Updated February 2003
Multisectoral Issue Brief
| The HIV/AIDS epidemic in Ethiopia presents an obstacle to development across nearly all sectors of society. |
Beyond devastating the health of individuals and communities, HIV/AIDS has weakened the basic economic and social infrastructure of education, agriculture, industry and government in Ethiopia. HIV poses a threat to all types of assets (e.g., human, financial, physical, social, natural, and capital). Efforts to facilitate Ethiopia’s economic, social, and technological development in spite of the epidemic must first assess the effects of HIV on multiple sectors of society. If these consequences of HIV remain unchecked, they could escalate to proportions that could erode Ethiopia’s basic social fabric. This issue brief estimates the breadth and projected course of the HIV/AIDS epidemic in Ethiopia, summarizes its toll on selected sectors of society, and suggests priority areas for intervention in each sector.
The impact of HIV/AIDS in Ethiopia has been, and is almost certain to continue to be, devastating. Currently, over 2.2 million Ethiopians (an estimated 6.6% of the adult population) are infected with HIV (MOH 2002). About 1 in 15 Ethiopians between the ages of 15 and 49 is infected with the HIV virus (MOH 2002). Many people, unaware they are infected, unknowingly continue to spread the epidemic. In 2001 alone, HIV/AIDS claimed the lives of 160,000 people in Ethiopia (UNAIDS 2002). The cumulative number of deaths from AIDS is expected to increase to between 4 and 7 million over the next 12 years, with 260,000 new cases each year (MOH 2000). Deaths of parents from HIV has also resulted in 1.2 million orphans, children who have lost a mother or both parents to HIV/AIDS (MOH 2002).
In order to curb the exponential spread of HIV and ensuing social disruption, change must take place on individual, community, societal, and political levels simultaneously. An individual can seek voluntary counseling and testing (VCT) to be certain of his or her HIV status. If HIV-negative, one can consider adopting protective measures to avoid HIV infection. If HIV-positive, one can learn and adopt conscientious behaviors to take care of one’s health and avoid transmitting the virus to others. Couples can seek counseling to identify whether they are at risk; they can also improve the ways they communicate about HIV/AIDS and condom use. At the community level, leaders must devise ways of dealing with the loss of prominent society members to HIV/AIDS. There is great potential for community organizations like Edirs to be expanded to care financially for those in need. Greater societal awareness of HIV/AIDS and its transmission, especially among groups particularly vulnerable to HIV infection, can be promoted through health education programs and behavior change communication (BCC) at this level. Much can be done to confront taboos about sexual communication and education, and reduce fears about seeking HIV testing, especially when local opinion leaders such as priests, celebrities, and business leaders can be involved. At the local, regional, and national levels of government, existing political will in each sector should be channeled into the coordinated implementation of existing frameworks for HIV/AIDS prevention and care programs, the strengthening and enforcement of antidiscrimination laws and workplace policies to reduce stigmatization of the HIV-infected and affected, and the issuance of authoritative HIV/AIDS prevention and care guidelines in key issue areas. In designing programs and policies, government and organizations in every sector must consider and address the underlying contextual determinants of the HIV/AIDS epidemic, such as gender inequality, poverty and socioeconomic disparities, low literacy levels and low awareness of HIV, and widespread social disruption due to war and famine.
