selected because of availability of some data to permit discussion. 26 by the Government indicate that contributions of about 4.2 percent of gross wages should be sufficient to make the scheme financially viable and be able to cover, in addition to retirement benefits, survivors and disability benefits. The benefits would be a minimum pension of N$ 240, and would over time provide for up to a maximum of 80 percent of the wage base, with a cap on pensionable wage at N$ 4,500 per month in 1998 Namibian dollars. In order to analyze the impact of HIV/AIDS on the pension system, a longer period is required than used in this study. Using the World Bank's projection program meant for this purpose (PROST),3 Namibia's population is projected to grow from just above 1.6 million in 1998 to approximately 4.1 million by the end of the simulation period of 80 years. The simulation exercise indicates that the population would age rapidly with the old age dependency ratio rising more than three times over the stipulated time horizon. This implies an increasing retirement burden on the working age population. The projections assume that total fertility rates would decline from approximately 4.9 percent in the base year to about 2.2 percent by the year 2040. AIDS is likely to have a major impact on the population projections, and on the affordability of the proposed pension plan by Government (World Bank, 2000). The impact of AIDS is captured in the assumptions about mortality rates based on UNAIDS data which show HIV prevalence estimated in excess of 20 percent in 1997. The impact of AIDS is modeled by analyzing the change in the incidence of new HIV infections. On the basis of the rate of change in infections, future prevalence of HIV can be derived. Projecting mortality from a given HIV prevalence level is done in a fairly straightforward way. It is assumed that there is a 9-year lag between infection and death; future medical advances might quite possibly result in a higher lag. In the absence of any statistical data, it is assumed that there is no impact of AIDS on fertility though there is some evidence that HIV positive women are likely to have lower fertility. However, the magnitude of the reduction is unknown and thus unlikely to be significant on mortality. If there is an effect on fertility, it will also mean that there would be fewer children infected through mother to child transmission, which may mean that the effect on life expectancy (which is heavily influenced by young age mortality) may not be as big. The primary impact of AIDS is the decline in the rate of increase in life expectancy and an increase in the crude death rate. On one hand, the reduction of life expectancy implies that individuals might receive pensions for a shorter length of time. On the other hand, however, since most of the impact of AIDS is concentrated on the working age group, there would be a loss of revenue and an increase in the number of survivor pensions. The latter would tend to inflate pension expenditures. In order to simplify the analysis, the likely effect on productivity of the whole economy are neglected, although it is recognized that the most productive members of society are most likely to contract HIV, with negative implications for the growth in GDP. The demographic projections indicate that the high HIV/AIDS prevalence rate in Namibia may lead to undue upward pressure on pension expenditures. Table 4.2 and 3 PROST (Pension Reforrn Options Simulation Toll-kit) has been developed by the Bank as a tool to analyze pensions issues. Refer to Namibia (2000). 27 Figure 4.2 illustrate the possible long-term impact of HIV/AIDS on the basic demographics of Namibia during 1998 and 2057 derived from the PROST model. They indicate that population pyramid for 1998 is projected to be radically transformed by 2075. As a result of the momentum of rapid population growth, close to 50 percent of the population in 1998 was below 15 years of age. HIV/AIDS is expected to reduce fertility, increase mortality in the critical productive and thus result in a bulge in the middle age groups by 2075. The demographic projections thus indicate a steady increase in the old age population dependency ratio and an increase in pension spending. The implications of the projected demographic changes are largely to be felt on the financial viability of the proposed pension program. In general, using existing pension schemes as safety nets in an environment of high HIV/AIDS prevalence does not seem to be prudent policy strategy. Special safety net programs needs to be develop to handle the income distribution implications of HIV/AIDS. Table 4.2: Summary of Long-term Demographic Indicators 1998 2010 2040 2075 Total Population (million) 1.7 2.0 3.2 4.2 Old Age Dep. Ratio 11.1 2.0 3.2 4.2 Life Expectancy at Birth (m/f) 53/55 57/59 66/70 76/83 Life Expectancy at2O (m/f) 42/44 44/46 50/54 57/64 Life Expectancy at Retirement - age 60 (m/f) 14/16 15/17 18/21 21/26 -Total Fertility Rate (m/f) 4.9 3.6 2.2 2.1 Source: World Bank Simulations (PROST model) Figure 4.2: A Young Though Rapidly Aging Population and the Uncertainty of AIDS M I, 28 Public Service: In Namibia, the public sector comprises the central government, regional and local government, public enterprises, public financial institutions, and a number of accounts and funds under control of the state. The public sector is a major source of employment and a major contributor to GDP. According to the 1991 population census, 23 percent of the population was employed in the public sector. In 1998, the contribution of the public sector and other services to GDP was nearly 27 percent. After independence in 1990, 11 ethnic administrations were consolidated into one national public service. Since then, employment in the public sector has grown as departments have been expanded and ministries have been added to take on new national responsibilities. The number of posts in the public sector has expanded from little more than 60,000 in 1991-1992 to nearly 79,000 in 2000-20001. Personnel expenditure in 2000- 2001 was 44 percent of the main budget. Of this, nearly 20 percent was allocated to the Ministry of Basic Education, Culture and Sport and 15 percent to the Ministry of Health and Social Welfare. In 1999-2000, there were nearly 75,000 filled positions. Leaving out the police, defense and special security, there were nearly 31,000 public servants. At independence, there was substantial gender bias in the composition of the workforce as there were 78 percent males to 22 percent females. This has changed over the years as many more women have been hired into non-management positions. A 1999 sample suggests a ratio of 66 percent male to 34 percent female. Women are concentrated in ministries of Women's affairs and child welfare, Basic education, culture and sports and health and social services. The civil service positions can be categorized into non-management, intermediate and management positions. The management level which includes deputy directors, chiefs, directors, under-secretaries, deputy permanent secretaries, permanent secretaries and secretaries to the president, prime minister and the cabinet (Grades 4A-C, 5A-B, 6A-C) account for 8 percent of the positions in the civil service. Intermediate posts which include chiefs, principals, or in specific technical areas, such as geophysicists, pilots and medical officers (Grades SP2, AP3, 3A-B) account for 17 percent of the posts. The remaining 75 percent of the posts is non-management, which includes cleaners, messengers, assistants, clerks, drivers and typists (GradesIA-C, 2A-C). A number of features of the current (1999/2000) civil service make it vulnerable to disruption through loss of manpower: * Based on a sample of 7400 civil servants, about 80 percent had less than five years experience and only 6 percent with more than 11 years of experience. Because of the disparity, even without the impact of AIDS, there would be shortage of upper management staff when the present generation retires. * About a third of the civil servants is under 35 years of age; while about another third is accounted for by staff aged 35 - 44 yeas. Thus, a large share of the public service fall into the highly vulnerable group for HIV infection. 