SAVING OUR FUTURE: Multiministerial Action Guide HIV/AIDS in Asia and the Pacific
Item
- Title
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SAVING OUR FUTURE:
Multiministerial Action Guide
HIV/AIDS in Asia and the Pacific - extracted text
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ECONOMIC AND SOCIAL COMMISSION FOR ASIA AND THE PACIFIC
SAVING OUR FUTURE:
Multiministerial Action Guide
HIV/AIDS in Asia and the Pacific
/AusAID
UNITED NATIONS
The Australian Government’s
Overseas Aid Program
Economic and Social Commission for Asia and the Pacific
SAVING OUR FUTURE:
Multiministerial Action Guide
HIV/AIDS in Asia and the Pacific
/AusAID
UNITED NATIONS
The Australian Government’s
Overseas Aid Program
ST/ESCAP/2250
UNITED NATIONS PUBLICATION
Sales No. E.03.II.F.26
Copyright © United Nations 2003
ISBN: 92-1-120166-7
The designations employed and the presentation of the material in this
publication do not imply the expression of any opinion whatsoever on the
part of the Secretariat of the United Nations concerning the legal status of any
country, territory, city or area, or of its authorities, or concerning the delimita
tion of its frontiers or boundaries.
The opinions, figures and estimates set forth in this publication are the
responsibility of the authors, and should not necessarily be considered as
reflecting the views or carrying the endorsement of the United Nations.
This publication has been issued without formal editing.
Mention of firm names and commercial products does not imply the endorse
ment of the United Nations.
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Glossary of selected acronyms
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Acknowledgements
vii
Introduction
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SECTION I:
SECTION II:
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Everyone is vulnerable
5
HIV/AIDS: An overview of the Asian and
Pacific situation
HIV/AIDS as a development challenge
5
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The way forward
13
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HIV/AIDS and the role of governments
What can governments do?
Four phases of policy development
Key actors in the policy process
The need for a multiministerial response
Office of Head of Government/Head of State....
Ministry of Health
Ministry of Finance
Costs of action
Ministry of Education
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17
22
25
28
35
43
61
68
70
79
91
101
Ministry of Labour
Ministry of Welfare
Ministry of Agriculture
SECTION III: Basic steps for all
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Actions common to all ministries
Impact of HIV/AIDS within a ministry
Table of Contents
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118
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BOXES
Section I:
Box 1.
Box 2.
The development approach to HIV/AIDS policy
Lessons from Africa
10
12
Section II:
Box 3.
Box 4.
Box 5.
Box 6.
Box 7.
Box 8.
Box 9.
Box 10.
Box 11.
Box 12.
Box 13.
Box 14.
Box 15.
Box 16.
Box 17.
iv
Bolstering multisectoral approaches
The national programme in Cambodia
Information needs by stage of the policy process ....
A national STI programme in Lao People's
Democratic Republic
Data makes the difference
Strategies
Health-care - just 75 cents away!
HIV/AIDS situation assessment in China
Global resources needed by region
Catching them early
Going beyond the obvious: adapting education
Reaching outside the formal economy
A model employer
Home and community care
Music brings the message
Saving our future: multiministerial action guide
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21
24
33
38
41
57
60
69
76
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87
89
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AIDS
acquired immune-deficiency syndrome
ART
antiretroviral treatment
ARV
antiretroviral
CBOs
Community-based organizations
HAART
highly active antiretroviral therapy
HBC
home-based care
HIV
human immuno-deficiency virus
IDUs
injecting drug users
MSMs
men who have sex with men
NAC
National AIDS Committee
NGOs
non-governmental organizations
PHC
primary health care
PLWHAs
people living with HIV/AIDS
STIs
sexually transmitted infections
TB
tuberculosis
Glossary of selected acronyms
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^^Whe preparation of this Action Guide drew from a variety of
research and information sources both from within and outside of
the Asian and Pacific region.
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Below are the main sources used:
•
•
The main analysis and recommendations for multiministerial
action were adapted from the AIDS Toolkit prepared by Abt
Associates Inc., together with the Health Economics and HIV/
AIDS Research Division of the University of Natal, both of South
Africa, and funded by the USAID Bureau for Africa, Office of
Sustainable Development.
•
Information on lessons from Africa were largely drawn from two
sources:
•
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The guide contains highlights from the theme study for the fifty
ninth annual Commission session. The theme study is entitled
''Integrating economic and social concerns, especially HIV/AIDS,
in meeting the needs of the region".
(a)
A paper titled "The art of policy formulation: experiences
from Africa in developing national HIV/AIDS policies" by
John Stover and Alan Johnston, prepared for the Futures
Group International's POLICY Project;
(b)
A paper titled "Lessons Africa has learnt in 15 years of
responding to HIV/AIDS" presented at the African Deve
lopment Forum 2000.
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Examples were also drawn from the Compendium of Reports,
2001, a publication based on the outcomes of the AsiaPacific Ministerial Meeting on HIV/AIDS and Development in
Melbourne, Australia, 9-10 October 2001.
Acknowledgements
vii
The secretariat would like to express its appreciation to all the
sources cited throughout this publication from which valuable contri
butions had been drawn for the preparation of this Action Guide.
In particular, the secretariat would like to express its deep apprecia
tion to AusAID for its generous funding support that made possible
the issuance of this publication for the fifty-ninth annual session of
the Commission.
The initial outline for the Action Guide was developed in consulta
tion with the UNAIDS SEAPICT Team. It was discussed with parti
cipants of the People's Forum on Partnerships against HIV/AIDS
(October 2002) and UNAIDS cosponsors, especially 1LO, UNESCO
and UNODC.
The team that prepared the Action Guide included the following: Mr
Satyanarayan Sivaraman, who prepared the Action Guide in its final
form, using inputs and drafts prepared by Ms Amalee McCoy; Mr
Amitava Mukherjee, who contributed substantially to the drafting of
the Action Guide; Mr Michael Chai, who reviewed and commented
on the manuscript; Mr Bruce Ravesloot, who provided support and
undertook research for the preparation of the Action Guide in its
final form; Ms San Yuenwah, who conceptualized the Action Guide,
coordinated its preparation and edited it; and Mr Cengiz Ertuna,
who reviewed its preparation and final manuscript.
Special appreciation is expressed to the following: Mr Stephen
Walker and Mr John Moon for giving time to review the manuscript
and contribute their valuable comments; Mr Andy Quan and Mr
Chandra Mouly for their useful comments on initial draft; Ms Karen
Schmitzberger and Mr Erich Monitzer of Fine Line, Vienna, for con
tributing the cover design of the Action Guide, to mark the signifi
cance of the fifty-ninth annual Commission session for advancing
regional action on HIV/AIDS issues.
viii
Saving our future: multiministerial action guide
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^^^ooking ahead into the future, identifying new challenges and
providing strategies to overcome them is the primary task of any
visionary leadership.
