Socio economic burden of hivaids in developing countries - education sector response (obioma nwaorgu)

Socio Economic Burden of HIV & AIDS in Developing Countries: Education Sector Response By Prof. Obioma Nwaorgu

Presentation OutlineBackgroundOverview of HIV and AIDS Situation:Globally and in Sub-Saharan AfricaFactors that contribute to theprogression of the epidemic in Sub-Saharan Africa

Presentation Outline (Cont’d)Impact on Social andEconomic DevelopmentOrphans and other special at riskpopulationImpact on EducationResponse of the Education sectorChallengesRecommendations and Conclusion

BackgroundHuman Immunodeficiency Virus and AcquiredImmune Deficiency Syndrome (HIV &AIDS)continues its course.HIV and AIDS are reversing decades ofdevelopment gains, increasing povertyespecially among the poor countries andundermining the very foundations of progressand security.The pandemic demands a response thatconfronts the infection in every sector, buteducation has a particularly important role toplay.

Overview of HIV/AIDS SituationThere were about 33.3 million people living with HIV at the end of 2009 (UNAIDS,2010) compared with 26.2 million in 1999.In 2009 an estimated 2.6 million people became newly infectedIn 2009 about 1.8 million died from HIV and AIDS.Also it is estimated that 2.5 million children are living with HIV in 2009.

Global HIV Trends, 1990 to 2009

Globally Prevalence of HIV, 2009

Sub-Saharan Africa (SSA) SSA, bears the global burden and remains the worst- affected region, with the highest prevalence in Southern African (between 15–35%)• At the end of 2009, 68% of all people living with HIV, or 22.5 million individuals, lived in sub-Saharan Africa.• In 2009, an estimated 1.8 million people in the region became newly infected with HIV and 1.3 million adults and children died of AIDS In 2009, 14.8 million children in the region have lost one or more parents to AIDS. Almost 90% of the total number of children living with HIV live in sub-Saharan Africa and fewer than one in ten of these children are being reached by basic support services.

Prevalence in Sub Saharan Africa

Factors that aid the progression of the Epidemic in Sub-Saharan AfricaPhysiological factorsPoverty Lack of information/ ignorance ,Discrimination and stigmatization, denial There is increasingly awareness of the femaleface of the AIDS epidemic (Feminization of HIVand AIDS)Women are more vulnerable to HIV infection onsocial and economic grounds which are clearlyrelated to gender, cultural norms, expectationsand harmful traditional practices eg wifeinheritance, FGC etc

Social Economic Impact of HIV and AIDSHousehold and individualsAgricultureHealthOrphans and other special at riskpopulationEducation

Impact on household & individualsIncrease in number of female headed households, exuberating povertySouth Africa Study in South Africa showed affected households have less monthly income than non affected households and funeral costs were four times the monthly income of households. The purchasing power of the market is affected because there is lower income to rising prices.

Household & individuals (cont’d)Nigeria In Benue state Nigeria, affected households took an advance on future earnings by reducing their investment in farming (19% reduced expenses on hired labour), 12% stopped the payment of school fees while 8% started working as casual labourers at the expense of their own farms or sold their land ( Hilhorst et al, 2006)

Impact on AgricultureReduction in Agricultural labour force : It is estimatedthat by 2020 the pandemic will have claimed 26%lives in Namibia, 23% in Botswana and Zimbabwe,20% in Mozambique and South Africa, and 17% inKenya.Decrease in range of crops being cultivated and outputby 50% (FAO).A study in Thailand showed a shiftaway from labor-demanding crops like rice and chili tocrops that need less labor.85% of the women farmers interviewed in a study atEnugu , Nigeria stated that HIV and AIDS causedreduction in their family income.

Agriculture ContEffects of HIV/AIDS on Major Agricultural Output(100kg bags grains) in BenueState Nigeria (Duru and Mernan, 2011)

Impact on the Health SectorReduction in health care work force eg in Botswana17% died between 1999 to 2005Increased infrastructure modifications, spending andcost on government.More demand for services and care due to longhospitalization.A significant increase in time spent by all householdmembers in caring for the ill. Women spent onaverage of 14 hours per week, men 12 hours, andboys and girls 10 and 11 hours per week respectively .