29 * A significant portion of the labor force with limited experience is made up of young adults in the age groups 20 - 30 and 30 - 40 years, who have high risk of contracting HIV. Given the youthful age of the civil servants and their predisposition for high sexual activity, the service is likely to lose a significant number of its members in the absence of timely intervention, assuming that they have same risks as the rest of the general population. As the skills gap would have led to a crisis in any case in a few years, AIDS losses will worsen the situation.4 Education: The education sector can plays a critical role in implementing the strategies to control the spread of the virus, but the capacity of the systems itself may be affected by the epidemic. Namibia has made significant advances in improving access to education. The net enrollment ratios (NERs) for basic education in Namibia rose from 84.7 percent to 89.1 percent between 1992 and 1998. The NER for secondary schools also went up from 28.9 percent to 37.8 percent (Gaveia 1999). Between 1991 and 1998, Namibia added nearly 3,054 teachers, a 22 percent increase in teacher strength to maintain teacher student ratio even with the jump enrollment. It also increased the percentage of teacher with grade 12 education or greater from 51.5 to 71.5 percent. Namibia continues to have problems staffing its schools with trained teachers. Majority of teaches in black schools do not have academic qualifications beyond secondary school and very few have undergone teacher training. As nearly 35 percent of teachers are likely to be HIV-positive, there will be dramatic losses from the teaching crops due to AIDS (Gaveia 1999). Even taking into account decrease in the overall demand for teachers, the loss of teachers will imply that teacher training will have to double its yearly output over the next ten years. Almost one in every six secondary school graduates will need to complete teacher-training college and enter teaching to keep up with the demand. Private Sector: The impact on the private sector is understudied and therefore little understood. AIDS may increase costs for local businesses. Costs increase may be both internal and external. Internal costs may include increased absenteeism, higher pension payouts, and breakdown in worker discipline and morale. There is not adequate information available for firms in Namibia to do a detailed impact analysis. Studies in other countries suggest that the costs may be as low as 1 percent of profit or as high as 9 percent, much of the cost coming from increased absenteeism (Simon et. al. 2000). However, the increases may be only a small share of the wage bill. Mining and agriculture (including fisheries) are particularly important for the Namibian economy. Agriculture and fishing, and mining contribute about 23 percent of GDP. Mining continues to be a dominant sector. The position of fishing has improved and prospects in the short and medium term are also bright. Mining may be particularly vulnerable as workers in the mining sector have high risks of infection in part because of long absence from their families. The likely effects of HIV/AIDS in the mining industry in Namibia may be a future work force that is younger, less experienced and more volatile (Elias, 2000). 4Detailed information on deaths in the civil service, which should be available, can confirm these fears. 30 The private sector also adopts several strategies to avoid costs of the epidemic (Simon et. al., 2000). They may illegally screen job applicants to avoid hiring those that have risky life style or already infected. They may reduce benefits to minimize their costs and also contract out work to reduce their labor force. The burden of dealing with the epidemic may be transferred to households and government. Where the households are poor, the burden falls on the government. C. Conclusions The impact of HIV/AIDS on macroeconomic fundamentals is mixed. From the macroeconomic perspective, HIV/AIDS is likely to affect the savings/investment relations. Expenditures for mitigating the impact of HIV/AIDS at both the household and public sector levels are likely to reduce the amount of capital (both public and private) available for more productive investment; thus in the absence of external flows higher the proportion of care financed from savings, larger the reduction in economic growth resulting from the epidemic. It is estimated that the presence of AIDS in Namibia could reduce the average real GDP growth rate during the period 1991 - 2015 from 3.2 percent without AIDS to 2.2 percent with AIDS. This implies that the economy would grow 1.5 percentage points lower (or 43 percent smaller in absolute terms) by 2015 because of the epidemic. This constitutes a projected income loss of about one- percent of per capita income for 2000-15. In assessing the likely impact of the epidemic on the economy of Namibia, a number of caveats should be in place: First, it is important to bear in mind that although the epidemic is already having a clearly substantial effect on the demography and economy of Namibia, its precise magnitude is difficult to determine as there is a general lack of information on many factors that determine the ultimate progression from HIV infection to AIDS and from AIDS to death. Small changes in the assumptions made regarding the progression time would have important effects on the nature of impact expected through mortality. Second, from an economic perspective, it is the cumulative impact of AIDS over a long period that is likely to be noticeable. Thus, policy response is likely to be slow in the short term resulting in devastating medium-to-long effect. In the absence of an effective intervention, the epidemic in Namibia could enter a second phase (as defined by Reid, 1993), characterized by high mortality and a large dependency ratio (many children and elderly without support). The economic impact of a high level of orphans, for example, are current not well understood. In view of the above, the development of programs to deal with the negative implications of HIV/AIDS should be of high priority. The education sector has an important role to play in this process. First, it is the key institution for generating preventive and mitigation messages, targeted at the youth. Second, with adequate planning, the education sector can undertake corrective measure which will help mitigate the negative impact on the supply of labor and associated productivity reductive deriving from the impact of HlIV/AIDS. Finally, the sector can take the leadership in dealing with its own staff in incorporating the messages of behavior modification in the curriculum. Improving knowledge of the epidemic among teachers and administrators would form an important base for attitudinal change among educators. The process could also include the development of a program for expanded school-based counseling and peer education. 31 Chapter V Response to HIV/AIDS HIV is spread mainly through voluntary unprotected sexual contact. It largely affects the most sexually active group in society, which is also essentially consists of young adults. In this context, as a priority, the main strategy for controlling the epidemic is to have the youth focus on the following: (i) develop an adequate understanding of the epidemic and assessment of the risks of contracting the virus given their sexual practices; ii) take precautions or change their sexual practices to reduce their risk; iii) seek full information on their status of infection through testing; and iv). for those who are infected, take measures to avoid infecting others, including possibly, sharing the information with their spouses and regular sex partners. It is likely that individuals would have the incentives to take the above actions if the following conditions prevail: information on the nature of the epidemic, including consequences and the means of avoiding are widely accessible; the means to reduce transmission such as condoms are easily accessible; reliable and confidential testing facilities along with counseling are available; the stigma attached to the epidemic is reduced enough not to subject infected individuals to social isolation; social factors that may shape individual behavior have been appropriately changed; infected individuals are legally protected from discrimination in the workplace and have access to essential services; and exposure to some of the risky situations, such as having to live for extended periods away from the family or alcohol consumption in public places, that encourage casual sexual relations, are reduced. For women in particular, bringing about change is more challenging. Recent studies suggest that husbands could be responsible for the high rate of infection among married couples (World Bank, 1996). While the issue is complex, it is associated with the economic status of women and gender relations, all of which is part of a larger problem of poverty and gender discrimination. Given the magnitude and devastating nature of the HIV/AIDS, the government has a role to play in controlling the epidemic. Government needs to provide information relating to prevention of the epidemic, a public good that may not be provided by the private sector (World Bank, 1997). Government may also need to foster the development of norms of behavior that reduce negative externalities and ensure that the epidemic does not exacerbate poverty or the poor are denied access to the means to protect themselves (World Bank, 1999). But if the case is made that public assistance should be extended equally to all those affected by the AIDS epidemic, there could be substantial impact on government expenditures (World Bank, 1997). Nevertheless, implementation of AIDS control projects at an early stage brings higher returns (Dayton, 1998). Mitigation of the epidemic raises a number of issues for a less developing country like Namibia. Poor countries may feel that it is too expensive to support people who will die eventually. The choices may be easier to make in preventing mother to child transmission. Nevertheless, in the case of adults, some simple measures may be available 32 to extend the productive life of those that are affected. These measures may include improved nutritional intake and preventive medication against opportunistic diseases. There is evidence that seems to suggest that it may be even profitable for private firms to invest in extending the productive life of affected employees (Simon, 2000). The objective of this chapter is to develop a policy response to the epidemic in Namibia cognizance of ongoing public, donor community and private sector activities to mitigate its impact. Section A reviews the existing Government policies and programs as well as donor and private sector responses to complement those efforts. Section B outlines proposals to strengthen Governments efforts in three key areas: (i) reducing and containing the transmission of HIV; (ii) prolonging life and reducing AIDS morbidity; and (iii) developing programs for skills replacement. Finally, section C defines the lessons to be learnt for further socio-economic research