0
And today there is no challenge to the Asian and Pacific region's
well-being that is more daunting than the HIV/AIDS pandemic.
Given the devastating impact the pandemic has already had on the
African continent and the rapid inroads it is making into our region
- it is a threat that can be ignored only at our own peril.
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While international bodies, civil society organizations and the
private sector - all have an important role to play, it is governments
in the region that are best placed to take initiative and tackle the
pandemic in a comprehensive manner. With their popular political
mandate, wide administrative reach and the ability to mobilize
human and material resources governments have the advantage and indeed the moral duty - to respond urgently to save the lives of
their people.
The urgency of the tasks to be accomplished however, need to be
well informed by good analysis and proper strategies. In the two
decades since the HIV/AIDS pandemic was discovered, there is a
wealth of experience from around the world in tackling it that can
be put to good use in our region.
One of the most important policy lessons to have emerged from
such international experience is that HIV/AIDS is a development
challenge. This is particularly so in low and middle-income coun
tries where the problems of under-development act as catalysts for
the spread of HIV and exacerbate its impact on the population.
What such an understanding implies is that any response to the
pandemic, has to be holistic in its approach - taking into account the
social, economic and even cultural factors that play a role in both the
Introduction
1
rise and fall of the pandemic. For governments in the region such
an approach would mean involving all ministries - and not just the
Ministry of Health - in the response to HIV / AIDS.
This Multiministerial Action Guide has been prepared precisely to
emphasise the need for governments to take a holistic approach to
the pandemic and suggest specific ways in which different ministries
can be involved. It is an attempt to merge the best insights in
tackling HIV/AIDS from around the globe with the specific needs
and capabilities of the Asian and Pacific region.
The government agencies targeted in this Action Guide for analysis
include the Office of the Head of Government/Head of State and
the Ministries of Health, Finance, Education, Welfare, Labour and
Agriculture. This is, however, by no means, a comprehensive list of
the number of ministries that need to be involved.
Both the choice of these agencies and the suggestions made vis-a-vis
their functions are meant only to illustrate the kind of assessments as
well as action that will be required by every ministry in its response
to HIV/AIDS. Due care has been taken to make suggestions that are
generic in nature and relevant to as many countries in the region as
possible. It is important to stress again that the best way to use this
document is by adapting it creatively to local situations.
Given the diversity of governments and their internal structures in
the Asian and Pacific region, the role of the same Ministry may vary
from country to country. This Action Guide, in order to cater to the
entire region, makes broad assumptions about the role assigned to
various Ministries, that are in general accurate, but may not apply in
some specific contexts.
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Saving our future: multiministerial action guide
The CD-ROM, " Bytes that matter", which accompanies the Action
Guide provides useful background information on HIV/AIDSrelated issues. It includes:
•
An explanation of facts and myths about HIV / AIDS;
•
A list of frequently asked questions (FAQs);
•
A pathfinder on international HIV/AIDS mandates and commit
ments for policy action;
•
A list of Internet information resources on HIV/AIDS;
•
A glossary of HIV/AIDS terminology.
It is hoped that this Action Guide will be useful to officials, in
government ministries throughout the region, to develop their own
models of response to the HIV/AIDS pandemic. The Action Guide
could also be a useful tool for civil society organizations, the private
sector and international donors working with governments on HIV/
AIDS issues.
Introduction
3
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HIV/AIDS: An overview of the
Asian and Pacific situation
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(a) Global context
The global HIV/AIDS pandemic, which started 2 decades ago,
continues to spread to every corner of the world. It brings in its
wake suffering and death to the individual household, disruption to
entire societies and threatens the security and well-being of many
nations.
The scale of the pandemic dramatically
exceeds even the most pessimistic scenarios of
a decade ago. At the end of 2002, there were
42 million people living with HIV/AIDS
(PLWHAs) around the world. A startling 5
million people acquired the virus during 2002.
Over 3 million people are estimated to have
died of AIDS worldwide in 2002, including
610,000 children aged under 15.
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(b) Regional dimension: cause for serious concern
The Asian and Pacific region threatens to displace sub-Saharan
Africa as the new centre of the global HIV/AIDS pandemic over the
next decade. With 62 per cent of the world's population and 19 per
cent of the world's PLWHAs, the HIV/AIDS pandemic could reverse
the social and economic gains made in the past half century in Asia
and the Pacific — unless an expanded and comprehensive response
is mounted across the region.
Section
I
For Asian and Pacific Governments and leaders, several develop
ments underscore the need for urgent action:
Everyone is vulnerable
5
(i)
Currently, one in 5 new HIV infections worldwide occur in Asia
and the Pacific.
(ii)
Globally, roughly half of all new infections are among young
people. In the ESCAP region, over 8 million people were living
with the virus at the end of 2002, of whom 2.6 million were
young people aged 15 to 24.
(iii) In 2002, AIDS claimed approximately half a million lives in the
ESCAP region, while an estimated 1 million adults, children
and youth were infected with HIV.
(iv) The pandemic is growing at an alarming pace, including in
parts of Central Asia, where HIV infection rates are rising
steeply;
At present, the main mode of HIV transmission in the
region is sexual intercourse, both heterosexual and
homosexual.
In many parts of the region, serious
epidemics are also under way among injecting drug
users. Other significant modes of transmission include
the use of unclean needles and syringes, and unsafe
blood and blood products.
Current country trends
Country trends in the ESCAP region may be separated into three
categories.
In the first group are those ESCAP countries whose societies have
reached serious HIV/AIDS levels, with adult HIV prevalence rates
of over 1 per cent. It includes Cambodia (whose prevalence rate is
over 2 per cent), Thailand, parts of India, parts of Myanmar and
parts of Papua New Guinea.
6
Saving our future: multiministerial action guide
The second group includes countries where the epidemic is still in a
transitional stage, but where HIV prevalence is rising rapidly in
specific populations and geographic areas. These include Armenia,
China, Indonesia, Kazakhstan, Malaysia, Nepal, the Russian Federa
tion, Uzbekistan and Viet Nam.
The third group includes countries and territories where extensive
spread of HIV/AIDS is not evident: Bangladesh; Hong Kong, China;
Islamic Republic of Iran; Lao People's Democratic Republic; Mongo
lia; Pakistan; the Philippines; Republic of Korea; Sri Lanka; Turkey
and several small Pacific island cormtries and territories. In the case
of the Pacific, limited information on HIV/AIDS spread is available.
Nevertheless, conditions favour the rapid spread of HIV in many of
these countries and territories.
However, macro-level trends do not always reveal the full picture.
India (which has States in all three groups) and China illustrate how
a low national HIV prevalence rate can hide serious localized
epidemics. HIV epidemics always begin as geographically localized
outbreaks and only later spread more widely across countries, terri
tories and societies.
