Health and HIV/AIDS

Health is another important determinant of socioeconomic status and of human develop-ment. Unhealthy persons will face challenges offering their labour for gainful employment and participating in the economy. Poor health indicators therefore signify health stresses that could potentially slow down, stall or even reverse human progress. Table 2.8 presents selected mortality indicators for SADC.

12 UNESCO. 2008. Medium Term Strategy 2008-2013

According to RISDP, the main challenges in the area of health in SADC include:

• Reducing the heavy burden of major diseases, particularly HIV/AIDS, tuberculosis, malaria, cholera and cancer, as well as the need to develop and strengthen mechanisms for addressing emerging communicable diseases

• Affordability, access to essential drugs, including antiretroviral drugs (ARVs), and quality of health care and the need to mobilise adequate resources and strengthen key stakeholders for the provision of health-care infrastructure, health services and the training of health personnel

• Addressing the problem of lack of understanding or appreciation of the gender dimensions and their mainstreaming in all the health interventions

• Reversing the loss of health professionals arising from the impact of the HIV/AIDS pandemic and brain drain

• Increasing access to services that improve health, such as water and sanitation, as well as combating high levels of malnutrition particularly among vulnerable groups such as children, youth, women and the elderly.

Table 2.8: Selected mortality indicators for SADC¹³

Infant mortality rate (per

1,000 live births) Under five mortality rate (per

1,000 live births) Maternal mortality (per 100,000 births)

Angola 139.3 128.3 -11.1 250.0 232.2 -17.9 1,712.5 1,512.5 -200.0

Botswana 42.3 49.1 6.8 93.1 70.0 -23.1 237.5 332.5 95.0

DRC 117.3 114.3 -3.0 211.0 197.4 -13.6 968.0 1,025.0 57.0

Lesotho 71.0 63.8 -7.2 101.4 99.6 -1.9 562.0 780.0 218.0

Madagascar 79.7 69.2 -10.5 123.5 108.0 -15.5 525.6 475.0 -50.6

Malawi 96.1 85.3 -10.8 165.0 134.3 -30.7 1020.0 981.5 -38.5

Mauritius 15.5 14.1 -1.4 18.6 16.7 -1.9 27.2 22.3 -5.0

Mozambique 123.3 101.5 -21.7 189.3 165.9 -23.4 1,100.0 520.0 -580.0

Namibia 44.3 44.9 0.7 75.0 67.2 -7.7 280.0 270.0 -10.0

Seychelles 13.3 11.3 -2.0 50.7 53.8 3.1 N/A 57.0 N/A

South Africa 41.2 45.7 4.5 67.5 67.1 -0.5 230.0 155.0 -75.0

Swaziland 72.8 70.1 -2.7 134.6 115.6 -19.0 230.0 410.0 180.0

Tanzania 104.4 85.1 -19.3 133.3 119.7 -13.6 1,112.0 567.5 -544.5

Zambia 95.0 92.2 -2.8 177.9 158.3 -19.7 725.8 775.0 49.2

Zimbabwe 61.1 58.9 -2.2 108.9 94.7 -14.2 598.3 595.0 -3.3

Average 74.4 68.9 -5.5 126.6 113.3 -13.3 666.4 565.2 -64.8

Source: constructed from SADC Statistics Facts and Figures.

13 Table 2.8 provides the most recent data available as provided by the SADC Secretariat

Poor indicators for the health sector in the SADC are largely a reflection of the prominent problem of diseases in the subregion. Expenditure on health indicates rather low govern-ment commitgovern-ment to supporting health, particularly relative to the various declarations that most governments have endorsed.

Table 2.9 shows a few indicators of spending on health during 2000-2010. The highest spender on health as a proportion of GDP was South Africa with a health outlay of 8.7 per cent of GDP. Other high spenders on health were Lesotho, Botswana, Malawi, Namibia and Zambia who were all higher than the SADC average of 5.8 per cent of GDP. On the other side of the spectrum, Zimbabwe was the only case of an extremely low health expen-diture bill of about 0.01 per cent.