to support HIV/AIDS policy formulation. It is important to point out that the discussion in this chapter is not exhaustive. It is offered to highlight the broad range of possible interventions that may form the basis for planning. A. Control Strategies in Namibia The Republic of Namibia launched the National AIDS Control Program (NACP) in 1990 after independence. A short-term plan was implemented between 1990 and 1992 followed by a medium term plan between 1992-1997. The first medium term plan focused on prevention messages aimed at the general population, condom promotion, training of counselors and home based care providers, STD/HIV/AIDS case management issues for health workers, and epidemiological surveillance. An external review of NACP conducted in 1996 recommended that to improve program management NACP should include a broader range of actors from other sectors and should explore options for greater collaboration with NGOs. Non-health sectors had played limited role in responding to the epidemic (UNDP, 1997). The review also found that high level support, commitment to action and a sense of urgency which are critical to AIDS control programs were lacking as a result of which control was not effective despite the implementation of two plans (UNDP, 1997&1998). The strategic medium-term plan 2 (MTP2) and the national AIDS Coordination Program (NACOP) that were launched in March 1999, focused on (i) social mobilization, (ii) prevention, (iii) access to services, (iv) reduction of discrimination, (v) policy and strategy development, (vi) program management and (vii) capacity building through research and human resource development (HRD). It is anticipated that the bulk of the resources mobilized would be allocated to information dissemination and condom promotion. Similarly, greater attention would be paid in the plan to improve access to services for those affected. Available evidence suggests that efforts by the National AIDS Control Program (NACOP), established in 1992, with the help of several NGOs and international agencies, has increased awareness of HIV/AIDS, its mode of transmission and consequences. 33 However, there is little evidence to suggest that the average citizen considers herself/himself to be at risk of acquiring AIDS, has a good understanding of the asymptomatic nature of STD/HIV infection, or has altered her/his behavior to lower the risk of STD/HIV acquisition. Educational programs have turned out to be ineffective in controlling the spread of the epidemic. By the middle of the last decade it is estimated that more than 90 percent of the population had an adequate knowledge of HIV, but the information had not resulted in behavioral change (UNDP, 1998) B. Proposals to Strengthen Ongoing Initiatives A key policy for reducing new HIV infection is the promotion of condom usage and improved public information system. Public radio and the mass media have been mobilized to transmit the message. However, the evidence of condom use indicates substantial scope for expansion. In view of the above, and building upon ongoing initiatives to deal with the impact of HIV/AIDS in Namibia, the focus of this section will be to deal with policy aimed at (a) reducing the transmission of HIV (prevention), and (b) prolonging life and reducing AIDS morbidity (mitigation). Table 4.1 outlines broad strategies for pursuing prevention and mitigation options. It is important to note that these options are not exhaustive and are presented to illustrate a methodology of incorporating HIV/AIDS policy and costing into the planning framework. All estimates of cost in this chapter are averages over a 15-year period 2000-15. They are presented to highlight the possible cost rage and are for illustrative purposes only. The discussion concludes with recommendations for mitigating the negative impact of AIDS on the economy of Namibia. Reducing the Transmission of HIV: Policies aimed at reducing the transmission of HIV has to be directed at two main groups, with substantially different approaches. The two groups are the youth (under 15 years) and the sexually active population (15 - 49 years). Policies focused at the youth under 15 years should aim at close to zero new infection. While this target may be ambitious, it is attainable under appropriate environment involving participating parent/youth involvement. This group is not yet sexually active or only at the onset of sexual activity. Two specific focused policies could be implemented on this group, recognizing the possible sources of transmission: * Age group 0-4 years: MTC of the HIV virus could occur in newborn children in three ways: during pregnancy, delivery or breast-feeding. In the absence of data on Namibia, it may be assumed that similar conditions to Zimbabwe exits where MTC is estimated at 20 percent during pregnancy, while 30 percent transmission took place during delivery and another 30 percent occurred during breast-feeding'. Existing medical knowledge suggests that if drugs, such as AZT or Nevirapine, are provided to pregnant mothers, the transmission rate could be reduced significantly. There are side 'Herald Daily Newspaper from Zimbabwe, July 26, 2000. 34 effects associated with these drugs such as toxicity and resistance. But two doses of the drug Nevirapine, one to mother and the other to the child, it is reported, can reduce MTC by 35 to 40 percent. Unit cost of AZT is approximately US$150 or Table 5.1: Selected Strategies and Options Category Selected Policy Option Implementation I. Prevention Ages 0 - 4 years Close to zero mother to child 100% testing of pregnant transmission women and encouraged use of antiviral drugs (e.g. AZT, Nevirapine, etc) as necessary Ages 5 - 9 years Close to zero new infection. Age specific sex education. Ages 10- 14 years Close to zero new infection. Age specific sex education/ (Childhood) Development of youth ._____________________ activities. Ages 15 - 19 years Focused and monitored Age specific sex (Teenage cohort) reduction in new infections. education/youth counseling/community condom distribution; reward for good behavior, part time employment. Ages 20+ years Reduction of new infection Work place condom (Adult) through behavior modification distribution, free and and safe sex. voluntary counseling centers, information dissemination through media, religious groups and indigenous groups, and stage performances/talk shows usin PLWHA. Special Risk Groups Special programs for targeted Same as 20+ category with groups such as miners and emphasis on counseling and commercial sex workers. anonymity. II. Mitigation Ages 0 - 4 years Improved quality of life Medical care. Ages 5 - 14 years Community based orphan Educational, medical care and (Childhood) care. food programs through school. Ages 15 - 49 years Improved quality of life! HIV counseling/medical Prevent further spread care/community & work place condom distribution/community home based care. Ages 50+ years Improved quality of life Medical care/ Pension benefits. N$814 per mother, which is more expensive than Nevirapine which costs about US$8 or N$43 per treatment2 of two doses, one to the mother and one to the child. Further reduction in prices could be expected in the future. 2CNN: http://cnn.com/SPECIALS/2000/aids/stories/treatment. 35 * Mothers and Infants: Estimated number of females in the child bearing age group averages to about 111,969 between 2000-15. If we assume that 15 percent of them would become pregnant, the estimated number of pregnant mothers would be around 16,795. The potential risk group in this category is estimated at about a fourth at 4,1993. The total cost per year for a close to zero MTC using AZT is therefore N$5.6 million (about 0.022 percent of GDP or alternatively N$298,000 using Nevirapine (about 0.00 1 percent of GDP). * Children: Children in the age groups 6 months to 4 years need regular checkups and vaccinations to maintain good health. They (not orphans) need to be monitored since not all mothers with HIV are tested. This age group constitutes about 100,081 persons and the estimated cost per child to support programs is estimated at about half of per capita health expenditure (N$215), implying a total cost about is N$22 million or 0.084 percent of GDP. * Age group 5-9 years: For this age group, early sex education would be the best preventive policy. These young children are the most important group to protect since they are not effected by the epidemic, as they are not sexually active. There are 287,707 children in this age group. Estimated cost per child for identified programs is based on a fifth of per capita education expenditure or N$198 per year, yielding total average cost of N$57 million per year or 0.2 percent of GDP. * The 10 - 14 year age Group: This cohort constitutes a group on the onset of sexual activity. For this group adequate sex/health education which is tailored appropriately to their age and- capacity to enable them to deal positively and responsibly with their sexuality is the first step. The program should deal with both abstinence and proper condom usage at the appropriate time. Based on assumptions about the framework for such a program4, it is estimated that an expenditure of N$66 million would cover 265,512 beneficiaries. This amounts to about 0.3 percent of the GDP. The identified programs above (while not exhaustive) require aggressive, accelerated and intensive IEC and peer education efforts targeted at the youth in order to facilitate individual assessment of risk and behavior change towards prevention. Parental/Youth participatory involvement with the assistance of the community and NGOs/CBOs is necessary. A successful publicity campaign focussing on the youth with effective IEC messages can prevent HIV transmission over the medium term. These efforts will further require support from behavioral and epidemiological research to determine the characteristics of the youth contributing to high risk. There is growing evidence that sexual activity among the youth is widespread, yet most health and educational institutions ignore their needs, resulting in unwanted pregnancies and an alarming high prevalence of STD. If the Government does not yet feel 3Herald Daily Newspaper from Zimbabwe, October 3, 2000 At least a quarter of all expectant mothers in Mutare are infected with HIV virus according to a survey. 