There is no guarantee that low prevalence rates will stay that
way. Indonesia and Nepal, which are in the second group, are
seeing a rapid rise in HIV infection rates, following years of consis
tently low rates. In Ho Chi Minh City, Viet Nam, HIV infection
among sex workers increased from virtually nil in 1996 to over 20
per cent by 2000. In the Russian Federation, within 8 years, HIV/
AIDS epidemics were discovered in over 30 cities and 86 of 89
regions. In that country, the total number of reported HIV infections
climbed by over 1,800 per cent between the end of 1998, when the
reported number was 10,993, to mid-2002, when the number was
200,000.
Everyone is vulnerable
7
In conclusion, the global HIV/AIDS epidemic has yielded 3 inexor
able facts.
8
•
No country is immune from a serious HIV epidemic.
•
Currently low HIV prevalence rates are no guarantee of low
rates in the future.
•
The current highest national infection levels in the region of 2 to
3 per cent of the general population do not represent a natural
limit imposed by behavioural patterns
Saving our future: multiministerial action guide
HIV/AIDS as a development challenge
Although HIV/AIDS is often presented as a purely medical problem,
a closer analysis reveals it to be a much deeper development issue.
It is no coincidence that, while highly developed countries have
relatively low and stable HIV prevalence rates, many developing
countries suffer from the highest prevalence levels.
Several broad development issues feature significantly in the spread
of HIV in many parts of the world, including Asia and the Pacific.
These include gender inequalities, illiteracy, population mobility, and
lack of access to basic services, and opportunities for self-advance
ment. The paucity of information, especially among young people
and other vulnerable groups (such as sex workers, injecting drug
users, and migrant workers), is also one such factor.
In general, poorer countries of the world are home to the vast majority,
some 95 per cent, of people living with HIV/AIDS. There are
indications that high rates of extreme poverty (measured as income of
less than US$ 1 a day) appear to be associated with HIV prevalence
rates, as do poor rankings on the United Nations Development
Programme (UNDP) Human Poverty Index. Poverty multiplies the
pandemic's impact and, in turn, is itself exacerbated by the pandemic.
Household data from Cambodia and Viet Nam show strong correla
tions between levels of wealth, education and vulnerability, and HIV /
AIDS. In Cambodia, which has one of the most advanced epidemics
in the ESCAP region, the poorest segments of society have much
less access to knowledge of how HIV is transmitted and prevented,
are more likely to have sex at a younger age, use condoms less
frequently and, in the case of young women, are more likely to turn to
sex work as a means of supporting themselves and their families.
Micro-level data from other parts of the Greater Mekong Subregion
countries show that poverty drives many women into the sex indus
try, where their vulnerability to HIV infection dramatically worsens.
Everyone is vulnerable
9
The impact of HIV/AIDS is unique because AIDS kills adults in the
prime of their lives, thus depriving families, communities, and entire
nations of their young and most productive people. Adding to an
already heavy disease burden in
poor countries, the HIV/AIDS epi
The development approach to HIV/AIDS policy will require a
demic is deepening and spreading
shift in the very process through which policies are framed
poverty, reversing human develop
and interventions undertaken. The shifts in paradigm that
ment, worsening gender inequali
will be required are outlined in the table below.
ties, eroding the capacity of govern
ments to provide essential services,
Box 1. The development approach to HIV/AIDS
reducing labour productivity and
policy
hampering pro-poor growth.
From
To
Focus on partial, specialized
knowledge of sectors.
Focus on holistic understanding
of the entire system.
Health-centred: emphasis
on sectoral goals.
People-centred and gender
sensitive: increasing, through
empowerment and creation
of enabling environments,
people's prevention and
coping capability.
Top-down development
for the people.
Bottom-up development by
the people, for the people.
Linear process.
Cyclical process.
Administrating, managing
others.
Leading and empowering
others.
Source: United Nations Country Team in Cambodia", Developmental
implications of HIV/AIDS", (Phnom Penh, July, 2002).
The development process itself can
inadvertently spur the spread of
HIV AIDS.
Widening inequalities
(often associated with the earlier
phases of development) can spur
internal and cross-border migration,
as people move in search of income
and employment.
Infrastructure
development, especially of trans
port networks, urbanization, and
rising disposable incomes, espe
cially for men, many of whom
spend periods away from their
wives, are often associated with
more extensive casual and multiple
partner sexual activity and the
growth of the sex industry.
Understanding the HIV/AIDS pandemic as a development challenge
is crucial for formulating both long- and short-term policies to tackle
the crisis at its roots. For example a development perspective
implies the need for countries to improve overall, long-term social
10
Saving our future: multiministerial action guide
and economic performance. At the same time, in terms of emer
gency measures for HIV/AIDS prevention and care-treatmentsupport, a development framework helps determine the process and
approach required to make such measures effective.
o° <
a
The national response to the HIV/AIDS epidemic must include 3
dimensions:
(a) Measures to address its basic causes;
(b) Provision of preventive health care;
(c) Programmes for the care of PLWHAs, and mitigation of the
impact of HIV/AIDS on PLWHAs and their families.
The national response should, therefore, include the following
components:
(i)
Intensification of education, health, and food security efforts, to
achieve progress on the unfinished development agenda, includ
ing of poverty reduction strategies.
(ii) Effective integration of HIV/AIDS concerns into national develop
ment planning, sectoral plans, and poverty reduction strategies, as
well as into all Ministries directly involved in the frontline of
development, such as finance, health, education, rural develop
ment, agriculture, industry and transport, to accelerate the
development process and tackle the HIV/AIDS epidemic.
(Hi) Support for greater social mobilization efforts to accelerate the
development process in general, and to tackle the spread of the
epidemic in particular.
(iv) Action on the economic empowerment of women and gender
equality as a national priority in the fight against HIV/AIDS.
(v) Expansion of policy and public action to provide a robust health
delivery system that works for the prevention of Hiy/AIDS and
promotes compassion and care for PLWHAs, as well as to minimize
stigma and discrimination against PLWHAs and their families.
Everyone is vulnerable
11
t3 8 A
Box 2. Lessons from Africa
In sub-Saharan Africa, the HIV/AIDS epidemic is taking a devastating toll in
terms of human suffering. It is undermining economic growth, development
prospects and political stability. Given the extent to which HIV/AIDS is eroding
progress, it is no longer a medical health problem, but a major development
crisis. While sub-Saharan Africa accounts for only one-tenth of the global
population, it bears the brunt of the disease, with more than 80 per cent of
AIDS-related deaths worldwide. Following is an excerpt from a paper titled
"Lessons Africa has learnt in 15 years of responding to HIV/AIDS"
presented at the African Development Forum 2000.
"AIDS is an epidemic with special features that call for a special response.
With no vaccine available against HIV, prevention hinges on informing peo
ple, motivating them and empowering them to protect themselves, their
partners and their new-born infants. Likewise, though the health sector is
the mainstay of health-care for those infected, it can do little to alleviate
the poverty that afflicts many AIDS-affected households, ease the plight of
orphaned children, or safeguard a country's development achievements.