Per capita health expenditures reflect the average level of health spending per member of the population. Countries with relatively small populations (Botswana, Namibia, Swazi-land, Seychelles and Mauritius) achieved the higher per capita health expenditure levels in the subregion. They were joined by South Africa, a country with a large population.

Again, the disparities in per capita health spending are substantial across countries. The highest period average per capita spending of $443.65 was recorded by Mauritius while the lowest ($9.08) was recorded by DRC. The subregional average was $140.52. In 2008, all but a handful of SADC countries fell dismally short of meeting the Abuja Declaration¹⁴ of allocating and thus spending 15 per cent of their annual budget on the health sector (SADC, 2010a; Equinet, 2004).

Access to health services is measured simply as the number of physicians, and nurses and midwives available to the population. It was varied but generally very low across the SADC subregion, especially by global standards (Figure 2.5), as might be expected in line with the above spending profiles. The leading countries in terms of availability of physi-cians were Seychelles, Mauritius and South Africa and the leaders in terms of availability of nurses and midwives were Seychelles, Swaziland and South Africa. It would appear that, again, small population countries fare very well in making health workers available to their respective populations and again South Africa is the main exception to this general observation.

14 Member States of what is now the AU met in Abuja, Nigeria, in April 2001 and pledged to increase government funding for health to at least 15 per cent of their national budgets and urged donor countries to increase support.

Table 2.9: Selected health expenditure indicators for SADC¹⁵

Source: Constructed from World Bank WDI data

The low levels of health workers to population reflect a well-known and well-documented situation, the health-worker crisis in Africa. Although particular causes of shortages of health workers vary by country, there are common threads which include, among others, brain drain, broken health systems, low prioritisation of community health workers, poor economic policy and the impact of HIV/AIDS on the work force. A number of efforts will be required to address this including increasing the amounts of public resources allocated to and spent in health, intensifying recruitment and retentions initiatives (particularly fair remuneration levels and other incentives) targeted at front-line health workers and broad enhancement of health systems using sector-wide approaches.

Notable health stresses, such as infant mortality, under-five mortality, maternal mortal-ity, diseases such as the HIV/AIDS pandemic and many other health ailments, are great threats to human development in SADC due to the risks they pose to public health, pro-ductivity, overall well-being and progress. Mortality indicators for the subregion recorded a general decline in infant, under-five and maternal mortality rates. Except for Botswana and South Africa, which registered moderate increases in their infant mortality rates, all countries recorded marginal declines (-0.7 infants per 1,000 live births in Namibia) to notable declines (-21.7 infants per 1,000 live births in Mozambique) between the averages 15 Most recent data available in WDI were to 2010.

for the 1999-2003 and 2004-2008 periods. Similarly, all countries experienced declines of various magnitudes in terms of under-five mortality rates, with South Africa seeing the smallest decline and Madagascar experiencing the largest reduction between the 1999-2003 interval and the 2004-2008 interval. Seychelles was the only country to experience an increase in its rate, albeit a modest one. Of these three indicators, maternal mortality has the worst record across the subregion and five countries (Botswana, DRC, Lesotho, Swaziland, and Zambia) recorded increases of varying degrees in maternal mortality.

Figure 2.5: Availability of front-line health workers in SADC

Source: constructed from World Bank WDI data

Despite general improvements, mortality rates in the SADC subregion are still rather high, with infant mortality averaging 68.9 per 1,000borths, under-five mortality averag-ing 113.3 per 1,000 births and maternal mortality rate averagaverag-ing 565.2 per 100,000 births during 2004-2007/8.

One of the most devastating scourges to hit the African continent has been HIV/AIDS, which has been a pandemic in sub-Saharan Africa (SSA) for some time now. By 2001 SSA bore the brunt of the global burden of HIV prevalence, accounting for 69 per cent of

peo-ple living with HIV/AIDS in the world (UNAIDS and IEO, 2002; UNAIDS, 2008). In the interim, global and subregional estimates of the numbers of people living with HIV/

AIDS showed marginally lower figures, about 67 per cent of the world’s people living with HIV/AIDS being reported in SSA (UNAIDS, 2008). By 2007, the HIV/AIDS pandemic was still a subregional disaster and was affecting Africa in the worst way.