4Age group 10-14 consists of 243,010 in 2000 and projected to increase to 290,080 by 2015. Cost of these activities is estimated at N$248 per person per year. 36 ready to openly promote youth counseling activities, it should at the minimum continue to encourage and assist those agencies and NGOs which do, in order to ensure that such services are available nationwide. This would entail the need for an expansion of facilities to provide appropriate space for counseling and for educational films and informational materials. Such facilities, provided in conjunction with playground and sporting game facilities, will help facilitate fruitful use of the free time of the youth. Toward the goal of providing comprehensive health care for the youth, the existing efforts to provide family life education to secondary school students should also be targeted at primary students as well. Several of the under 12 years found with HIV, suggest that some students probably begin sexual relations while still in primary school. Targeting primary school students with HIV related education is a very difficult task that will require health workers and parent/teacher to work cooperatively as a team. The second group involves the sexually active population (15-49 years). The policy proposal for this group is to promote increased and consistent condom use for the sexually active population. A framework of logistics and management information system for condom supply and promotion already exists but it needs to be pulled together and adequately monitored. The main problems which persist include inadequate appreciation by health service management and staff of the importance of maintaining user statistics and using these to determine future requirements; the absence of a tracking system which signals low stock levels; and the availability of too wide a range of contraceptive types and brands, as a result of the high reliance on donor funding. In this context, it is suggested that Government should: * Ensure adequate condom supplies: The MOH relies too heavily on donors for the funding of condoms (for male). It is essential that funding be identified to meet requirements for two to three years into the future if reliable supplies are to be assured. For purposes of estimating cost of condoms required, it is assumed that (male) youth in the age group 15-19 require 2 condoms per week or 156 per year and adults require 4 per week or 234 per year. The number of male youth in the 15-19 year age group is estimated at 119,685 and those in 20 plus age group males at 349,692. Total estimated cost per year for condoms for all youth 15-19 age group is N$12 million or 0.05 percent of GDP; for adults it is N$55 million or 0.2 percent of GDP. Given these cost ranges, in the absence of donor assistance, the Government must be in a position to ensure that funding will be available from the budget. To support the process, the Government should explore the concept of social marketing of condoms. Evidence from surveys in Zimbabwe and elsewhere indicate that people are willing to pay for condoms. * Enhance NGO support for condom distribution: The extent to which HIV/AIDS counseling and condom distribution services are offered differ markedly between Government and that of the private facilities. This suggests that Government needs to increase its efforts to enlist non-governmental institutions in its efforts. 37 * Provide community based and work-based services: Experience worldwide has demonstrated that the use of alternative delivery systems, such as community-based delivery of condom can increase usage, even in inaccessible rural communities. With a pool of rural health workers, Namibia has the potential to extend HIV prevention programs in the rural areas at a relatively low cost. Work-based condom distribution and HIV education programs (already being implemented) may require active participation of management and appropriate allocation of required budget. a IEC, voluntary testing and counseling: It is extremely important, when appropriate, to provide voluntary testing and counseling (described in detail in the following paragraphs) for prevention purposes. For the 15-19 year age group it is estimated that such a program would cost about N$123 million or 0.5 percent of GDP to cover 248,850 male and female youth at a rate of N$495 per person (which is about half of the per capita education budget). The comparable estimate for adults (both male and female) is N$312 million or 1.3 percent of GDP that covers an estimated 798,665 million people at an average cost of N$391 (which equals one fourth of per capita education budget plus one third of per capita health budget). Prolonging Life and Reducing AIDS morbidity: Because HIV/AIDS is stigmatized, affected people are often prevented from gaining access to some of the few social support mechanisms for which they might be eligible. Programs to mitigate the household impact of HIV/AIDS therefore should deal with legal concerns, voluntary HIV counseling and testing, ration of health care, and the role of home-based care. Voluntary counseling and testing can play a useful role in helping individuals with HIV/AIDS to seek assistance in dealing with the epidemic. Active public promotion could also serve as an instrument in assisting potential AIDS patients and serving as a prevention measure for controlling risk behavior. Studies conducted in Malawi (World Bank, 1998) indicated that, males who received voluntary counseling and testing reported a decrease in unprotected sex from 30 percent to 18 percent, compared to males who only received health information who reported a decrease from 30 to 26 percent. Counseling on HIV can be useful in decision-making on a variety of areas - from prevention to care. Testing however helps to solve the issue of uncertainty in that a positive test serves as a strong incentive for the use of condom, while a negative test may help to reinforce responsible sexual behavior. The role of counseling and testing is to handle the psychological aspects of HIV/AIDS, but may serve as a useful instrument for finding individual solution for prolonging live and reducing AIDS related morbidity. Counseling and testing sites need to be established in each urban center, with special facility devoted for high-risk groups. In an environment of high AIDS cases, the inevitable increase in health care demand may lead to the rationing of health care, mainly on the public hospital sector. Figure 5.1 shows the projected increase in hospital bed-days attributable to AIDS based on projections in Chapter III. It is possible that in a constrained resource environment, non-HIV related patients would experience a greater degree of rationing than AIDS 38 related patients. In Namibia, close to about 60 percent of hospital beds are already being allocated to AIDS-related patients. The options are either to increase the number of hospital beds or to seek alternatives to hospital-based care. The challenge is for both the public and the private sectors to shift to fundamentally more cost-effective mode for terminal care. Figure 5.1: Hospital Bed Days Needed for AIDS Patients Hospital Beds Days Needed for AIDS Patients 2,400,000 , 1,900,000 . 1,400,000 * Non-ADS *AIDS 900,000 4100,000 -100,000 In this connection, a widespread adoption of cost-effective program such as home-based care may be recommended. The type of home-based care envisaged in Namibia will not be limited to only AIDS patients but also to all terminal patients. It will aim at providing a range of services (clinical and nursing care, counseling and social support) extending from home to hospital and different levels of health facilities, all linked by discharge planning and referral network. Besides being cost-effective in reducing caseload at health facilities, home-based care is likely to promote positive outlook for terminal patients and enhance the capacity for preventive education for other members of the extended family. In order to promote the concept of community home-based care widely, there is the need for a comprehensive study to address the following: . Feasibility issues concerning the availability and adequacy of staffing, transport, supervision and drug supply arrangement. Furthermore, the acceptance of the concept by the community and households would need to be ascertained. * Detailed work would need to be done concerning the number of patients that would be covered, frequency of visits, type of home visitor (e.g. Family Welfare Educator, nurse or both), and the nature of administrative support, including the staffing of clinics to support home visit. 