Instead, the response to HIV/AIDS demands strong and creative leadership
from all sectors and parts of society, as much as increased community
ownership of the problem and of its solution. Having analysed the impact
of the epidemic, ministries of planning and finance must help ensure
financing of crucial interventions for prevention and care - the two
reinforce each other - and devise ways to alleviate the epidemic's toll on
households, agriculture, mining and other sectors. Respected community
leaders need to encourage people to take the invisible HIV threat seriously
and, where necessary, change local attitudes and traditions that make
people unnecessarily vulnerable to HIV or to the impact of AIDS.
Schools have a responsibility to inform children about HIV before they
become sexually active and risk exposure, and teach them the skills they
need to navigate safely through life. Religious leaders need to combat the
blame and rejection associated with AIDS and encourage a "social contract"
between the affected and the as-yet-unaffected. In places where the AIDS
stigma is diminished, individuals living with HIV will feel freer to give the
epidemic a human face and make their full contribution to combating it."
Source: http://www.uneca.org/adf2000/theme2contents.htm
12
Saving our future: multiministerial action guide
Q
HIV/AIDS and the role of governments
QC
I
The Asian and Pacific region stands at a critical crossroads. A
concerted and sustained response can hold the HIV/AIDS epidemic
in check. Further delay in mounting effective prevention and care
would see the region forfeit its opportunity to prevent the epidemic
from spinning out of control.
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Many governments in the region recognize the challenge and have
begun to act. Those governments that have had some success in
holding the epidemic at bay have publicly recognized the true nature
and extent of the HIV/AIDS threat, committed sufficient resources,
focused early efforts on the most vulnerable groups, and adapted
their activities to new developments in the epidemic.
X
The pattern and course of the pandemic are known and predictable.
This means that the epidemic yields to appropriate and sustained
interventions. Examples of these include youth-focused prevention
education, high levels of condom use among sex workers and their
clients, and in casual sex settings and multiple sex partner relation
ships, as well as low levels of needle and syringe sharing, and use of
safe blood and blood products. The spread of HIV/AIDS can be
controlled.
Why early action?
Initially, the virus spreads mainly among vulnerable groups, such as
injecting drug users, sex workers and their clients, and might remain
so for several years. This tends to encourage the notion that the
epidemic will stay confined mainly to those groups. In reality, none
of the groups are sealed off from the rest of society. The epidemic
eventually spreads among the wider population. Where circum
stances favour the rapid spread of HIV, the consequences can be
calamitous. The best course of action is early, comprehensive action.
The way forward
Section
II
13
In the early stages of the epidemic, comprehensive prevention
among vulnerable groups is most cost-effective and could reduce
new infections by over 60 per cent. The longer the delay, the lesser
the payback in terms of infections prevented. For example, delaying
by three years the introduction of a comprehensive prevention
programme could mean that twice as many people would acquire
the virus.
The types of approaches that boost results are also now better under
stood. Countries that have brought epidemics under control have
cultivated wider acceptance of people living with HIV/AIDS, shown
greater tolerance towards marginalized groups, effected large-scale
improvements in access to treatment and care, and mounted preven
tion programmes that focus especially on vulnerable groups.
Cambodia and Thailand, for example, launched large-scale HIV/
AIDS campaigns in the early stages of the epidemic, concentrating
on the most vulnerable groups whose behaviour placed them at
highest risk of infection. This enabled Cambodia and Thailand to
reduce the spread of HIV and save millions of citizens from infec
tion, illness and eventual death. Thailand could have had an esti
mated prevalence rate of 10 to 20 per cent and lost an additional 6
million lives, were it not for effective interventions launched early in
the epidemic.
What works?
Societies are not powerless against the HIV/AIDS epidemic. The
Asian and Pacific region provides some of the leading global exam
ples of success against HIV/AIDS. Experiences worldwide confirm
that the leadership of Prime Ministers and Presidents in directing
national HIV/AIDS responses helps ensure that the responses are
implemented as the highest national priorities. There is evidence of
such leadership in the ESCAP region. For example:
14
Saving our future: multiministerial action guide
•
Since the early 1990s, Thai Prime Ministers
have served as Chairpersons of the National
AIDS Committee;
•
The Prime Ministers of Cambodia, India,
Indonesia, Malaysia and Papua New Guinea
have personally endorsed national efforts to
tackle the epidemic.
The multisectoral approach
Many countries in the region are adopting a multisectoral approach
and are extending their HIV/AIDS responses across various minis
tries. Examples of this include the following:
•
Resource allocation and AIDS prevention, Thailand: The 1996 AIDS
budget of the Government of Thailand covered 91 per cent of all
expenses in the country's AIDS programme. Creative prevention
measures included life skills empowerment of young people, 100
per cent condom coverage of all sex service users, and strategic
alliances with PLWHAs.
•
National coordination, Cambodia: The national government set up
a national body composed of 15 ministries, provincial govern
ments, and the Cambodian Red Cross;
•
School AIDS education, Australia, Philippines and Myanmar: Minis
tries of Education have included AIDS in the school curricula;
•
Protecting defence forces, Bangladesh, Lao People's Democratic Repub
lic and Nepal: Ministries of Defence conduct HIV prevention
among uniformed service personnel;
•
Transport mode and mobile youth, China and Mongolia: Ministries of
Railways conduct AIDS education and HIV prevention among
young migrant workers;
The way forward
15
•
Infrastructure construction workers, Cambodia and Lao People's Demo
cratic Republic: HIV prevention among workers and surrounding
communities is conducted in Sihanoukville International Port,
Cambodia, and National Road No. 8, Lao People's Democratic
Republic.
•
Mobilizing the media, India: The Press Information Bureau helps
sensitize the Indian media on HIV/AIDS issues.
Box 3. Bolstering multisectoral approaches
National coordinating bodies are also realizing the importance of bolster
ing the response through the workplace, and of including organizations
with specific expertise in this area. Recently, India's National AIDS Control
Organization (NACO) set up a technical resource group at the V.V. Giri
National Labour Institute to develop research and training resources for
workplace AIDS programmes. The Institute's partners in this effort include
trade unions, employers' organizations, companies, NGOs undertaking HIV
projects in the informal sector (notably with truck drivers and migrant
workers), State or District AIDS Control Societies, and ILO.
Source: UNAIDS, Report on the global HIV/AIDS epidemic (Geneva, 2002), p. 111.
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Saving our future: multiministerial action guide
What can governments do?
The Asian and Pacific region holds the key to the future of the
HIV/AIDS pandemic. Governments in the region face vital choices,
if they are to control the epidemic and save millions of lives. Mak
ing those choices will require leadership marked by extraordinary
vision and courage. Below are 5 sets of choices: policy environment;
resource generation and flow; institutional mechanisms; re-engineering
government processes; and action on commitments, that governments in
the region could consider initiating in order to successfully stave off
one of the gravest threats that the region faces today.