Within SSA, a cross-country comparison of HIV prevalence suggests significant variations of the disease since it was recognised as a pandemic. In 2001, prevalence rates in the sub-region ranged from 0.1 per cent of the total adult population in the Comoros to a high of about 26.5 per cent of the total adult population in Botswana. Swaziland had the highest prevalence rate of 26.1 per cent in 2007 (a marginal decline from 26.3 per cent in 2001).

On the other hand, a few dramatic declines in the prevalence rates are noteworthy, such as in Zimbabwe, Uganda, Rwanda and Burundi (Figure 2.7).

Figure 2.6: Estimated number of adults and children living with HIV/

AIDS

Source: constructed from UNAIDS (2008)

Within SSA, Figure 2.7 suggests that SADC countries were among the hardest hit by HIV/AIDS, as SADC countries occupied the top nine positions for HIV prevalence in the subcontinent in 2007. In terms of absolute numbers of people with HIV/AIDS, South Africa was at the top.

Figure 2.7: Total no. of people living with HIV/AIDS (Panel I) and HIV prevalence rates (%) (Panel II)

Source: constructed from UNAIDS (2008)

While HIV/AIDS constitutes the single greatest developmental and public health concern in SADC, mixed pictures are seen in terms of HIV/AIDS dynamics. The whole subre-gion has seen a slight decline in average HIV prevalence rates but it was only Zimbabwe which made significant progress in the final interval compared to the first (see figure 2.8).

A few other countries such as Botswana, Lesotho, Zambia, Malawi and Tanzania have made marginal gains in bringing down the prevalence rate; suggesting a stabilisation of the HIV/AIDS pandemic. Madagascar maintained the lowest prevalence rate in SADC.

For the majority of countries (all the rest) moderate increases in the prevalence rates were witnessed between 1999-2005 and 2006-2011. According to the recent UNAIDS Global Report (UNAIDS, 2010), HIV incidence fell by more than 25 per cent between 2001 and 2009 in 33 countries including 22 in SSA. South Africa, Zambia, and Zimbabwe were cited among the countries that have either stabilised or have shown decline in HIV preva-lence, while Botswana, South Africa, Tanzania, Zambia, and Zimbabwe have also showed significant declines in HIV prevalence among young women or men in national surveys.

Though these gains are commendable, the prevalence rates are still high, thus underscoring that HIV prevention and social-mobilisation interventions in SADC are still as important as, if not more important than, ARV treatment interventions, and must be heightened.

The former are intended to change the sexual behaviours of the population positively with

a view to reducing the risks of getting infected with HIV. Such efforts will be essential for making meaningful gains in bringing down HIV/AIDS and keeping it down, and thus protecting formation of human capital, productivity and socioeconomic development.

Figure 2.8: HIV prevalence (total % of population aged 15–49 years)

Not data for DRC and Seychelles

Source: constructed from World Bank WDI data

The SADC Heads of States have demonstrated their commitment to the fight against HIV/AIDS through the July 2003 Maseru Declaration on the fight against HIV/AIDS in the SADC subregion. The Declaration reaffirms the commitment to combat the HIV/

AIDS pandemic in all its manifestations as a matter of urgency through multi-sectoral strategic interventions. Consequently some of SADC’s core concerted efforts in the recent past have included the formulation of the Revised SADC HIV/AIDS Strategic Frame-work 2007-2015, which is designed as a tool for combating the HIV/AIDS pandemic

through effective subregional collaboration and mutual-support programmes. The stra-tegic framework commits SADC member States to fight and contain HIV/AIDS aggres-sively. The SADC Secretariat reported that it had facilitated the development of a number of policy documents in support of the subregional response to HIV/AIDS, including RISDP, which pays significant attention to HIV/AIDS, the HIV/AIDS Strategic Frame-work 2003-2007 (predecessor to the current plan), the Maseru Declaration, the SADC HIV/AIDS Monitoring and Evaluation Plan of 2006, and the SADC HIV and AIDS Business Plan 2005-2009. These subregional policy documents were developed in order to synchronise policies, strategies and programmes and took account of the fact that the SADC member States were at different levels in terms of their capacities to plan, imple-ment, monitor and evaluate HIV/AIDS programmes.