39 * The extent to which home-based care lowers costs of inpatient care. It should be noted that home based care works in a more organized and densely populated urban setting but it is more complicated in rural areas due to the distances to be covered by any supporting outreach services. Mitigating the Negative Impact of AIDS on the Economy: Policies to deal with the negative impact of HIV/AIDS would need to focus, along with other policies on: (a) strategies for human resource development (replacement of lost labor and skills), and (b) preserving savings and investment levels. These policies would need to apply at the household, enterprise, and public levels (both sectoral and national). Human resource development efforts must aim at replacing lost skills and ensuring adequate pool of skills. Namibia is generally skilled labor deficient although a great deal has been done since independence to narrow this gap. The impact of HIV/AIDS is to exacerbate the shortage of skilled labor, especially in the public sector where most trained personnel are employed. Because salaries, benefits and other incentive policies to retain skilled people are reasonably better in Namibia, this shortage might be easily filled by migration. Dealing with the skilled labor shortage in Namibia may require increased information as well as incentives. In the area of information gathering, there may be a need to update existing census of skills both in the private and public sectors. Such a census may be followed by projections and plans of skills needed at sectoral level that may be necessary for developing an incentive program for the private sector. Private sector incentives could be in the form of tax rebates for retraining programs. The need for skills replacement is likely to be more important for the public sector than the private sector. The public sector may need to identify critical areas for the preservation of skills. There may also be the need to intensify staff development programs, training and public/private partnership in these areas. Related to the skills replacement needs of the economy is the role of AIDS deaths in increasing the number of orphans. The estimates suggest that the number of orphans (loss of mother or both parents) in Namibia will increase from an estimated 24,403 in 2000 to about 156,172 by 2015. As of 1999 there were an estimated 18,603 existing orphans (living) and every year 8,636 on average would be added to this pool. An orphan's status has major implications for the growth of the child and human capital development. Orphans tend to feel low sense of self-esteem and in the absence of appropriate programs could lead to abuse, neglect and a life of crime both as a child and adult. Based on assumptions of development needs, including schooling, feeding, and clothing, it is estimated that a comprehensive incremental orphan care in Namibia would cost about N$661 million per year or 2.8 percent of GDP. 40 Dealing with the orphan problem may require studies that address the following options: * Given the resource constraint of the extended family, orphanages provide an option that has been used in western countries but may be problematic in Namibia's cultural context. * Home based orphan care in the community, especially in the rural areas, provide an alternative similar to the home based care in which support is provided to the extended family in kind. The intervention could be in the form of financial resources, advice and counseling to the extended family. * Complementing the home based orphan care is support for schooling and the establishment of income generation projects to provide employment for orphans exiting from the school system. The proposal for home based orphanage could be developed in the context of the home based care for AIDS patients. The rationale for this is that during the period before the death of AIDS parents, older siblings and other members of the extended family who provide care for the sick tend to withdraw from the labor market, resulting in major implications for household income. The most affected are children who tend to be neglected and may withdraw from the school system even before they become orphans. An expanded home based system incorporating care of the terminally ill with and assistance for potential orphans may provide the most cost-effective means for dealing with both problems. Costing such a program should be the objective of further study. Table 5.2: Summary of Estimated Costs of Selected Policy Interventions Cost per year Category (Million N$ in % GDP 1999/2000 prices) I. Selected Prevention Support for MTC transmission 22 0.09 (Age cohort: 0-5 years) Sex Education & Community Programs 123 0.5 (Age cohort: 6-15 years) Sex Education for Teenagers 136 0.5 (Age cohort: 15-19 years) Increased Condom Use 55 0.2 _(Agecoh rt: Adult) IEC/Voluntary testing/counseling 312 I1.3 (Age cohort: Adult) II. Selected Mitigation Orphan care 662 2.8 Hospital care for AIDS Patients 716 3.1 Old age pension for AIDS patients 220 0.9 The costing of some of the proposed initiatives in this study are summarized in Table 5.2 (with necessary assumptions outlined in Annex II). Recognizing that both the 41 proposed options and the costing are for illustrative purposes, the preliminary estimates suggest that various individual elements of prevention could range between 0.10 to 1.3 percent of GDP per year adding up to an average 2.7 percent of GDP per year (or N$652 million). In terms of mitigation, orphan care is estimated at about an average of 2.8 percent of GDP per year (or N$661 million). The largest single cost element is hospital care, which is estimated at about an additional 3.1 percent of GDP p.a. (or N$716 million), on average, during 2000-2015. The latter points to the need for alternative programs for handling AIDS and terminal care. Although these illustrative programs may underestimate the likely cost of prevention/mitigation activities, they point to the likely magnitudes and suggest that such programs can be accommodated by existing resources of Government. The loss of GDP associated with HIV/AIDS is estimated at, on average, N$1,773 million per year in constant terms, or about 18 percent of GDP in the absence of HIV/AIDS during 2000-15. If the country is loosing such a magnitude in potential GDP, it should be able to contain these losses by appropriate prevention programs that amount to less than 2.7 percent of GDP per year. On the other hand, since mitigation costs are substantially higher than the loss of GDP, it is prudent that Government intensify preventive measures. Finally, policies to reduce the cost of both preventive and mitigation programs may be warranted. C. Some Lessons to Consider International experience suggests that some of the features of effective national responses are: (a) political will and leadership, (b) societal openness and determination to fight against stigma, (c) strategic responses, (d) multi-sectoral and multilevel action, (e) community based responses, (f) social policy reform to reduce vulnerability, (g) sustained response and (h) learning from experience (UNAIDS, 2000). It is also necessary to prioritize and focus initial action. Open discussion of the epidemic by people at the highest levels in government as it happened in Uganda, appears to be key to effectively changing individual behavior. The particular difficulties in controlling the spread of AIDS in Namibia is the silence, which leads to the lack of open discussion and recognition that widely accepted sexual practices are the source of the problems (Caldwell, 2000). Governments are reluctant to recognize and openly challenge sexual practices. Individuals, especially women, also may have limited scope for adopting restrictive sex practices in marriage as a solution. Another reason for failure to control in Namibia is the stoical attitude toward death, perhaps because of limited health transition (Caldwell, 2000). High mortality and low life expectancy makes individuals not worry about dying from an epidemic with about ten years of gestation. Life expectations are likely to be low in countries in which nearly one half of young adults are unemployed. The solution is therefore of raising expectations and improving prospects of livelihood opportunities. Control programs also need to be community based to facilitate discussion at community levels. Changing sexual practices in a generalized epidemic will be more challenging than in concentrated epidemics where substantial gains can be made by persuading a small group of the population, such as the prostitutes, to use condoms. Open 42 discussion at communities is the only way to reduce the stigma that is attached to the epidemic. Community discussions could also empower individuals, particularly women, to assert themselves in their sexual relations and to take preventive measures. Focussing on individuals, without paying attention to the social context they are in, and assuming that they will rationally assess their risks and respond by changing their behavior has not proved to be successful (UNAIDS/PennState 1999). This is clear from coexistence of widespread knowledge of the epidemic and continued practice of risky behavior. The communication strategies therefore need to target the contexts in which individuals make decisions and seek social change. Community-based approaches need to be taken in Namibia so that cultural values of communities may play a central role in behavior-change communication (UNAIDS/PennState, 1999). Community-based approaches can facilitate the development of context specific strategies and more effective implementation. They are likely to be more effective for identifying and mapping risky situations and developing strategies to effectively minimize them. Community participation in the development of strategies will make the programs more accountable to them. To be strategic and to learn from lessons, it is necessary to strengthen the information base. One of the difficulties in targeting behavioral modification strategies is the absence of behavior studies of the type alluded to in chapter II. International experience suggests that AIDS control projects that are not well focused on groups that are at risk are not effective (Dayton, 1998). Standard prevention messages alone are not likely to be effective in changing behavior. Focused behavioral research is required to develop effective communication strategies. Therefore, an effective monitoring system is essential. Finally, the need for multidisciplinary work is often confused with the need to take a multi-sectoral approach, which is some cases, is interpreted as dealing with structural factors such as poverty and underdevelopment. However in most cases, sectoral approaches merely imply various sectors taking stock of how AIDS may impact on them, and taking actions similar to those spearheaded by the health ministries. Decentralization often has similar outcomes: rather than providing for solutions to emerge from communities, decentralization merely means passing on what is done at higher levels to lower levels without including mechanism which enable lower levels to better understand their situations and come up with solutions that are suited to their conditions. None of these approaches, multi-sectoral or decentralization per se, lead to an understanding of the problem that a multidisciplinary approach, which looks at the epidemic as more than a health problem. 