(1) Policy environment
(a) Integrate HIV/AIDS issues into national development
planning, sectoral plans, and poverty reduction strategies, for
full mobilization of all sectors and levels of government:
Address the HIV/AIDS epidemic as a development issue, with
education, health and nutrition, gender equality, and social
justice dimensions, at the centre of a national HIV/AIDS re
sponse. Promote respect for the rights of PLWHAs and intro
duce anti-discrimination measures.
(b) Focus on preventive and promotive health care, with special
attention to HIV/AIDS: Develop a wide spectrum of measures
to prevent the spread of HIV infection among vulnerable
groups.
These include prevention fundamentals: focus on
young people, achieve better understanding of the main modes
of transmission, and acceptance of PLWHAs, promote condom
use as a simple and effective prevention measure, and use of
clean needles and syringes, and safe blood and blood products.
Develop women-friendly measures that enable women to boost
their autonomy and to take decisions that protect them from
The way forward
HIV/AIDS.
Assist in the development of HIV prevention
vaccines that are best suited to Asian and Pacific conditions.
Expand coverage of a comprehensive response to HIV/AIDS
through improving the design and reach of current efforts, to
increase the coverage of geographic areas and vulnerable
groups.
(c) Strengthen the integral link between prevention and caretreatment-support: Include treatment and care for PLWHAs as
an essential component of a national response to HIV/AIDS,
whose long-term foundation is prevention. Provide vulnerable
group-friendly services (condoms, clean needles and syringes,
safe blood and blood products, sexually transmitted infection
treatment), and foster conducive, user-friendly environments for
accessing these services.
(d) Guarantee equitable access to antiretroviral treatment and
other HIV-related medicines: Intensify action by governments
and the pharmaceutical industry to increase the availability of
affordable drugs. Initiate negotiations in appropriate forums to
remove the patenting of ARVs from national legislation govern
ing intellectual property rights. Exercise exemption from patent
protection of ARVs, until 2016, in the case of least developed
countries. Reform national legislation to achieve the lowest
prices for quality pharmaceutical products, and to ensure that
governments are able to use the flexibilities permitted under
WTO agreements.
(2) Resource generation and flow
(a) Ensure that adequate resources are available for implementing
the national HIV/AIDS response: Secure domestic resources for
effective and sustained national responses that serve as building
blocks of a region-wide response, with essential coverage of
areas and vulnerable groups. Share country experiences on
18
paving our future: multiministerial action guide
international resource flows, such as from the Global Fund to
Fight HIV/AIDS, Tuberculosis and Malaria, and other sources,
and coordinate towards concerted regional responses to urge
increased international resource allocations, that are in conso
nance with national priorities, to stop the spread of the
pandemic in the Asian and Pacific region.
(b) Mobilize the full potential of the corporate/private sector to
operationalize the national HIV/AIDS response: Create an
enabling environment for the corporate/private sector to
discharge its social responsibility and demonstrate good corpo
rate citizenship by playing a larger role in the HIV/AIDS
response, generating resources, implementing HIV/AIDS
workplace programmes, supporting treatment and care for em
ployees living with HIV/AIDS, and boosting care activities for
children who become orphaned when their parents die of AIDS.
(c) Make special provisions for the smooth flow of funds: Enact
regulations and adopt practices for speedy fund transfer and
disbursement of HIV/AIDS resources to executing and imple
menting agencies, to expedite timely receipt and utilization.
Establish, where necessary, new channels for expeditious fund
transfer.
(3) Institutional Mechanisms
la) Locate the national focal point for HIV/AIDS in the Office of
the Head of Government/State: Accord the highest national
priority to HIV/AIDS by locating the national HIV/AIDS focal
point under the direct leadership of the Prime Minister or the
President.
(b) Constitute a national committee of ministers of relevant
ministries, such as health, education, finance, planning, urban
and rural development, agriculture, information and broad-
The way forward
casting, industry and transport, chaired by the Head of
Government/State, to formulate a comprehensive national
response to the epidemic, and with the powers to ensure its
implementation: Guarantee resource availability, and optimize
its utilization, by entrusting the key ministers for economic
and social development with the responsibility of meeting the
challenge of HIV/AIDS.
(c) Decentralize implementation of the national response: Design
the national response to adequately meet local needs and
priorities through delegation of authority and resources to
implementing agencies and personnel at the local level.
(d) Develop a wide network of agencies and organizations to
implement the national response: This could include govern
ment agencies, civil society groups, and the corporate/private
sector.
(4) Re-engineering government process
(a) Establish social auditing of HIV/AIDS programmes: Identify
institutions and organizations for conducting social audits of
responses to HIV/AIDS issues, and entrust them with the
responsibilities and resources for this. Guarantee that the social
audits are participatory, with the active involvement of
PLWHAs and community members. Make avail
able the audit results in the public domain, to
"If you can mobilize
improve transparency and accountability.
resources for war,
why can't you mobilize
resources for life?"
Kofi Annan,
Secretary-General, United Nations
20
(b) Establish an effective monitoring and evaluation
system: Establish a credible system to monitor and
evaluate the national response under the national
committee of ministers (see 3[b] above). Foster a
culture of taking prompt corrective action based on
monitoring and evaluation.
Saving our future: multiministerial action guide
(5) Action on commitments
(a) Implement commitments made in United Nations forums:
Formulate an action plan for implementing international com
mitments made to tackle HIV/AIDS, including at UNGASS
(2001), the Fifth Asian and Pacific Population Conference (2002),
and at the fifty-seventh ESCAP Commission session (2001).
(b) Strengthen regional cooperation for tackling HIV/AIDS issues:
This includes sharing knowledge and resources, as well as
nurturing a common regional commitment to tackling the HIV/
AIDS epidemic.
Box 4. The national programme in Cambodia
The national programme in 1997 conducted a situation and response analysis which brought together all
the major stakeholders, from provincial AIDS offices to NGOs, bilateral donors, international organizations
and the United Nations system. By that time the country was rated as one of the hardest-hit countries in
the region. The team of reviewers set out a number of priority strategies and approaches based on the
analysis undertaken. Among others, they recommended that the country base geographic and population
priorities on the current epidemiological situation. Given the burden of HIV/AIDS they also recommended
that provision of care and support be a priority cross-cutting strategy. With regard to sex work and STIs,
major factors in the spread of HIV, specific priority activities were recommended to initiate and expand
interventions among sex workers and their clients, promote condom use, especially in sex work settings,
and improve the accessibility and quality of STI services. Another area for development and/or improve
ment was the capacity for voluntary testing and counseling. At the same time, the team emphasized the
need for a response to match the dynamics of the epidemic, recommending that socio-behavioural and
socio-economic research be strengthened so as to better inform programme design and guide policy.