Orphans and other special at risk populationsLargest impact of the AIDS pandemic, with an estimated 15million children who have lost one or both parents to AIDSDue to death of parents or to take care of other familyneeds, OVC withdraw from schooling .Initially estimated at 2% but has now risen to as high as 15to 20 percent in some African countries.Children orphaned by AIDS often exhibit cognitive deficitswhen compared with their uninfected peers (Martin et al2006).These deficits can adversely affect learning andearning ability later in life.

Orphans in selected sub-Saharan African Countries (UNAIDS, 2004) Orphans as share of young Average Dependency Ratio of population 2003 1 ratio2 orphan to non orphan children attending school All Orphans AIDS Orphans Households with Households with Orphans children not orphansBotswana 15.1 10.6 1.4 1.7 0.99Cote d’Ivorie 13.3 6.2 1.4 1.5 0.83Ethiopia 13.2 3.4 1.5 1.6 0.60Malawi 17.5 8.7 1.5 2.0 0.93South Africa 10.3 4.5 1.4 1.7 0.95Uganda 14.6 7.5 1.7 2.3 0.95Zimbabwe 17.6 13.5 1.4 2.2 0.85

Impact on EducationThis can be analyzed at different levels:1. Access to Education - Children may be denied access to school due to fears and stigmatization in the community2. Demand for education – decline in the number seeking education3. Supply of education – reduced number of teachers4. Quality and management – decreased human and material resources.

Impact on Education (Cont’d)The impact and devastating effect of HIV/AIDS to the education system has not been calculated or determined in SSA. Deaths of children born with HIV and the removal of AIDS orphans and other children affected by the epidemic from school, result in smaller numbers of children needing education. In Swaziland, it is projected that by 2016, there will be a 30% reduction in the size of the primary school population for each grade. In South Africa, 21% of teachers aged 25 – 34 and 13 % of those aged 35- 44 are estimated to be infected; even with decline in teacher’s resources, there are reports that the number of teachers being trained is not enough to fill the gaps.

Impact on Education (Cont’d) In Zambia, 60% of teachers are absent in schoolsbecause of personal illness or taking care of familymembers. Also a survey carried out among teachersfound a five percent increase in a teacher’s rate ofabsence, there by reduced students’ average gains inlearning by four to eight percent per year.Tanzania estimated that 45,000 additional teachers areneeded to make up for those who have died or left thesystem because of AIDS.The average age, and therefore the level of training ofteachers, is also expected to fall, which will mean thatteachers may be less experienced.

Why does education matter?‘Education is the most powerful weapon you can use to change the world’ (Nelson Mandela, Global Campaign for Education (GCE), 2004), and ‘is a basic instrument for eradicating poverty’ HIV/AIDS has significantly reduced average years of schooling or enrolment rates. Investment in education is vital: It promotes achievement of six of the eight MDGs Better educated women are more likely, in comparison with their peers to adopt and sustain behaviours that will reduce the spread of the virus

Why education? (Cont’d)Data in the late 1980s and early 1990s, mostly showed apositive correlation between level of education and rates ofinfection. E.g. a study in Zambia found a marked decline inHIV prevalence rates in 15- to 19-year-old boys and girlswith a medium to higher level education, but an increaseamong those with lower educational levels (Kelly, 2000c). Countries’ education sectors have a strong potential tomake a difference in the response against HIV/AIDS. Interms of monetary impact, HIV/AIDS is estimated to addbetween US $450 million and $550 million per year (USdollar values for 2000) to the cost of achieving the mandateset out in ‘Education For All’ (UNESCO, ) in 33 Africancountries.