43 BIBLIOGRAPHY Bloom, David and Ajay S. Mahal (1985), Does the AIDS Epidemic Really Threaten Economic growth? NBER Working Paper #5148. Caldwell, John. C. (2000), Rethinking the African AIDS Epidemic. Population and Development Review. Vol. 26, No. 1, pp. 117-135. Cohen, Desmond (1998), Socio-Economic causes and Consequences of the HIV Epidemic in Southern Africa: A Case Study of Namibia. Issues Paper No. 31. UNDP. http://www.undp.org/hivlpublications/issues/english/issue3le.htm Cuddington, John T. (1993), Modeling the Macroeconomic Effects of AIDS with an Application to Tanzania, World Bank Economic Review 7 (2): 173-89 Dayton, Julia (1998), World Bank HIV/AIDS interventions: Ex-ante and Ex-post Evaluation. World Bank Discussion Paper No. 389. Elias, Ralph (2000), Managing the Impact of HIV/AIDS on African Mining. African Mining 2000 Symposium, Quagadougou, Burkina Faso, 4-6 December Goveia, Jeffrey Joseph (1999), Education and the Epidemic: The Effects of HIV/AIDS on Basic Education in Namibia. Kambou, Gerard; Shantayanan Devaraja and Mead Over (1993), "The Economic Impact of AIDS in an African Country: Simulation with a Computable General Equilibrium Model of Cameroon," Journal of African Economics, Vol. No. 1, pp 109-130 Over, Mead (1998), Coping with the impact of AIDS. Finance and Development. March, pp.22-24. Over, Mead (1992), The Macroeconomic Impact of AIDS in Sub-Saharan Africa, AFTPN Technical Working Paper 3, World Bank, Africa Technical Department, Population, Health, and Nutrition Division, Washington D.C. Reid E. (1993), The HIV Epidemic and Development: The Unfolding Epidemic, New York: UNDP. Republic of Namibia (1997), National population Policy for Sustainable Development. Windhoek, Namibia: National Planning Commission. Republic of Namibia (1998), Poverty Reduction Strategy for Namibia. Windhoek, Namibia: National Planning Commission. Republic of Namibia (2000), Projecting the Impact of HIV/AIDS in Namibia: A report on Work In Progress to Establish a national Consensus on HIV/AIDS Impact projections for Namibia. Windhoek: MoHSS Working group on HIV/AIDS Impact Modeling. 44 Republic of Namibia (2000a), Report on KAP study related to HIV/AIDS. Windhoek: Ministry of Health and Social Services. Simon, Jonathon, Sydney Rosen, Alan Whiteside, Jeffrey R. Vincent and Donald M. Thea (2000), The Response of African Businesses to HIV/AIDS in HIV/AIDS in the Commonwealth 2000/01. London: Kensington Publications. Tjapepua, and Mapari, 1994 UNAIDS (2000), Report on the global HIV/AIDS epidemic. Geneva, Switzerland: joint United Nations Program on HIV/AIDS. UNAIDS (2000a), Namibia Epidemiological fact sheet on HIV?AIDS and sexually transmitted infections. Geneva: UNAIDS?WHO Working Group on Global HIV?AIDS and STI Surveillance. UNAIDS (2000b), Guidelines for Studies of the Social and Economic Impact of HIV/AIDS. Geneva: UNAIDS. UNAIDS (2000c), Trends in HIV Incidence and Prevalence: natural course of the epidemic or results of behavioral change? Geneva, Switzerland: UNAIDS UNAIDS/PennState (1999), Communications Framework for HIV/AIDS: A New Direction. Geneva: UNAIDS. UNDP (1997), Namibia Human Development Report 1997. Windhoek, Namibia: UNDP. UNDP (1998), Namibia Human Development Report 1998. Windhoek, Namibia: UNDP. U.S. Bureau of the Census (1999), Report WP/98, World Population profile: 1998, U.S. Government Printing Office, Washington, DC, 1999. WHO&UNAIDS (2000), Second-generation surveillance for HIV: The next decade. http://www.who.int/emc World Bank (1996), AIDS Prevention and Mitigation in Sub-Saharan Africa: An Updated World Bank Strategy. Washington, DC: The World Bank. World Bank (1997), Confronting AIDS: Public Priorities in a Global Epidemic. Washington, DC: Oxford University Press. World Bank (1998), AIDS Assessment Study, Report 17740 MAL (Vols. I & II) World Bank (1999), Namibia: Recent Economic Developments and Prospects. Washington, DC: The World Bank. World Bank (2000), Namibia: A Diagnosis of the Emerging Pension System, Washington, D.C.: Southern Africa Dept. 45 Annex I Modeling the Impact of HIV/AIDS in Namibia 1. The purpose of this Annex is to describe, in detail, the models used in the report to analyze the impact of HIV/AIDS on Namibia's economy. It also outlines the assumptions and the sensitivity of the results. 2. The main model is Spectrum, which is a windows-based program, developed by The Futures Group International with funding from the USAID. This model analyzes existing information to determine the future consequences of current population programs and policies. It has several modules of which two are relevant for our purpose here: DemProj (Demographic Projections) used for the demographic projections on the basis of current population, fertility, mortality, and migration; and AIM (AIDS Impact Model) used for projecting the consequences of the AIDS epidemic. 3. DemProi: The following information is required by the DemProj module. * Base year population by age and sex. * Total fertility rate. * The age distribution of fertility. * Life expectancy at birth. * Life table. * International migration by sex. All the above variables require future assumptions relating to expected future trends except the population estimates, which are derived as the basis of the estimates generated for these parameters. The following information is used in the demographic projection module for Namibia. * Base year population by age and sex for 1981 (actual): Age group Male Female (in years) 0 - 4 75,100 77,000 5 - 9 74,800 73,300 10- 14 66,500 66,800 15-19 56,100 59,700 20 - 24 37,500 45,400 25 - 29 34,400 37,900 30 - 34 29,800 31,500 35 - 39 24,600 25,200 40 - 44 22,900 24,100 45-49 20,500 18,800 50 - 54 17,400 15,800 55 - 59 13,100 11,200 60 - 64 10,830 10,962 65 - 69 8,664 9,072 70 - 74 7,942 8,316 75 - 79 3,971 4,158 80+ 4,673 5,292 Total 508,780 524,500 (=1,033,280) (Source: Statistical Abstract 1999: Table 2.1.5. Model uses 1981 as the base year, five years before the first HIV/AIDS case was detected in 1986). 46 * Total Fertility Rate (TFR): Assumed to be 6.0 for 1981,5.7 for 1991 (from pp.ii) and projected to decline to 4.0 by 2015 (which is close to government assumption of 4.5). Interpolated for the intermediate years. (Source: National Planning Commission 1994 pp.ii for 1991). * Age Specific Fertility Rates (ASFR): These are defined as the number of live births per 1,000 women in the age groups. Age group % distribution % distribution (in years) in 1981 in 2015 15- 19 16.42 15.52 20 - 24 24.72 25.68 25 - 29 22.12 22.07 30 - 34 17.32 17.07 35 - 39 11.71 11.66 40 - 44 6.21 6.31 45 - 49 1.50 1.70 100.00 100.0 (Source: Default from AIM model uses UN Sub-Saharan Africa averages). * Sex Ratio at Birth: 95 male births per every 100 female births. (Source: National Planning Commission 1994 pp.iii for 1991). - Life Expectancy: (without AIDS) 1981 2015 Male: 52.4 64.0 Female: 56.4 67.0 (Source: National Planning Commission 1994 pp.50 for 1991). - Infant Mortality Rate (IMR) and Crude Death Rate (CDR): IMR: 88; CDR: 15.9 (Source: Statistical Abstract 1999 pp.12 . CDR was 72 for 1978 and 12 for 1991. The model uses UN assumptions of IMR 88 and CDR 15.9 as an average, which were close to the actual data). * International Migration (net): negative number indicates more people from Namibia went out than entering the country. Net migration was zero for Namibia. 1981 2015 Male: 0 0 Female: 0 0 (Source: Statistical Abstract 1999). 4. AIM: The following assumptions are used in the AIDS impact module for Namibia. * Epidemiology: 1981 2015 Adult HIV Prevalence: 0.00 25.0 HIV/AIDS parameters * Start year of AIDS epidemic 1986 * Percent infants with AIDS dying in the first year 67.0 * Life expectancy after AIDS onset (years) 1.0 * Reduction in fertility among HIV+ ( %women) 30.0 * Prenatal transmission rate (%) 30.0 30.0 47 HIV Incubation period Adults Children Cumulative percent developing AIDS by number of years since infection Years I 0.0 30.0 2 3.0 45.0 3 5.0 55.0 4 11.0 70.0 5 18.0 80.0 6 28.0 90.0 7 37.0 95.0 8 47.0 95.0 9 58.0 95.0 10 66.0 95.0 11 73.0 95.0 12 79.0 95.0 13 83.0 95.0 14 87.0 95.0 15 90.0 95.0 16 92.0 95.0 17 94.0 95.0 18 95.0 95.0 19 96.0 95.0 20 97.0 95.0 (Source: Faster pattern of cumulative percent developing AIDS by the number of years since infection for both adults and children based on UNAIDS estimates). Age Distribution of New HIV Male Female (Ratio of HIV prevalence at 25-29) Ane group 0- 4 0.0 0.0 5 -9 0.0 0.0 10-14 0.0 0.0 15- 19 0.2 0.4 20-24 0.3 1.0 25 - 29 1.0 1.0 30 - 34 1.5 1.0 35 - 39 1.4 0.7 40 - 44 1.0 0.6 45 - 49 0.9 0.7 50 - 54 0.9 0.6 55 - 59 0.6 0.3 60 - 64 0.4 0.3 65-69 0.2 0.1 70 - 74 0.0 0.0 75 - 79 0.0 0.0 80+ 0.0 0.0 48 * Impacts: 1981 2015 * Expenditure per AIDS patient 493 9,395 * Percent AIDS hospitalized 20 90 * Ministry of Health budget (Million N$) 206 1,416 * Hospital beds 6,435 15,000 * Bed capacity factor (1=100% beds used) 0.60 0.7 * Bed days/AIDS patient (days) 60 90 * Prop of 0-5 vaccination for measles (%) 40 50 * Measles vaccine efficacy (%) 80 80 * Measles case fatality rate (%) 2.4 2.4 * Malaria episodes/person/year 2 2 * Malaria case fatality rate 0.003 0.003 * TB incidence without HIV (%) 2.4 2.4 * Percent population with latent TB 50 50 * TB incidence with HIV (%) 10 10 (Source. Infonnal discussions with the Government and NGOs). 