Source: Peter R. Lamptey and Helene D. Gayle eds., HIV/AIDS prevention and care in resource-constrained settings: A handbook for
the design and management of programs (Family Health International, Arlington, 2001) p. 16.
The way forward
21
Four phases of policy development
Below is an extract from a report entitled "The art of policy
formulation: experiences from Africa in developing national HIV/
AIDS policies". The report captures key elements of the HIV/
AIDS-related policy-making process in nine Anglophone African
countries: Ethiopia, Ghana, Kenya, Malawi, South Africa, Tanzania,
Uganda, Zambia and Zimbabwe.1
There is a clear distinction between recognizing AIDS as a problem
and determining the need for formal policies to tackle the disease.
In most African countries, the first AIDS cases were reported in the
mid-1980s. However, the development of comprehensive policies
did not begin until the 1990s. Governments responded to the emerg
ing problem with a variety of incremental steps before recognizing
the need for a comprehensive policy. These responses can be sum
marized in 4 phases of policy development as described below.
The African experience
Phase I. Medical response: The initial response to AIDS in most
countries was to treat the disease as a medical problem. Activities
focused on screening donated blood, ensuring safe medical practices,
and conducting surveillance and research, hi most countries, the
medical response coincided with the development of the first
medium-term plan under the guidance of the Global Program on
AIDS. The first cases of AIDS were identified, and while research
showed that infection levels were increasing in some population
i
22
John Stover and Johnston, A, "The art of policy formulation: experiences
from Africa in developing national HIV/AIDS policies" (http://www.policy
project.coni/pubs/occasioiial/op-OS.pdf, August 1999).
Saving our future: multiministerial action guide
groups, the number of AIDS deaths remained low. At this stage,
medical and research guidelines were needed, but there was little
recognition of the need for comprehensive national policies.
Phase IL Public health response: As the epidemic progressed,
governments and international organizations began to realize that a
medical approach to HIV prevention and care was insufficient.
Intervention research showed that progress toward prevention could
be achieved with a combination of programmes, such as condom
promotion, peer counselling, and mass media campaigns. In this
phase, the response to AIDS broadened considerably and, as a result,
difficult policy issues began to arise, such as condom advertising in
the mass media. Governments generally dealt with these issues on
an ad hoc basis through specific regulations or laws.
Phase III. Multisectoral response: At a later stage in the epidemic,
the number of AIDS deaths began to rise. International organizations
began to stress the broad social and economic impact of AIDS,
spurring multisectoral responses. The involvement of all sectors of
government in HIV prevention was encouraged. The role of the
private sector, NGOs, and communities took on greater importance.
By this time, the full range of difficult policy issues had become
apparent, forcing governments to consider, for example, the situation
of orphans, AIDS education in schools, the human rights of people
living with HIV/AIDS, treatment and care, and research ethics. At
this point, the need for a comprehensive national policy to address all
of these issues became even more evident in most countries.
Phase IV. Focused treatment and prevention: In many countries,
the latest phase is distinguished by a focus on proven approaches.
This may mean less emphasis on the multisectoral approach and
greater emphasis on the most promising prevention interventions.
The latest phase also includes a sharper focus on the ethical and
resource issues associated with new treatment and prevention
options, such as antiretroviral therapy and prevention of mother-tochild transmission.
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23
Box 5. Information needs by stage of the policy process
Stage
Illustrative information needs
Problem identification
•
•
•
Need recognition
•
•
•
Number of reported people living with AIDS by age, sex and region
of country.
Surveillance information on HIV prevalence by vulnerable group.
Estimates of the number of infections.
Projections of the future number of infections, people living with AIDS
and deaths.
Estimates of the social and economic impact of AIDS.
Personal stories of the hardships caused by AIDS, illustrating impact on
individuals, families and communities.
Advocacy
•
Information showing the impact of AIDS on vulnerable groups and
effectiveness of interventions.
Drafting and review
•
•
•
•
Status and extent of epidemic.
Policy inventory of existing laws and regulations.
Model policies recommended by international organizations and
conferences.
Examples of policies adopted by other countries.
Approval
•
•
•
Views of interest groups on draft policies.
Estimates of the impact of policies on controlling the epidemic.
Estimates of the costs of policies.
Legislation
•
•
Inventory of existing legislation.
Drafts of legislation required to address key policy issues.
Guidelines
•
Scientific information concerning approaches that work and those that
do not work.
Strategic planning
•
•
•
Effectiveness of proposed interventions.
Cost-effectiveness and cost-benefit analyses.
Projections of resources required.
Source: John Stover and Johnston, A, "The art of policy formulation: experiences from Africa in developing national HIV/AIDS
policies" (http://www.policyproject.com/pubs/occasional/op-03.pdf, August 1999).
24
Saving our future: multiministerial action guide
Key actors in the policy process
There is a wide range of actors in the policy process. Each plays a
distinct role. The degree of participation varies according to the
stage of the process.
A. Key actors
Although all actors may be involved to some extent in all stages,
they make their key contributions in only a few stages. In the case
of HIV/AIDS, the groups include, but are not restricted to, the
following:
1.
Technocrats: epidemiologists, physicians, scientists, public health
specialists, policy analysts, and economists in the Ministry of
Health, national research institutions, and international organi
zations.
2.
Bureaucrats: primarily from the Ministry of Health, Ministry of
Planning, and the Office of the Prime Minister or the President.
3.
Special interest groups: non-governmental organizations (NGOs)
that provide HIV/AIDS prevention and care services, organiza
tions of PLWHAs, community organizations, and organizations
representing vulnerable groups, such as sex workers, travelling
businesspersons and long-distance drivers.
4.
Politicians: Ministers, Deputy Ministers, Members of Parliament,
Cabinet Members, the President, and the Prime Minister.
5.
Donors: representatives and staff members of key bilateral
donors such as USAID, DFID, as well as the Danish, Japanese
and Swedish development agencies, DANIDA, JICA and SIDA.
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25
6.
United Nations and other intergovernmental organizations:
staff members of the United Nations system, including
UNESCAP, and UNAIDS and its cosponsors (UNDP, UNESCO,
UNICEF, UNFPA, UNODC, ILO, WHO and the World Bank).
B. Functions of key actors
26
1.
Problem identification: is led by technocrats who collect and
analyse data and present the analyses in various forms, and to
different audience groups to illustrate HIV/AIDS trends, and
current and future policy and programming scenarios. Informa
tion is often drawn from reported cases of people living with
HIV/AIDS and surveillance studies for HIV infection.
2.
Need recognition: comes from politicians who place AIDS on the
policy agenda. Therefore, advocacy efforts are often focused on
convincing politicians of the need for a comprehensive response.
3.
Advocacy for action: can come from any group. Typically, inter
est groups and donors carry out advocacy. Advocates may forge
alliances with technocrats and bureaucrats who see the need for
accelerated policy action to advance their case through normal
government channels.
In some cases, far-sighted politicians
recognize the need for more action and champion the develop
ment of comprehensive and effective responses.
