Unite for Children,

Unite against AIDS.

Crises impact on children vulnerable to HIV

UNICEF, ODI ConferenceThe Global Economic Crises – including children in the economic response9-10 November, 2009

Nicola Jones, Carlotta Tincati, Caroline Harper, Shreya Mitra, Jessica Espey

Presented by Ken Legins

Senior Advisor, HIV Policy and Evidence

UNICEF

Outline

1. Framework to guide the linkages between HIV and the economic crises

2. Broad impacts and the special case for children and their mothers

1. How it impacts on children and mothers living with HIV

2. How it makes women and children more vulnerable to HIV

3. Case studies across epidemic types

4. Policy Recommendations for consideration

Framework

Declining social capital ; rising social violence

Financial Crisis –Impacts on Children Vulnerable to

or Living with HIV/AIDS

Exchange Rates

Rising unemployment,

under-employment, declining working

conditions

Declining investment in public Services

(education, health, nutrition, water and sanitation, housing,

protection, care)

Intra-household dynamics & household composition

Child-specific vulnerabilities Deprivations of rights to survival, development, protection, participation

Orphanhood, child-headed households, stigma, care burdens, lack of legal rights to assets

Household management

of assets and investments

Household consumption

(food and services, both quantity and quality)

Household time use

Reproduction, nurture, and

care

Policy Responses

Pre-existing and crisis-response investment in basic HIV/AID servicesPre-existing national plan on HIV/AIDS with focus on children

Pre-existing social protection infrastructure and crisis-specific measures

Protection (physical

and emotional)& promotion of well-being

Fiscal space

Civil society policy

advocacy + service

provision

Political economy dynamics

General regional and international macro-

economic health

RemittancesFinancial

flows

Trade and prices (commodities and services)

Aid

Dimensions of the macro-economic environment

Functions of the household

Meso-level effects of the financial crisis

Policy responses

Reduced access to credit

Declining social capital ; rising social violence

General regional and international macro-

economic health

The world of HIV

© Copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).

The world of income

© Copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).

Total annual resources available for AIDS 1986-2007

Resource Availability for HIV, 2005-2008

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

2005 2006 2007 2008

US

$ m

illi

on

Domestic (Public and Private)*** Bilateral ODA*Multilateral ODA* Philanthropic sector**

$7,918$8,835

$13,765

$11,322

Source: *OECD/DAC CRS; data extracted on 2009/01/15 13:13 from OECD.Stat** FCAA (2008) and EFG (2008)*** UNADIS, 2008

52%

31%

12%

5%

Respondents expecting an adverse impact in the next twelve months on antiretroviral treatment (%) (comparison of April and July 2009 surveys)

Challenges posed by crises - financial

• The huge investment in treatment means that without new money there will be very little resources that can be directed toward prevention and it will be tough to increase treatment numbers. • The pace of new infections also continues to outstrip the number

treated. For every one person being put on a therapy regime, three people contract the disease.

• Trend is worrying because the majority of HIV positive people don’t know their status (<40% and lower for high risk groups) and the majority of people who need treatment are not getting it (40-47% on treatment)

Why pay attention to children and HIV?

• 50% of all children living with HIV will die by their 2nd birthday if they do not get ART.

-

How is the crisis impacting on children living with HIV and their mothers

• Health Seeking Behaviour for PLWHAs• Out of pocket expenses

• Travel• Corruption (bribes for tests, etc). There are legitimate users fees and

associate costs as well.

• Burden sharing – child’s responsibilities increase• Seek allopathic health care (witch doctors)

How is the crisis impacting on children living with HIV and their mothers: HH expenditure

Health Expenditure Ratios (2006)

Public Versus Private Expenditures

Total expenditures onhealth as % of GDP

General governmentexpenditures on healthas % of totalgovernmentexpenditures

General governmentexpenditures on healthas % of totalexpenditureson health

Private expenditures onhealth as % of totalexpenditures on health

Out-of-pocket expenditures as % of private expenditures on health

External resources forhealth as %of totalexpenditures on health

Botswana 7.1 17.8 76.5 23.5 27.5 5.8

Haiti 8.4 29.8 67.6 32.4 89.6 65.8

Lesotho 6.8 8.2 58.9 41.1 68.9 14.3

Mozambique 5.0 12.5 70.8 29.2 40.6 60.3

Namibia 5.4 10.5 66.7 33.3 15.7 21.1

Russia 5.3 10.8 63.2 36.8 81.5 0.1

South Africa 8.0 9.1 37.7 62.3 17.5 0.9

Swaziland 6.3 11.2 65.8 34.2 41.4 12.3

Thailand 3.5 11.3 64.5 35.5 76.6 0.3

Zambia 6.2 16.4 60.7 39.3 67.2 38.1

Zimbabwe 9.3 8.9 48.7 51.3 50.3 17.3

How is the crisis impacting on children living with HIV and their mothers

• Social exclusion• HIV+ migrants looking for jobs will not have the same access to

health and protection services• Exploitation and abuse, loss of homes and inheritance rights,

potential to become street children and child trafficking were all recorded risks in South East Asia (Save the Children)

• Gender/Age Economic Risks - anticipated• Women/girls are primary health care providers.

• In Africa over 90% of care of PLWHA is provided by women• Women often consume less and poorer quality food in an effort to protect their

families

• Children living with HIV need 100% more nutrition• 80% less quantity of food in households affected by HIV in India / girls less

How is the crisis intensifying vulnerability to new infection

• Food consumption• Dependence on asset selling, as poverty, HIV and malnutrition

are are linked.