Ethiopia’s severely constrained health sector has been further challenged by the rapid progression of the HIV/AIDS pandemic. In 2001, Ethiopia had 115 hospitals, 412 health centers, 2,452 health stations, and 1,311 health posts to serve more than 65 million people (MOH 2001). In 2001, there were 1,888 trained medical doctors in Ethiopia: only about one physician for every 36,000 persons (MOH 2001). This ratio is substantially worse than the average for sub-Saharan Africa. Additionally, one-third of doctors and one-sixth of nurses work in Addis Ababa, where just 4% of the country's population lives (MOH 1998). Low numbers and uneven distribution of medical personnel mean that only about 52% of Ethiopians have access to health care (MOH 2001). Government expenditure on health care has improved in recent years, from 5.6% of the total national government budget in 1997/98 to 7.0% in 2001/02 (MOH 2001). The Ministry of Health's comprehensive Health Sector Development Program, now in its second multi-year phase (HSDP II), is working to restructure health care and increase access and utilization of services. Under this plan, performance in health facility expansion and rehabilitation has so far been fairly slow (MOH 2002). Increased outlays of funds and restructuring have not yet been sufficient to mitigate the burden HIV has placed on the health system. Despite emphasis on HIV/AIDS during results reviews of HSDP I, measures to address HIV/AIDS in HSDP II is lacking, as only two of 26 national monitoring indicators pertain to HIV, and no comprehensive community-based indicators have been released as part of HSDP II (MOH 2002).
Out of the nearly 12,000 hospital beds available in Ethiopia, AIDS patients occupy almost half (MOH 2000). The high cost of care for people living with HIV/AIDS (PLWHA) has diverted government funding from the provision of other essential health services like primary health care, maintenance of adequate referral systems, and essential drug programs. The host of opportunistic infections that eventually claim the lives of those infected with HIV require expensive drugs and supplies over long periods of chronic or terminal illness, further burdening both individuals and health systems with mounting costs. Furthermore, basic and specialized care for AIDS patients has increased the workload of already overburdened health care providers and further congested health facilities.
A lack of available resources contributes most to the constraints on the Ethiopian health care system. This problem will best be addressed by improved planning (at all levels, from national government to health posts), better management training, and formulation of government protocols for prevention of opportunistic infections, provision of prophylaxis, VCT, basic care, and prevention of mother-to-child transmission (PMTCT). Additional resources must be committed to this very important sector and dedicated to training more personnel, strengthening facilities, and maintaining good management systems. Health facilities can design programs to attend to stress and burnout, including promoting team spirit, providing training in coping skills, and providing counseling for emotionally burdened and grieving staff.
Education plays a pivotal role in improving a country’s capacity for development, as it generates:
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The education infrastructure also provides the most promising framework for disseminating information about HIV/AIDS to contain the epidemic. For these reasons, the Ethiopian government’s recent emphasis on reforming the education sector is well guided. Total expenditure on education has been increasing steadily in recent years, by more than 1 billion birr since 1997/98 (MOE 2001). In 2000/01, the education sector was allocated 13.74% of total national budget expenditure (MOE 2001). Increased spending on education has facilitated a subsequent rise in gross primary school enrollment ratios, from 41.8% in 1997/98 to 61.6% in 2001/02 (MOE 2002).
However, using the example of Southern African countries (where the epidemic is more advanced) as early warning, projected depletion of the education labor force by HIV will severely curtail the potential of the education sector. The education sector relies on availability of well-trained professionals to be teachers and sectoral managers, both of which are frequently in short supply. Evidence of infection among highly visible educators is also likely to erode their credibility as role models, and the overall value of the education system as a vehicle to encourage preventive behaviors and stigma reduction.
Out-of-school youth, including a large proportion of street children, already constitute the most difficult group to reach with HIV behavior change communication (BCC) campaigns. These children are doubly disadvantaged because they lack the life skills training offered in the classroom. While the proportion of out-of-school youth has recently been declining, increases in the number of children orphaned by AIDS or living in AIDS-affected families are likely to obliterate recent improvements in school enrollment rates, especially of girls. Perceived value of education for girls is already low in many regions of Ethiopia, and increased caregiving responsibilities for HIV/AIDS-affected adults frequently fall to the female children in households, increasing the likelihood they will be unable to attend school. Similarly, children orphaned by AIDS often have neither time nor funds to go to school, and may resort to income-generating activities (such as prostitution) that put them at risk for HIV/AIDS if they are not already infected. As they reach adulthood, this growing class of unschooled children, lacking basic skills such as reading and writing, will be unable to obtain high-paying jobs. A larger unskilled work force will hurt rather than help Ethiopia’s economic development, and the costs of supporting an even larger unemployed class may burden communities and local government.