4.
Information collection: is conducted
by technocrats, academics, expert consult
ants and also PLWHA groups. Members
of the United Nations system could help
gather examples of good practice and
in facilitating study visits to examine
lessons from programme implementa
tion elsewhere.
Saving our future: multiministerial action guide
5.
Drafting of policy documents: is usually carried
out by bureaucrats, with the participation of other
groups. Donors, members of the United Nations
system and other international organizations often
play a role by presenting inter-country informa
tion to facilitate policy consideration of national
experiences.
6.
Approval: is usually a political process. In some countries the
Minister of Health approves the AIDS strategy, although this is
possible only with tacit approval from the Prime Minister or
President. In most other countries, the Cabinet or Parliament
approves the policy.
7.
Implementation: can and should involve everyone. Technocrats
need to provide information and remain involved in policy plan
ning, review and strengthening. Bureaucrats create and run the
formal structures that develop and implement policy. Interest
groups advocate for action on specific portions of the policy.
They also work through NGOs and other types of organizations
representing civil society to implement some policy components
and generate feedback for strengthening policy. Politicians need
to be involved in developing the enabling legislation that may be
required to implement some portions of the policy; they also
allocate the funding for implementation. Donors often play a
major role in funding and setting programme priorities.
8.
Review and feedback: all groups have a role to play in helping
to generate feedback on the efficacy of policy adopted, particu
larly its implementation dimensions. With the feedback pro
vided, further efforts may be made to fill gaps and strengthen
policy measures. In view of the urgency of early action in
stopping the spread of the epidemic in Asian and Pacific coun
tries, continuous feedback from diverse groups could be useful.
The way forward
27
The need for a multiministerial response
Governments of the Asian and Pacific region today face a challenge
for which few precedents exist. With every minute that ticks by, the
HIV/AIDS pandemic makes inroads into the stability of societies,
the foundations of development.
The need for adopting a multiministerial strategy stems from the fact
that HIV/AIDS is a threat to social and economic development.
Thus, only the full commitment of all ministries will suffice, to avert
a human and development crisis.
The situation demands that vital choices be made. Making those
choices requires that decision-making be marked by vision and
courage. Special mechanisms, institutions, policies, resources and a
new process are essential elements of an adequate response to the
challenge that the pandemic poses to governments that are respon
sible for the lives of two-thirds of the world's population.
In order to achieve a comprehensive response that can turn the tide
of the epidemic, government must reach most of its people in the
shortest possible period of time and in a sustainable manner. This
can be done through the work of diverse ministries and sectors that
are already reaching vulnerable groups according to their respective
development, social and business agendas.
c.'
Each ministry can motivate and facilitate
the involvement of diverse development
sectors that the ministry works with, ac
cording to its mandate, thereby ensuring
that the national and subnational AIDS
responses include sectors such as health,
education, agriculture, commerce and
transport.
Saving our future: multiministerial action guide
For example, in its regular work, the Ministry of Education is
already reaching young people and their teachers. Thus, it can
integrate AIDS prevention into the education system. HIV preven
tion work also helps reduce the impact of AIDS on the education
system.
A primary requirement for an expanded response is that govern
ment demonstrates a high level commitment to fighting HIV/
AIDS through mutually reinforcing, multiministerial action set
within the framework of a national AIDS strategic plan. Multi
ministerial involvement in a national AIDS programme and commit
tee and integration of AIDS into a national development plan
ensures that:
•
A large pool of government resources is mobilized and shared;
•
Ministerial activities are coordinated for sustained impact.
WHO should take the initiative?
•
Head of Government/Head of State;
•
National AIDS Council/Committee;
•
Civil society groups, people living
with HIV/AIDS groups;
•
International donors;
•
Members
system.
of the
United
Nations
The way forward
29
WHAT needs to be done?
Below are a checklist of actions
A. First things first - take stock of the situation:
1.
Develop a clear understanding of the following:
•
•
•
•
•
At what stage is the epidemic?
What is the current and potential impact of HIV/AIDS?
What steps have already been taken by government agencies,
non-governmental organizations, other actors?
What resources are already available to tackle the problem?
What resources are likely to be mobilized?
2. To develop a successful multiministerial strategy to meet the
HIV/AIDS epidemic, the following actions must be taken:
•
Assess Ministry capacity to anticipate the onslaught of the
epidemic, and prepare for it accordingly.
•
Assess levels of HIV awareness and knowledge among workers
in the respective sectors under the Ministry, and any produc
tivity loss that might occur with a HIV/AIDS epidemic.
•
Recruit and train staff to deal with HIV/AIDS issues, includ
ing workforce morale and support provision, in areas of
responsibility under the purview of the Ministry, as the
epidemic hits.
•
Monitor, on an on-going basis, the impact of HIV/AIDS
on the Ministry and its Departments, through internal and
external assessments, to identify remedial responses within
the remit of the Ministry.
•
Develop Ministry-specific impact assessment and responses
that are synchronized with those of other ministries and
departments.
-
30
Saving our future: multiministerial action guide
For example:
•
Is the HIV/AIDS epidemic still growing or has it stabilized?
•
Are there important differences between the severity of the HIV /
AIDS epidemic in different areas or among different population
groups?
•
Has a specific strategy for the Ministry's sectoral response to
HIV/AIDS already been developed?
•
Have cost-effective, sustainable approaches to prevention and
HIV/AIDS care been identified or are further data or analyses
needed to identify them?
•
To what extent have other sectors recognized the need for multi
sectoral action and what is the role of the Ministry in mobilizing
and supporting those sectors?
•
What is the contribution of the private sector to HIV/AIDS
prevention and care?
•
To what extent are appropriate policies and treatment strategies
already in place?
•
Are there any indications of what extra resources might be
available from the government, international donors or private
sector for the response to HIV/AIDS?
B. Define priorities:
1.
To prioritize areas of concern for a strategic plan, define the core
functions of the Ministry. Assess the challenge of HIV/AIDS,
guided by the following key questions for each ministry function
and priority:
The way forward
31
Key questions for ministry priorities:
(a)
How does this function or service impact on the spread of
HIV?
(b)
How will the way HIV/AIDS impacts on wider society
affect needs to be addressed by the Ministry and its func
tion or services?
(c)
What factors may increase or reduce ability to manage the
impact of HIV/AIDS?
HOW to respond?
A. Establish a planning system:
1.
Establish a system of multiministerial planning:
•
2.
Composed of a national plan and sectoral plans for all
central (federal) level ministries, and state or provincial
plans, wherever applicable.
Observe, as a matter of policy and practice, the following essen
tial principles of planning in the planning process:
•
Pursue at all levels, planning for action on HIV/AIDS issues.
•
Be strategic, long term, and deal with the factors that trigger
the epidemic, as well as those that fuel its spread.
•
Provide a participatory platform for achieving a higher level of
synergy among ministries, departments and sectors, in tack
ling the epidemic through a multiministerial approach.