There is a complex three-way relationship between malnutrition, the immune systems and infection, with malnutrition eliciting immune systems dysfunctions with in turn promote increased vulnerability of the host to infection, and the latter intensifying severity of malnutrition– Enwonwu (2006)

• Health seeking behaviour• Access to testing – and throughout the cascade of PMTCT

interventions

Percentage of pregnant women who received an HIV test in low- and middle- income countries by region, 2004-2008

.

How is the crisis intensifying vulnerability to new infection

• Loss of livelihood and risky coping strategies• Hazardous forms of work and the sex industry• 58% of current Cambodian sex workers had entered the trade since the

onset of the crisis.

• Impacts on Schooling• Being in school exempts children from working in risky occupations.

• Gender/age dimensions• Employment – coping strategies and female susceptibility• 2 to 4.5 times higher infection rates for girls in Eastern and Southern

Africa. • Age

• Social exclusion of children affected by HIV and other vulnerable children

Respondents reporting or expecting an adverse impact on prevention and OVC programmes

Percentage of orphans and vulnerable children whose household received basic external support, 2005-2007

Applying the Model across different epidemics: Literature & interviews

Macro: Decline in FDI / Declining Trade Volumes and Prices / Lower remittances / Declines in ODA

Meso: Growth deceleration / Unemployment / Reduced Government Fiscal Space / Potential for cuts in health public expenditure (e.g. South Africa) and health private expenditure (e.g. Zambia mining companies)

Micro: Increasing Transport Costs / Lower remittances / Unemployment

Thailand: Commercial sex-workers

Macro: Growth contraction / Private Investment and consumption declines / Poorer volumes of trade / Decline in remittances

Meso: Suspected HIV budget cuts as per 1997? / Unemployment

Micro: Lower external HH inflows like remittances / unemployment / hazardous forms of employment like sex work / trafficking.

Policy Response?

- National Health Security Scheme

- Children: Compulsory free basic education

- Contributory and non-contributory social protection schemes, including unemployment benefit. Coverage for unemployment benefit was extended from 6 to 8 months as part of the government's stimulus package

Policy recommendations for consideration

1. Age and gender sensitive analysis• An analysis of the risks women face has provided the basis for further analysis of

women and children as living with HIV, care givers and at increased vulnerability.

2. Development of an AIDS sensitive, but not AIDS exclusive comprehensive package of protection measures which reflect context specific vulnerabilities.

• Context specific approaches: child grants, social insurance, etc.

3. Promote HIV as an entry point for health systems strengthening – improved access and coverage of MCH leading to impact and reduce inefficiencies in the current programmes.

4. Build back better – national policies must reflect the true capacity of civil society and to monitor the impact of the crises on their capacities so government responses can compliment.

Thank you!

Catastrophic out-of-pocket payments

0

1

2

3

4

5

6

7

8

9

10

1 500 999 1498 1997 2496 2995 3494 3993 4492 4991 5490 5989

Households ranked by expend w/out hc payments

HH

exp

endi

ture

as

mul

tiple

of

PL

Pov line = VND 1.8m/year Expend w/out hc paymentsHC payments

Out-of-pocket payments for health care pushed 2.6m

Vietnamese into poverty in 1998. Increased poverty

headcount by 23%

Russia: Intravenous Drug Users

Macro: GDP contracting by c. 7.9% in 2009 (World Bank 2009) / Lower FDI / Lower trade / Falling commodity prices (price of Urals brand oil fell 70% in first 4 months of 2009).

Meso: South-south remittances from Russia vulnerable (b/c of currency depreciation) / Unemployment up to 13% (World Bank 2009) / Real wages reduced by 2% (ibid).

Micro: Poverty up to 17.4% (World Bank 2009) / Lower HH consumption (down 2.2% in Q1 ‘09) / significant effects on out of pocket expenditure….

• The trip F crisis will increase the Global poor between 53 and 64 million people in 2009 for those living on less than $2 and $1.25/day.

• Continued high prices of domestic food and fuel• Challenge because no previous crisis.• How to work with programmes to inform policy• Addressing inefficiencies within social sectors• HIV relationship to poverty

Crises specific impacts

• Budgets – national and household• Pubic and private

• Outpacing of new infections with number of peoplw accessing drugs

• Inefficient use of resources (cuts on interventions for most at risk populations, including children MARA and MARPS)

Exacerbating pre-crisis conditions

• Absence of strategic national responses to address children affected by AIDS and other vulnerable children

• Ineffective health systems and knowledge about HIV testing, especially for parents

• Evidence base for working with MARA and MARPs is limited, but political will to address the needs of these populations is difficult

How is the crisis impacting on children living with HIV and their mothers: Factors causing or expected to affect the HIV and AIDS response across regions

Regions1/ 2/ AP Caribbean ESAF ECA LA MENA WCAF

Household income

27% 100% 55% 50% 50% 33% 69%

NGOs and CBOs capacity

27% 67% 64% 50% 50% 33% 74%

Food and nutrition

18% 100% 64% 30% 33% 0% 68%

External Aid 18% 67% 55% 70% 50% 67% 84%

Government budget for HIV

27% 67% 64% 60% 50.0 33% 68%

Prices for ART 0% 67% 18% 50% 17% 0% 32%

User fees 9% 67% 0% 20% 0% 0% 16%

Private sector 0% 67% 27% 30% 0% 33% 58%

Source: UNAIDS/World Bank survey