The education sector has the dual responsibility of limiting susceptibility and ameliorating the impact of HIV, especially among Ethiopia’s youth. Political and administrative heads of education at national, regional, zonal, wereda, and kebele levels must collaborate to formulate a coordinated response to HIV. Once an authoritative and implementable sectoral framework is adopted, sectoral managers and teachers will require targeted training to encourage modification of their risk behaviors and discourage discrimination by and among these leaders. Educators should be placed in their home community wherever possible, to avoid the emotional alienation and anonymity that can sometimes encourage teacher–student sexual relationships. Sexual education in the classroom or in anti-AIDS clubs can reach youth during the “window of hope” (9–13 years), before most children are sexually active and while most are still enrolled in school. Out-of-school youth may also be targeted through community anti-AIDS clubs, peer group education, and condom promotion. Additionally, policies and programs should be designed to promote care programs for orphans, greater involvement of families in the learning continuum, and equal access to the classroom for all students.
Agriculture is Ethiopia’s most economically important sector, accounting for 50% of gross domestic product (GDP), 90% of exports, and 85% of jobs. The current development strategy, called Agricultural-Development-Led Industrialization (ADLI), exemplifies Ethiopia’s dependence on agriculture for economic growth. Under this strategy, the government has embarked on several initiatives such as establishing an agricultural extension program, distributing fertilizers and improved seeds, and providing credit for smallholder agriculture.
The commercial and subsistence agricultural sectors in Ethiopia are non-mechanized; intensive labor requirements demand a strong, healthy labor force. However, the HIV/AIDS pandemic is incapacitating the most economically productive age group (20–49), severely limiting gains from the above agricultural programs and jeopardizing food security. By the year 2014, over 280,000 Ethiopians between the ages of 15 and 49 will die every year due to HIV/AIDS (USAID 2002). Similarly, the number of PLWHA in this age group is predicted to increase dramatically; illnesses afflicting these PLWHAs will reduce economic productivity and compromise operations efficiency.
As labor supply decreases due to AIDS illness and deaths, commercial farmers commonly shift from labor-intensive cash crops to subsistence farming. On a national level, this adaptation reduces national agricultural production (and consequently, GDP) and depletes Ethiopia’s ability to trade commodities internationally. At the community level, ability to produce, buy, and exchange food is hampered because neighbors become too burdened themselves to help one another. On a farm-household level, this practice reduces income available for off-farm purchases such as equipment, fertilizers, pesticides, or purchased foods. Shifts to less labor-intensive crops also tend to have lower nutritional value, contributing to malnutrition. If a malnourished person becomes HIV-positive, he or she often suffers more rapid wasting and accelerated progression to AIDS. Many households sell land and livestock to deal with medical costs or to offset the financial consequences of smaller farming yields. Medical and funeral expenses further reduce cash income available for school fees and off-farm purchases. Additionally, insecure land tenure in many areas means that the death of a household head can deny occupancy and inheritance rights to widows and children. Widows and daughters frequently turn to sex work to generate income.
While HIV prevalence is currently highest in urban areas, this trend is expected to reverse as HIV spreads to rural areas. Already, many urban dwellers that become ill with HIV/AIDS return home to rural areas to receive care, further impoverishing these areas with the cost of hard-to-access treatments, and occasionally spreading the virus through sexual contact. Farmers, who travel from rural areas to nearby towns and cities to sell their crops, have been identified as likely carriers of HIV into rural areas (Shabbir and Larson 1995). While many smallholder farms may be crippled by the loss of a laborer, larger commercial farms may compensate for lost labor by hiring seasonal migrant workers, a strategy that can encourage casual sexual contact and consequently, HIV infection.