HIV &AIDS and education: The consequences of inaction

Why Education sector ResponseThe largely uninfected age group (0-14) is found in the sector andrepresents a window of hope for prevention of new infectionsSchools not only offer an organized and efficient way to reachlarge numbers of school-age youth but the students are particularlyreceptive to learning new information.Schools provide a base for reaching out to the wider communityThe sector provides tools for behaviour change and providescomparative advantage with an existing framework – thecurriculum.Education sector is now unanimously recognized as having a keyrole to play in HIV prevention and mitigation of the impact ofAIDS; not only in its capacity to reach large numbers of the mostat risk group (the youth) but also in its ability to change thenegative attitudes, behaviours and practices that put staff andlearners at all tiers at risk.

Response (cont’d)The Dakar Framework for Action during theWorld Education Forum drew attention to theurgent need to combat HIV/AIDS, if Educationfor All (EFA) goals is to be achieved. It called ongovernments to ensure that by 2015 all children,particularly girls, children in difficultcircumstances and ethnic minorities haveaccess to complete free and compulsory primaryeducation of good quality.

Response (cont’d)Millennium Development Goals for Educationwhich seeks to “ensure that by 2015, childreneverywhere, boys and girls alike, will be able tocomplete a full course of primary schooling”,cannot be achieved without urgent attention toHIV/AIDS.UN GASS targets and the MDG for HIV/AIDS,malaria and other diseases cannot be achievedwithout the active contribution of the educationsector.

Response of Sub- Saharan African CountriesAt national level, some countries in SSA havetaken steps to address the impact of HIV andAIDS on the education sector and to adaptsystems to respond to the epidemic.Mass media campaigns have been conducted,but many have not been formally evaluated.Life skills programmes have been introducedwithin the education sector as part of the schoolcurriculum.

Response Africa (cont’d)Less attention to teachers’ programmeson HIV and AIDS.Comprehensive programmes on OVConly available in 29% of countriesImplementation tends to be weak, withgeographical disparity within countries; it ismostly focused on schoolchildren and isonly just beginning to focus on teachers.

Response NigeriaFaced with controlling HIV&AIDS in its 36 states and theFederal Capital Territory (FCT), Nigeria’s response until1999 was coordinated by the Federal Ministry of HealthStages in response to the epidemic included: an initialperiod of denial; a largely medical response; a publichealth response; and now a multi-sectoral response thatfocuses on prevention, treatment and impact mitigationinterventions.In 2000, National Action Committee on AIDS (NACA)was inaugurated and a 3-year HIV strategic plan,HIV/AIDS Emergency Action Plan was formulated in2001 (HEAP 2001- 2004)

Response Nigeria (Cont’d)In 2001 provision of subsidized ART was announced bythe President through the Abuja Declaration.In 2003 the first national workshop on accelerating theeducation sector response to HIV&AIDS organized bythe FME, supported by the UNAIDS and otherdevelopment partners, helped set the stage.In 2004 National Policy on HIV&AIDS for theEducation Sector was developed and finalized in2005. This helped to inform the NationalEducation Sector HIV&AIDS Strategic Plan(NESP) 2006-2010.

Nigeria cont’dAcceleration of education sector response is infour main areas namely:Policy and Strategies with five main strategicareas for responsePlanning and mitigationPreventionOrphans and Vulnerable Children

Response Nigeria cont’ 26 out of the 36 states and the FCT had developed state level strategic plans based on NESP, with technical support from development partners. This led to following responses:o Increased capacity for programme management, leading to establishment of critical mass within FME, States and mobilisation of fundso Development of culturally appropriate national HIV prevention curriculum - Family Life and HIV Education (FLHE) between 2003 and 2004

Response NigeriaIn 2006, 26 states reported that they had initiatedteachers training on FLHE. In 13 states, the FLHEwas already being taught in secondary schools, whilenine states reported teaching the FLHE in primaryschools .E-learning methods for delivering the FLHE werealso being piloted in three states.