5. Analysis of the Results and Conclusions: * Number of HIV patients will increase from 188,969 in 2000 to 329,412 in 2015. * Cumulative AIDS cases will increase from 50,508 in 2000 to 389,537 in 2015 an annual increase of 14 percent. * Average annual AIDS deaths for the next 15 years will be around 20,746 (cumulative 360,254) or 7 percent increase per annum. * Life expectancy will go down by 23 years during the next fifteen years due to HIV/AIDS thus reducing the average life of a person in Namibia by 2 years per annum. * On average 12,000 orphans will be added to the cost of government budget to provide food, education and employment. By 2015 a total of 116,172 orphans will be waiting to be taken care of by somebody. The following tables and diagrams provide the complete outputs for the modeling process. The analysis and qualifications of the projections are undertaken in the main body of the report. 49 Demography 544~o54o~ P~I.~04s 1005 1002[ 1003 1004 1000 1090 104 1060 100 206 20 00 03 04 005 20 25 06 2000 201 2011 C250 03 204 21 A.5 ~ 1 40S52 21 2 A 3. 3 % lW21 -qA M4 1% 1,73j.1% 30 0 6 0% 30 .% 3 30031% _ %I.1 31 _.1% 3 71I 1 %II , _3.0 30%M 130"W% 2 9% WM_ ________ __ 0 6(347700_1352454 1477 03W 1453__ - _2 _ _ _- C54040,00s 05052,035 13.3 13.3 13.3 123 12.5 1~~~~2,5 n:s% 2141 2_.5 1.5 ... 17.5 5 1. 5. 5 15.1 151 5... 15.2V 15 53 0 155 1. AW..y 0005052 9.03 054 0.5 5,2 5.0 1.04 50.00 3 0.07 O0.56 05. .5 053 .3 051 0.056i 5.0 0.006# 0 5.57 0.0 5.57 5.572i 0.07 ~ ,36_5.07 0.07M ,~50I55%5~9,!P .0 .5. 0.5 05 05 15 .5. 550 552 500 05 _5.53_ 50_5g _ _qR2 551 05 0_ 5 _0 50 1'50 __L56 50_05 5 50 90 A40J9..0 054505 A (55 14 50,9971 649-sw V....M i... ...........1......Il "M .3 . 9 0~ M ~ 1~4,0 344i47 HIV-AIDS m P1.0120225~~MO- MnSM 100-18 _____-1,7 02M 10 ,1," 159 - & -1"7 -"m 'M"7 t1,l -M-m - -A - ____ _ __ - _ - _ - - - - 1 1 _ _ WA 9 7os7 !__ tEa7 l-=N- 13-37 9 -W- I20s2 l z ,ON53 ,19_t '..... . .......... -ti W!16. =6............... -- 27^.F Z,7-1 ___Ad___._______ 1s.,____ _D_ _ _____ _ _- _.~0¶~ _ AA20_ _205A7~ _200278 _,31 0 _, ,0 _ _1 _1 ,,1, , _ ,,, _ _7_ _ ,_0,2,__ HW..-- - _ WrAl50sz~~72100,301 _ - ioi ,,n S9 ri7Loz Zogo t 1,002 X~2,9 tA7 A0.59 177206 10-5,93 2,7 - 234 - 2100 27 18tOZ_ a,47-s- Z1S --Z0S- _ 2341 , 20350z74 203A3s -27110 200 ?221 za 0_ z7s4L 2007 0oA.S 0501*100 3ls z 3.7 - .55 - 7,41 1 _ 13.5s 14.7 15-n.0 115 _ 1600 ISA 157. 180 - 4 IS - 200_, 203 207 21.0 21.3 2i16 220 fl23 226 220 H W0o 9 200 311 6273, --=- 00501 019103 12485s7 ~14a0230 154.006 77825 j231,7 100,407 22230 769a i 225.20 04201 - 7423 252.323,4 202601 627220 20-X191s8 201,0 300,0 31021 31.7 3204127 01W 0.050.101 CIV k4.0,o~~~~~~~~~~~~~~~~~~~~~~~~~ 5.0552.0504 - - - -- - - - ~ ~ ~ ~ ---23 26- tz ve =0 ~ n- -- AIDsa3.. 05064000 750 1,100 1.770 - - 3311 3202. ,323 -6004 7,055 ,0,39 _253 -M14600 15470 10100 10622 20M261 20 i - 22260 ,204, 24202 2Z 103 25,00? 272.. 30213 20 20_06. D.7- h m _ ---- - 00, , , I__,, 23010400.D* . WOO2200 -1437 2000 4,334_ 90 - * . 9 24221 2220 0213 -_ 0,3,3,zss0 '1620 9 29_1-0, I1 161213 A 16 204 - 220 203500 2,7013 30,o20 370,042 360354 305237 - ~ x ,lag___- 1.52.30,20 83.0-11 0100 6W M OM 2 4.6 e.7 2 202015 002 1N 2 N 2. .1 W 2A ,23 n _,, _ Oum_A'DS D 9s7M!4L-tp AID3 Qepe![tl __~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~1- 27 A M M __iSoa WiA _io 4 L7 9_ 13 430 10635 2.4 3483M 0407 0_41 8 0.250 10201 -_ 12000 -13.002 15403 15.401 116 1790 22 9 10 1024 20600 2147 22 23233 240 2 A 400621020 0501*005 20 E -- - 1 15, X t3 > 190 2107 1a7000-n/5 1756 232 1,95 13aL *3 29,007 -oz,s 23012 23105 ui 23,79 E 200 2,03- 2?2 ,2331_ 2s,7is i30,48 - si29 31 133 .070039 33,300 _462 ,___ HW.1174. .01401 3_0 '*40L - 11 - -- -- t a_ _ _ _ _ _- - -- -- - - A640AMS.06000 Wi AiDS 0 973%os 210% 3.-3% 32 700W - , _1f 215 7.20% 00 100% _ 2079 2 .7..% ... 21 231% 233% 2.3504. 213% 230% i30%-2 44% 2.0s LP-- _90 i 0.l HW _-_ - Mortality Mortality Impacs of 4.DS IndIcator-.y~ln -19 19920 19931994, 1995s 1996 '1997 1888 1999 2990 _ 290 2002 2903 -20964 2005 2004 -2007 - 200 2009 2010 2011 2012 2013- 2014 _2015 Y Wgd ooa tth.0 -ID 3,495 3.,830. 4,247 4,710 _5326 _6.115 7,199 819W 10 211. 12.023_ 14.,021 15948 17,304 18,789, 18959 20,603 271J27 21,692 322489 23,153~ 23,982, 24.765 25 604 26,610~_ 27,529 (A-.ruadeaths to NoRAIDS 3,119 3,103 _ _. -3~0 3.249 .286 ~3319 3.377 34.63 3,506_ 3.571 3.633, 3665_ 3,763 3.831, 3.902 - 3,973, 4.051 4,140 4.231 4.313, 4,367 4.421 4,511, 4.566_ 4,616 ad,lts 15-49) -Y50978adk8deaths= fro DonrPw)j - -- --- InIantn I~04 rte With AIDS 72.8 72.1 719 21.8 72.2 72. 23 7. 71.6 _ 02 69.7 66.6 67.8 60.9 66.9 650 8. 3. 25 6.8 6. 69 81 5. 57.4 _IAInsndodaths00 90 15 . 21 19 717 7 72725 1. 1. 7.9 0.6 66 7.7 06.4 055 64.5 63.5 62 1 6. 9 566 5. 9.8 55.6 -54.6 1000 Ryo N4~ infamnt_m rt -jaltale IrltantdooS(TotaLihS ICOO t0on DOP71- -- -.-- .- UN., rSorortaj4yfat__lIAlS 156 71 4.4 113.2 112.6 12.5. 113.5 115.0 1106.0 115.9. 116.5 156 114.6. 113A4 1 11.6, 110.3 106.0 107.4 100.2 _1551 103.9 1032.7. 101.6 100. 662 88.8 ADath. too0-4 per No AIDS 113.2 111.2 _199.2 _ 107.2 155.2 163.3 101.2 99.2 897.2 85.2 93.2 91.2. 89.2 67.2, 852.2 83.2 61.3. 79.4 77.6 75.6, 74.1. 723 70.5 9987- 089 1000 I..obirth) _Und.E rmortj_y__rate = Deathstr9q_,h.7dro -/ ( T!L8irts9l 1000) -- . t.j~ LrIoeope~rmy 0009 AIDS 56. 50.5 55.9i 65.3 54.1 0.9 90. 49.1 47.1 456 43.1 41.9 4569 45 97_ 90 3. 95 3. 93 3. 90 3. 0 6 tnj 0190Sf NoAIDO 56.4 58.7 56.0 09.3 58.6 59.9~ ~~~~~~ 06.2- 6 0.5 00.8 61.1 61.4 6.7 620 62.3 62.0 62~9 63 2 835 63.9 0. 644 47 6.8 53- 65.6 ArnnualAdDSdoalhe 9W0 AIDS … 32 74 19 1,728 _ 231~l1 3.302 4.360W 69 85 . , 1,6 644 1)0 1.2 215, 722143~ 327068 23.294 24292g 23,183 26,087.~ 27.221 28.213 AID1S Oaafb*tliSos*f.- . Comuts54oAlSS 00460113$ 047 260 4,34 6 65 ,947 14,327 20,42128-310 383255 50506 65.160 61.642 99,7980119,420 148,181 161,253 1 .199 200.96 229.258 253_55 278.733 3354230.5 deaths :Cam ~AIDS deathoft]=c Cue ADS Dahl-1AD eOsl . . ..- . , .- C.xI AIbsSdeath ma0Wi8AIDs & 0.3 85- 0.8 - 1.1 14 20 32.6 3,5 _4.5 5.5 6.7 7.8 8.7 8.4 99 10.3 18.3 10.5 10.7 150, 11.1 _ 11.3 11.5 191.8 12.9 Corde_AIDS qtatarotsjAIDS_deaf915I pop__sizo 1009 ______ ~~~~~ ~ ~~1991 1992 f9ii@iI -1gj--Tsoo . 7gjj8 199360 201 2022263D7 _ 2D 2510 2_ - 2 21 2014 3615 YoOnla.otdeafto W00h AIDS 3.495 3.63 4.247 __4.71 5.320 6.115 7i8199 8.616 18.211 12.023 14.031 15.848 17.34. 18.7689 10.959i 20.003 21.127 21.092 22.409 33.193 23.962 24.765 2564 2.1 27.529 jAoooaldeethoto No AIDS 3.118 3.163 __.207 .4 .8 .1 . 3.3248358 .71 363 6.95 3.763 3.637J_ 3.902 4.001J 4.14 4.221 4313 437 451 .61 .56 4.616 adults 15-491 ZTV,, j~~~~ m,~~, -ci _W,~~~~ 'o-tv -wt, - ~~~~~ - -ntN~~i MIMW el -Sa-..~a a 0 H - H-- a6aW0Hass as _~~~~~~~~~0 -'_~~~~~~.a-aasrWHaa - eatb N bkb kni - 5's Hlb- 5bit SiNI ktHS S a SOa as N N N taa SnS 5 Ha .LHSSS Wm. ab an O aSS ln 5'a TbN M'E sabenaa nat aab kkL 5b n aSV nb' Saa baY bla HbH in ba bt Sn Lea as Hs en- - iii 59 b SoasS -Mama VW - (oabaSba as.Z Iasalnaal Hti.. a.ib5bslaa'9alb-bb ,aCaa wW n f nt ib s. al b Sg ab SI S 8 N 91 isS SV -H V 0 nabam. 0 0 o'- o -o o- 0 ___o~~~~~-- Hl 5t 'k~ aa I n i g~ FOEdblgd ____ 5 a S ~~~~~~~~~~a - a a~~~~~4 am bW jwa a -'aaWaS w ms aetl sS's§Sru-awbaHb-b-a& leMls bbslebtag'SjstjaaHi 85 a n St'Wg 5559 lstle e'NO 9is5W nas aaa as55b gssas 55Mb ibcb mn et b's mn StM'b sti 54ba 5119188HlaMt Orphans N.,,boroAJDSOroh*n. -- - . -- - 00 -- ~~~~~~-1991- 199 1-993- 19941 199051 -1990 1997- 1998 IM99 -2900 2001 -200&2- 2903- 2004 2005 -2000 2007 200 -2009 2610 -2011 201-2 2013 2014- 201-5 ADs dW~to - 291 -462 70-7 9429 1-349- 1704 2479- 3253 4161 MM 5178 020 7112 - 93 9507 909- 91706 9509 9925 10122 10570 -10955 11340 11809 12313 120 Towl - 00 5.7 5.7 0.6- 5.6 5. 5.4 5.4--- 52 53 - 5.-3 5.2 -5.2 5.1 5:1 5 45 4~9 _ 48 49 4.6 47 47 49 46 4 N464o _10do-th 1.6 1.6 1.6 1.6 1.____ 1.6 10 1.6 1.6. 1.0 1.6. 1.6 1.6 1.6 1.6 1.3 1.3 _1.3 1.3 1.3 13 _1.3 _ 1.1.3 .3__1.3 __g lp- 3.6 2.6 5.6 3.6 3.6 3.6 3.6. 3.6 3.6 3.6 30 - 3.6 -6 3.6 -3.6- 38 17 3.9 3.8 3. _ 3.8 3.8 - f 3 - 3.8 Jwenw 0al to09 5a .0 08 6 .9 00 8 .9 08 .9 08 0.00 0.80 0.9 0.9 0 0.0.69 .99. 0.89 0.0 0.80 0.90, 0.90 0.90 0.90? 0.90 No *-s - 419 669__1,019 1.339~ 1944 2,541i 3564~ 4~675, 0979 7,434 9,032 1026j _1,57 1~2,35 1312 10925 -11410 11,852 12,105 12,654 13,133 13,623 14,264. 14,818 15433 Th1l 1phas 706 i- 13099 2,213 ~30 5 17 107 13.840-189003 24,403 31,292 38,777 46.729 54.991 6324 68.593 73,896 79,159 84,215t 89.371 9405 99748 105 130 110,507 116,172 _ 0 tO -0 tOO 50 9 _ - *O - -0 O--- it - II I 'r1 .tLtt0 SI 0,0 - ootO= - p;0C _~ __ r 9 - - L 00 t5- tO It To 00_ 00 0-W 00 ---0 _- 90n 00 - l _t - . sa _ 0 _ o C t Z I __ _I r +- ft V _ f - 5 M _ ___ ___A , ---6i-- = 00E_ --0 _ _ - 0O0 . f __ i a __ - t-I - Sa0 9561 _ Wz,0 Yoi t_o Itt g -50 - Let 9599 0 -- e taC -- 0900 n- - -- -~~~~~~~ - - - - ---m ,i w - - - - - - z 50 50 1 ft9O iX 00 tO - 00 - , 00 fi_ 0 -- i t i f IV -- 000- 00 00 10 00 0. . t _ 5 . 