Increased prevalence of HIV will create a severe shortage in quality and quantity of the labor force available to work in agriculture, consequently diminishing success of agricultural improvement programs, as well as harvest yields in general. In order for the anticipated benefits from these programs to be realized, HIV/AIDS prevention and control programs must target rural audiences in particular, where a majority of the Ethiopian population lives. Unfortunately, most published studies on sexual behavior in Ethiopia have been carried out in urban areas, meaning that very little data is available to identify high-risk behaviors in rural and tribal populations. Reinforcing this urban focus is a lack of an effective telecommunications infrastructure, as well as low radio ownership, in rural areas. Because of the lack of channels through which to reach geographically remote rural populations, interventions to prevent HIV/AIDS have most frequently concentrated on Addis Ababa and other major cities in Ethiopia, to the exclusion of those in rural areas. Awareness of HIV and how it is transmitted remains extremely low among the vast majority of Ethiopia’s largely rural population. This rural majority generates the economic base on which the country depends for survival.
Innovative methods for promoting awareness and modification of risk behaviors among rural populations are paramount to controlling the spread of HIV. Addressing the HIV/AIDS epidemic in rural areas will require a combination of health interventions and sectoral/policy interventions. While agricultural extension workers are increasingly affected themselves, their mobility and coverage makes them a possible channel for educating rural people about HIV/AIDS. BCC events at markets, frequented especially by women, can also provide a point of entry for educational interventions. Significant opportunities exist for collaboration between agriculture and education. Agricultural training and skill building, especially for orphans and youth, can serve as a form of skills succession planning to minimize the impact of lost skills as agricultural experience is claimed by HIV/AIDS. Careful research into climate and rainfall may suggest alterations in planting schedules or crop choices to improve yields and minimize labor requirements while maintaining nutritional value of crops. Advocacy for improved infrastructure and pro-rural policies may lead to funding for improvements to make testing opportunities and medical care available to the rural population. Protective policies to assure land inheritance rights for widows and children after the death of a tenant are also sorely needed.
Revenues from business, including manufacturing, industry, and services, make up about 48% of Ethiopia's GDP. The leaders in this sector often represent the most educated or skilled members of the Ethiopian labor force. They also tend to live in urban areas, where HIV/AIDS prevalence is currently highest. Even if HIV does not spread rapidly to rural areas, as projected, anticipated high casualties in the industrial and business sector will cripple the pipeline of goods transfer nationally and internationally. Heavy burdens of HIV/AIDS among the workforce are also likely to discourage foreign investment, further hampering attempts at economic development.
AIDS is contributing to extremely high rates of absenteeism due to illness and funeral attendance among the Ethiopian workforce. A five-year survey of 15 firms in Ethiopia implicated AIDS in 53% of all staff illnesses (UNAIDS 2001), implying employers are bearing a growing burden of sick-leave payments. As AIDS claims the lives of more highly trained businessmen, technicians, and operators, companies can develop critical gaps in their skill base. Rapid staff turnover means increased hiring costs. Additionally, employers must combat poor staff morale resulting from fear and uncertainty about HIV/AIDS, as well as disruption in the workplace due to increased workloads and discrimination. Increasingly, employers are facing pressure to pay the cost of care for workers who become ill, including treatments for opportunistic infections.
Workplace HIV/AIDS prevention programs have yet to be widely implemented in Ethiopia. These programs require the formulation of comprehensive policies addressing management, human resources, prevention education, VCT, occupational exposure, confidentiality, and employee benefits issues related to HIV/AIDS. In other sub-Saharan countries such as South Africa, expenditures on prevention programs and STD care have proven to be highly cost-effective alternatives to treating workers later. Employers must also be able to predict the impact of lost labor, plan for skills succession to replace lost expertise, and be prepared to run company audits including data collection to develop effective strategies to reduce employee risk factors and cope with lost labor. Partnership with local NGOs and involvement in community projects may be effective methods of pooling resources to respond to the HIV epidemic. There is also a growing need for the government to design effective policies that protect businesses from being held responsible for HIV in the population at large and costs that overwhelm their capacity to function.