Response Nigeria (Cont’d)Co-curricular methods ( peer education, anti-AIDS clubs, Drama, Music comic books, postersetc) were widely promoted in all states.UNICEF supported Co-curriculum programme forNYSC members in schoolsSupport to orphans and vulnerable children: In2007 The FME proposed holistic scholarshipsupport to OVC children working with theFederal Ministry of Women Affairs to identify andrespond to the educational needs of these children

Trend in HIV prevalence in Nigeria from 1991 - 2005

Case Study States

FLHE ImplementationStates were asked to implement underculturally acceptable standardsGlobal Health Awareness ResearchFoundation (GHARF) a non-governmental,non- profit making and humanitarianorganization based in Enugu State, south EastNigeria facilitated the process in the state

FLHE ImplementationGHARF facilitated the integration of Family Life and HIV Education into the curriculum of all the 286 Public Junior secondary schools in Enugu State with support from the John T. and Catherine D MacArthur FoundationIntegration was in two subjects Social Studies and Integrated ScienceFLHE was implemented in three phases : Phase 1: PRE IMPLEMENTATION Phase 2: IMPLEMENTATION Phase 3: POST IMPLEMENTATION

Pre-implementation PhaseThe following activities were carried out: Advocacy visits to Enugu State Government which led to the signing of Memorandum of Understanding (MOU) between GHARF and Enugu State Government in 2004 Formation of Think- Tank Committee (Staff of Ministries of Education: Health, Gender Affairs & Social Development, Human Resources & Poverty Alleviation, Post Primary School Management Board (PPSMB), State Universal Basic Education Board (SUBEB) and State Technical Science and Vocational Schools Management Board (STSVSMB) and chaired by the Commissioner for Education

Pre-implementation Phase (Cont’d)Selection and training of Master Trainers (3GHARF staff & 2 from MoE)Baseline survey in selected schools andcommunities to ascertain the KAP of students,community members and leaders using bothqualitative and quantitative methods

Implementation PhaseThe following activities were carried out: Sensitization of stakeholders (Traditional rulers, FBOs leaders, PTA, CSPs, Media, Principals) Capacity building of implementers (Teachers of Social Studies & Integrated Science now Basic Science) Capacity building of GHARF staff, PPSMB, Zonal supervisors (ZIE) & State Supervisors (AIE) for monitoring of FLHE implementation in schools.

Implementation Phase (Cont’d) Teaching of FLHE in classroom Monitoring of FLHE implementation – Two types of monitoring visits were conducted-Baseline monitoring: To ascertain the availability of the curriculum, scheme of work and number of teachers trained-Classroom monitoring: To determine the extent and quality of teaching.Checklist of indicators was developed for the monitoring in schools

Summary of Results483 teachers trained by end of 2007252 schools monitored3, 615 students reachedResults of Mid term evaluation showedstudent’s performance levels in knowledge,skills and attitudes were highComfort level on sexual and RH issues ofteachers improved

Post implementation PhaseThe following activities were carried out: Monitoring of FLHE Evaluation of FLHE implementation Consensus building meeting with major stakeholder Scale up of FLHE to other subjects Home Economics, Physical and Health Education, Social Studies and Integrated Science

Participant’s group work presentation

During the teaching practice

Evaluation ResultsIncrease in knowledge score compared tobaseline especially among females (from 24%to 82.4%)Decrease in sexual activities amongintervention groupReduction in number of sexual partnersIncrease in number of individuals usingcondom for protection against unwantedpreganancy and STDs

Evaluation continuesDecrease in incidence of unwanted pregnancyamong the intervention groups. Only 2.0%indicated that they have been pregnant or madesome one pregnant compared with control thatreported 4.9%

Knowledge of Reproductive Health Issues among Respondentsby some Demographic Characteristics and Evaluation

Distribution of Respondents by Sexual Experience (Everhad sex) by some Demographic Characteristics

No. of Sex Partners of the Sexually Active Respondents by Armand Evaluation Period

Effort made to Prevent Reproductive Health Hazards bySexually Active Respondents, Study Arm and Evaluation

Frequency of use of Protective Devices againstReproductive Health Hazards among Sexually Active Respondents