0 . , _ .t _, _ , .- _ _ ,,_ _. _ __. _ ._ , T , _ t 9 . 4ilStf~ ' moi;lr@ jlDOme 'I&aZ fti -e jwu_ - -, Z,, °v-iZOL'It _ _ i L 1 i _ 1 t1 Z5 5FS SIflC I CO C 11 s 0 Z 0 _11 wO C _ 12 = W S £ ~ ~0it~ Ot I 000 0 isos 0IiC 0't i'0 0iW - i00 --I000 i00~ £00, 'iO0£ ~ 0tC~ Wt -000 cot - i 400 0tWE - --tovoo - I.o-V If _ L _ ___ _ _ ._ _ _. _== _ = = T ff-im. tw .ilf __ __ ____ e_ _ . -_ _. ___ __._ j._-_ _ ._._ . . p, I 5 -- - 00iact' -r0' Ot ?2T 70W 00'o Sot 00W~ 00 99 00 ~0~ 99W~ 700 0500 -dug-, £050 00W- i4 W 0 - 4m 9i0 - ui0 10 000 00 - 000 £00.0 11W 000 00Ot 0500 000 OiF 40V 00V0it -1 00'. -00iC tto -.00 ii0r.-,_____-_____ ____M ___ u00 0'~99001S I000T~90 ~ Tl~J,t80 s i __ 501 00 0001 100T mdi 10- SOOt- SOOt £00 MT91 soo --mo 0001 i 0001 tOl 00 I0 810, - ilO - 01 5t' 01 011 OO 10 It 000 .Vv --- - -, - __m, __L - = - -'- -_- L o 000000009000 -o __- & - 0 0-' 00 0 0 0*0 __Q 9,00 - 00 Sit 10 lIt 00- 09 - 09 W 00 00 St - £00 -- W,-800 __ 991 -- 900 0091 0000 109890 " iti- w ft ~~~~ __65FM_ _ - W -_ m ~~~~~~ - -W T,-.-- - - - , z- 9 00 0.W l0 50 5 00 01. ALuouo*3 Namibia: Assumptions Used in the Costing Selected HIV/AIDS Programs Annex II (Page 1) Indicator Per Year PREVENTIONtMITIGATION 2000-10 Total Cost Million -Namiblan SJ Averaae Cost Per year Million (Namibian S) 2,396 Total Cost % to GDP Averaae Cost %, to GDP 9.4% PREVENTION Total Cost MAllion (Naribian S) Averaqe Cost rer ear Million (Namiblan S) 669 Total Cost % to GDP Averaae Cost % to GDP 2.6% 1. AGE 0-5 Total cost per year Million (Namibian $) Average Cost per year Million (Namibian $) 22 Real GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 0.086% la. AGE 0-6 months: MTC Policy:V.. Zero MTC. Source: Herald (Zimbabwe Daily News Paper) July 26,2000 Cost of Nevirapine (US$) + 10% adiministration cost $8.8 Exchange rate Namibian $ per US$ 8.1 Cost of Nevirapine (Namibian $) 71 Number of Females 15-49 (Average 2000-15) 111,969 Proportion of these Pregnant 15% Pregnant Women 15-49 (Average 2000-15) 16,795 Proportion_of these Pregnant women HIV+ 25% Mothers requiring Nevirapine 4,199 Total cost per year Million (Namibian $j Average Cost peryear Million (Namibian $) 0.298 Real GDP (199912000) Million Namibian $ _ Ratio to GDP Average Ratio for 2000-15 0.001% lb. AGE 0.6-5: Policy: Health care Source: Health Budget (Actual) for 1999/0 Million (Namibian $) 756 Population in 1999 Million 1.755 Percapita Health Expenditure 431 Cost per Child per year ( 1/2 of per capita Health exp) 215 Number of children 0.6-5 (Excluding Orphans) (Average 2000-15) 100,081 Total cost per year Million (Namibian $) 56 Namibia: Assumptions Used in the Costing Selected HIV/AIDS Programs Annex II (Page 2) Indicator Per Year Average Cost per year Million (Namibian $) 22 Real GDP (199912000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 0.084% 2. AGE 6-14: Total cost per year Million (Namibian $) Average Cost per year Million (Namibian $) 123 Real GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 0.5% 2a. AGE 6-10: Pollcy: Age Specific Sex Education Source: Education Budget (Actual) for 1999/0 Million (Namibian $) E 1,738 Population in 1999 Million 1.755 Percapita Education Expenditure _990 Cost per Child per year ( 1/5 of per capIta Educationexp) 198 Number of children 6-10 (Excluding Orphans) (Average 2000-15) 287,707 Total costper year Million (Namibian $9 Average Cost peryear Million Namibian$ 57 Real GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 0.2% 2b. AGE 11-14: Policy: Age Specific Sex Education/Youth Activities Source: Education Budget (Actual) for 1998/9 Million (Namibian $ 1,738 Population in 1999 Million _1.755 Percapita Education Expenditure 990 Cost per Young Child per year (114 of per cappit Education expJ 248 Number of Young children 11 -1-4 Average 2000-15) 265,512 Total cost per year Million (Namibian $) Average Cost per year Million (Namibian $) 66 Real GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 0.3% 3. AGE 15-19 Policy: Age-Specific Sex Education/Youth & Community ActivitiesiCondom Distribution Source: Total cost per year Million (Namibian $. Average Cost per year Million (Namibian $) 136 57 Namibia: Assumptions Used in the Costing Selected HIV/AIDS Programs Annex II (Page 3) Indicator Per Year Real GDP (199912000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 0.5% 3a. AGE 15-19: Both Male and Female Policy. Age Specific Sex Education & Youth Activities Education Budget (Actual) for 1998/9 Million (Namibian $) 1738 Population in 1999 Million 1.755 Percapita Education Expenditure 990 Cost per Youth per year ( 1/2 of per capita Education exp) 495 Number of MALE & FEMALE Youth 15-19 (Average 2000-15) 248,850 Total cost per year Mil-ion (Namibian $) Average Cost per year Million (Namibian $) 123 Real GDP 1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 0.5% 3b. AGE 15-19: Male onh' Policy: Condom Distribution CONDOM cost per year (2 Aweek, 1 condom N$ 1.00) Number of MALE Youth 15-19 (Average 2000-15) 119,685 Total cost per year Million (Namibian $) - Average Cost per year Million (Namibian $) 12 Real GDP (1999/2000) Miilion Namibian $ Ratio to GDP Average Ratio for 2000-15 0.05% 4. AGE 20+ Policy. Workplace condom distributlon,4ECNVoluntaryand free counseling Source: Total cost per year Million (Namibian $) Average Cost per year Million (Namibian $) 389 Reai GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 1.5°%/ 4a. AGE 20+: Both Male and Female So.urce:---- . Education Budget (Actual) for 1998/9 Million (Namibian $) - 1738 Population in 1999 Million 1.755 Percapita Education Expenditure 990 Cost per Adult per year ( 1/4 of per capita Education exp) E 248 Health Budget (Actual) for 1998/9 Million (Namibian $ 756 Population in 1999 Million - 1.755 Percapita Health Expenditure 431 CounsellngCost (1/3 of Health percapita exp) 144 Cost per Adult (20-64) per year 391 58 Namibia: Assumptions Used in the Costing Selected HIV/AIDS Programs Annex II (Page 4) Indicator Per Year Number of Adults 20-64 (Average 2000-15) 798,665 Total cost per year Million (Namibian $) Average Cost per year Million (Namibian $) 312 Real GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 1.3% 4b. AGE 20+: Male on"l Source: CONDOM cost per MALE adult year (4 per week, 1 condom N$ 1.00) 156 Number of MALE Adults 20-59 (Average 2000-15) 349,692 Total cost per year Million (Namibian $) Average Cost per year Million (Namibian $)55 Real GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 0.2% MITIGATION Total Cost Million (Namibian S) Averaae Cost per year Million (Namibian $) 1,573 Total Cost % to GDP Averaqe Cost % to GDP 6.8% 1. AGE 0-14 Policy:Orphan Care Total cost per year Million (Namibian $) Average Cost per year Million (Namibian $) 661 Real GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 2.8% la. AGE 0-5: Policy: Improved quality of life Source: Health Budget (Actual) for 199819 Million (Namibian $) 756 Population in 1999 Million 1.755 Percapita Health Expenditure 431 Cost per Child per year ( 1/2 of per capita Health exp) 215 Number of Children 0-5 (Average 2000-15) 223.243 Total Cost of all orphans age 0-5 Average Ratio for 2000-15 48 Real GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 0.2% 59 Namibia: Assumptions Used in the Costing Selected HIV/AIDS Programs Annex II (Page 5) Indicator Per Year lb. AGE 6-14 ORPHANS: Policy: Provide better health services and education Source: TOTAL COST of ALL ORPHANS (Namibian $ Million) Average Cost per year Million (Namibian $) 589 Real GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 2.6% lb(i). AGE 6-14 NEW ORPHANS: Education Budget (Actual) for 1998/9 Million (Namibian $) 1738 Population in 1999 Million 1.755 Percapita Education Expenditure 990 Cost per Child per year ( 1/2 of per capita Education exp) 495 Health Budget (Actual) for 1998/9 Million (Namibian $) 756 Population in 1999 Million 1.755 Percapita Health Expenditure 431 Cost per Child per year ( 1/2 of per capita Health exp) 215 Cost of FOOD per Child per year Namiblan $ 2960 Total Cost per Orphan per year 3670 Cost per Orphan for 15 years 55,049 NEW orphans (Average 2000-15) 11,136 TOTAL COST of New ORPHANS (Namibian$ Million) (10 years per orphan) Average Cost per year Million (Namibian $) 613 Real GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 2.6% 1biLi). AGE 6-14 EXISTING ORPHANS: EXISTING orphans as of END OF 1999 0 Cost per Orphan per year (estimated same as above) 3670 Cost per Orphan for 8 years 29,359 Cost per Orphan for 8 years adjusted for Inflation 0% TOTAL COST of EXISTING ORPHANS (Namibian $ Million) (8 years per orphansj 0 Average Cost per year Million (Namibian $) 0 Real GDP (1999/2000) Million Namibian $ Ratio to GDP 0.0% Average Ratio for 2000-15 0.0% 2. AGE 15-49: Policy: Improved quality of Life by providing Medclniesfood, water Source: Direct and Indirect Costs, WHO Team Report, November 1994. Cost of medcines/hospitalization per HIV patpient per year Namibian $ 5,000 Number of Youth/Adults 15-49 (Average 2000-15) 143,133 Total cost per year Million (Namibian_$) Average Cost per year Million (Namibian $) 716 Real GDP (1999/2000) Million Namibian $ 60 Namibia: Assumptions Used in the Costing Selected HIV/AIDS Programs Annex II (Page 6) Indicator Per Year Ratio to GDP Average Ratio for 2000-15 3.1% 3. AGE 50+: Policy: Improved quality of life through pension Source: Average Pension Amount for Civil Servants for 1998/9 (Namibian $) per year 9,000 Cost per Person per year ( 1/3 of average civil servant's pension) 3,000 Number of persons 50+ (Average 2000-15) 73,227 Total cost per year Million (Namibian $) Average Cost per year Million (Namibian $) 220 Real GDP (1999/2000) Million Namibian $ Ratio to GDP Average Ratio for 2000-15 0.9% 61