The loss of family members, breadwinners, and prominent community leaders to HIV/AIDS sends devastating ripples through families and communities. Costs of care during characteristically long periods of illness preceding death from AIDS divert household funds from basic necessities such as food, rent, and school fees. Family relationships are increasingly strained by increasing poverty and pressure to take in relatives orphaned by HIV/AIDS. Less and less traditional family structures are emerging, threatening continuity of family traditions. On a population level, high death rates among the most economically productive age groups are increasing the dependency ratio, meaning that a small number of younger adults must provide for children and elderly persons who have lost their source of financial support.
Ethiopian communities are often tightly knit by family and ethnic ties, even establishing informal communal insurance schemes to provide their members with a financial safety net. In most cases, when an individual dies from HIV/AIDS, there are notable financial expenditures due to care, treatment, and income lost from sick days. Traditionally, when an individual dies, the costs of burial and mourning rites are so high that families rely on external assistance to cover funeral arrangements. The primary source of this external assistance is the burial association, or Edir. Edirs are local savings societies that pool funds as basic insurance to assist members with the often-high costs of mourning rites and funeral arrangements (lekso and kebbir). Edirs occasionally become involved in other activities, including development and sanitation projects or care and financial support for the sick (Seifu, 1968). Many Ethiopians belong to at least one Edir, and so these organizations play a significant role in limiting the costs families incur after the death of a loved one. Unfortunately, the increasing number of deaths due to HIV/AIDS is overwhelming Edirs’ capacity to provide financial support. Anecdotal evidence suggests that some of these Edirs are now on the brink of bankruptcy, due to a death rate inflated by HIV/AIDS.
Close community and religious bonds are features of Ethiopian culture that must be maximized to address the threat and consequences of HIV/AIDS. Dialogue on how HIV/AIDS is affecting various communities and community organizations is badly needed in order to propose effective community-based solutions that create an environment empowering people to cope with and respond to the epidemic. Strengthening the response of communities—and the ability of community organizations like Edirs to respond—to HIV/AIDS is particularly urgent because an overwhelmed health care sector and low access to care indicates that a majority of those who suffer from HIV/AIDS in coming years will require community- or home-based care.
HIV/AIDS affects more than people’s health. The analysis contained in this sectoral issue brief documents and forecasts the effects of HIV/AIDS on various sectors of Ethiopian society. Clearly, high HIV prevalence has the potential to undermine the nation’s economic, government, and social structure, with dire consequences for Ethiopia’s economic development prospects. Combating HIV/AIDS and dealing with its consequences is a multisectoral challenge - the health sector alone cannot address the problems HIV/AIDS engenders. This document has enumerated potential responses and interventions within each sector to illustrate the unique capabilities of each sector to influence the course of the HIV/AIDS epidemic.
Identifying the vulnerabilities of different sectors of society is a first step toward designing practical frameworks for preventing or capably handling the social and economic consequences of HIV/AIDS. Of particular importance are policies and programs targeting youth, farmers, and businessmen: these are the groups in Ethiopian society essential to its present and future economic survival. Rural areas, home to Ethiopia’s agricultural lifeblood, are of particular importance in any multisectoral response to HIV/AIDS. Unfortunately, these areas also pose some of the greatest challenges to intervention programs due to the lack of communication and transportation infrastructure; this explains why previous efforts have often neglected these areas.
While awareness of HIV/AIDS is high in many parts of Ethiopia, knowledge about how to prevent transmission of the virus remains low (DHS 2000). Designing effective messages that encourage adoption of more responsible sexual behaviors but also avoid stigmatizing those who are infected is essential. Continuing to promote measures that prevent the further spread of HIV/AIDS, while providing appropriate care and support to all those who have been infected or affected by HIV/AIDS, will require careful and consistent collaboration between government and private-sector organizations, community groups, and individuals. Every sector, and every level, of society must be involved to mitigate the effects of the HIV/AIDS epidemic in Ethiopia.
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