Distribution of Respondents by PregnancyExperience, Study Arm and Evaluation

Scale up of FLHE to other subjectsThrough The Global Fund Round 9 grantsstrengthen of FLHE implementation in 4 subjectsin Nigeria was initiated.This took off in the 20 states in Nigeria includingEnugu in 2010.GHARF is also involved as one of the MasterTrainersFLHE has been integrated into four subjects:Social Studies, Basic Science, Home Economicsand Health & Physical Education

Summary of Results14 batches of training conducted in the 6educational zones560 teachers trained16, 000 students reached using 3 strategies inline with the Minimum Prevention Package ofthe National Prevention Plan

Achievements: Enugu StateIn Enugu, the training of trainers was cascaded down tomost of the estimated 282 public junior secondaryschools teachers between 2005 and 2006, with fundingfrom the Ford Foundation and MacArthur Foundation(FME & AHI 2006).During that year, additional teachers were trained by thestate government to bring the total to 600 (approx. 2teachers per school) . At the same time, 30 schoolinspectors were trained on monitoring andevaluating the FLHE curriculum. FLHE was taught insocial studies and integrated science in 88% of juniorsecondary schools.

Assessment of the responseThe steady decrease in the prevalencerate obtained from the sentinel surveys isencouraging (6. 00 in 2001, 5.3 in 2003,4.3 in 2005, 4.6 in 2008 and 4.1 in 2010).This has given us some rays of hope thatour preventions/interventions areeffective.

Lessons LearntThe programme in general has won support of parents,community and religious leaders, there by has helped toremove policy barriers and change service provider’sprejudices.Other lessons learned indicate the need to enlist childrenand young people in programme design and delivery,inform young people specifically what they need to do,and help them to acquire interpersonal skills to avoidrisks. Finally, it is crucial to link information and advice withservices, offer role models that make safe behaviourattractive and invest enough-for long enough- to make adifference.

ChallengesSome of the challenges faced by the education sector were due to the country’s diverse demography, variations in HIV prevalence and technical capacity for response across states, and the availability of resources. These include: • Inadequate funding (provided by the state government): • Monitoring and evaluation is inadequate.• Poor networking within the sector and between States Non inclusion of out-of-school youth Non acceptance of condoms despite evidence for risk reduction• Lack of incentives for staff of the Education ministry to implement HIV and AIDS activities.

Challenges Cont’dMisconception on the content of thecurriculum in some schoolsSome of the school Principals did not allowFLHE teachers to teach FLHE topics in suchschools due to lack of knowledgeThe division of schools into junior and seniorsecondary schools Trained teachers wereunable to step down the training to otherteachers in their schools

Challenges (cont’d)Constant and frequent transfer of FLHE teacherswithout replacement in some schoolsConstant change of scheme of work by the Ministryof Education. This has led to schools using differentschemes of work most of which do not havecomprehensive FLHE topics.Frequent transfer of policy makers in the SMOE bythe state government

RecommendationsImplementation of the national education sector HIVpolicy (Work place policy), particularly at the statelevel should be accelerated for improved result.Improving the coordination, monitoring andevaluation of programmes especially at the statelevels at all stages of implementation.Increasing the provision of education incentives forOVCImproving Information data bank on HIV and AIDSin this sector (Unavailability of data also made itdifficult to assess the impact of the supportiveschemes and to improve its management )

Recommendation Cont’dContinuous monitoring of classroom teaching ofFLHEScale up implementation to the senior secondaryclasses.Conduct interactive sessions for FLHE teachers forexperience sharing and best practicesConduct trainings /re-trainings for teachersEstablish/strengthen peer education programme inschools and for out of school youthState government should provide budgetaryallocation for FLHE for sustainability purposes

ConclusionOur children represents our future and windowof hope.No stone should be left unturned towardsensuring that a HIV free generation is achievedIn view of the above, their education remainsthe best place to start

Socio economic burden of hivaids in developing countries - education sector response (obioma nwaorgu)

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