•
Predicate the national strategic plan, as a matter of policy,
on the participation of all stakeholders, including PLWHAs,
groups with high-risk behaviours, and community repre
sentatives.
Saving our future: multiministerial action guide
Box 6. A national STI programme in Lao People's Democratic Republic
Problem:
In a 1995 survey of countries and areas of the Western Pacific Regional Office of the World
Health Organization, only Lao People's Democratic Republic was identified as being without
some form of a national STI programme.
Solution:
An international donor undertook a situational assessment and, based on its findings,
contracted with the Ministry of Health to develop a national programme.
Means:
•
•
•
Strengthening the capability of the Ministry of Health to manage a national STI programme.
Strengthening the public health care system to provide access to consistently acceptable, effective and
affordable STI services.
Establishing support mechanisms for planning, monitoring and supervising a national STI care and
prevention programme.
Constraints:
•
•
•
Support to the project is time-limited.
Uncertainty over the ability of the Ministry of Health to finance consumables, materials and reagents, or
service and replace equipment as necessary.
Lack of funding for extension of the referral services to a wider area.
Results:
•
•
•
A national central and peripheral STI programme structure is in place with appropriate support
activities.
Access to STI care is available at all levels of the health system in the pilot areas, and is being extended
nationally through training.
Access to acceptable STI referral services with aetiological case management in pilot areas
Expected Outcomes:
•
•
Lower STI rates with improvement in the health of the community, particularly women and children.
Reduced risk of HIV transmission.
Source: Peter R. Lamptey and Helene D. Gayle (eds.), 2001, "HIV/AIDS Prevention and care in resource-constrained settings:
A handbook for the design and management of programs", Family Health International, Arlington, p.399.
The way forward
33
B. Decentralize implementation of the national
response:
1.
Ensure that the national response to HIV/AIDS is multilevel:
•
Fully utilize the multilevel reach of ministries, which are
often in many locations, covering national to provincial and
local levels.
•
Strengthen the national response to HIV/AIDS by bringing
together an ensemble of constituent elements and pursuing
the following actions:
-
-
-
-
Operationalize the response at different levels.
Expedite implementation of different aspects of the
national response by the agencies that can best imple
ment them.
Introduce sufficient flexibility and dynamism into the
national response, to allow for community-, local- and
provincial-level variations.
Ensure that, at the implementation stage, the national
response adequately reflects local needs and priorities.
The national response must also be invested with
administrative and financial flexibility, through delega
tion of authority and resources to implementing agencies
C. Facilitate a wide network to implement the
national response.
The HIV/AIDS pandemic calls for highly diversified national
responses. Government institutions, civil society groups, and the
corporate sector, each with a comparative advantage and operating
in diverse environments, can all contribute to efficient implementa
tion of the national response.
•
34
Entrust to those agencies that have the greatest comparative
advantage the implementation of the national response.
Saving our future: multiministerial action guide
Office of Head of Government/Head of State
STEPS DESCRIBED IN THIS SECTION
WHY?
Introduces the role of the Office of Head of Government/
Head of State in tackling HIV/AIDS
WHO?
Identifies key actors for national responses
WHAT?
Contains a checklist of questions that identifies priorities
HOW?
Suggests appropriate action responses
The way forward
35
For some countries, HIV/AIDS is already a national emergency. For
others, if prevention efforts are not significantly scaled up and made
more comprehensive, it could become a national emergency. Either
way, there is no room for complacency in the Asian and Pacific
region.
The location of the national focal point for HIV/AIDS is a key
indicator of the degree of support that it has from the highest
authority in the land and its scope for effective action. When the
Head of Government/Head of State is the focal point, as is the case
in all emergencies, a strong political message is conveyed that action
on HIV/AIDS has full national backing.
Clear horizontal coordination across ministries can facilitate optimal
resource deployment. This is possible only when the national focal
point for HIV/AIDS is in the Office of the Head of Government/
Head of State. Locating the national focal point in that Office signals
to all ministries and government departments that HIV/AIDS ought
to receive the highest consideration. Thus, it is extremely important
to locate the national HIV/AIDS focal point under the direct leader
ship of the Prime Minister or the President.
The Office of the Head of Government/Head of State can be the
nerve centre of the national response to HIV/AIDS by:
36
•
Coordinating horizontally and vertically the multiministerial
response;
•
Monitoring regularly, on a monthly or quarterly basis, overall
multiministerial performance, with close supervision of progress;
•
Ensuring, where possible, that public information and advocacy
create an environment conducive to stopping the spread of the
epidemic;
Saving our future: multiministerial action guide
•
Facilitating partnerships among government, private sector and
civil society;
•
Mobilizing government and societal resources;
•
Ensuring convergence of programmes initiated by various
ministries.
WHO should take the initiative?
•
Head of Government/Head of State;
•
Minister, Office of the Head of Govern
ment/Head of State;
•
Focal point in the Office that coordi
nates with the National AIDS Commit
tee and the Cabinet of Ministers.
WHAT needs to be done?
Governments may consider some political, or
ganizational, planning and budgetary mecha
nisms that provide the necessary incentives, and
enable the multiministerial programme to be im
plemented and sustained.
Below is a checklist of questions that provide a guide to the type of
assessment needed regarding the various functions of the Office of
the Head of Government/Head of State.
The way forward
37
Box 7. Data makes the difference
Public health officials need no convincing on the importance of dedicating time and resources to prevent
the further spread of HIV. The same cannot always be said for policy makers in other sectors, who are
confronted with pressing priorities of their own.
In the early phases of the epidemic, well-designed, credible behavioural data can warn of the possibility of
rapid HIV spread and encourage policy makers to act to prevent that spread. But this can happen only if the
data are presented in language that policy makers can understand, and in ways to which they can respond.
For example, a Ministry of Education may be interested in knowledge and attitudes among youth, while a
Ministry of Manpower may want to know how widespread risk behaviour is in the urban adult population.
The Finance Ministry may be startled by the implications of financing health-care if 10 per cent of those
reporting risk behaviour were to become infected with HIV.
Demonstrating that behaviours do change following prevention activities - in groups with higher levels of
risk behaviour and in the general population - is one of the most effective ways to increase support for
prevention activities. Behavioural data showing changes over time should be presented simply and rapidly
to policy makers who have the power to influence spending and programme direction.
Source: Peter R. Lamptey and Helene D. Gayle eds., HIV/AIDS prevention and care in resource-constrained settings: A handbook for
the design and management of programs (Family Health International, Arlington 2001), p. 16.
(a) Political and organizational strategies:
38
1.
Have all relevant ministries been included in the response to
HIV/AIDS?
2.
Is the ministerial involvement in the National AIDS Committee
(NAC) at the highest levels?
3.
Have HIV/AIDS capacities developed across all ministries?
4.
Is the NAC secretariat effective in coordinating a multiministerial response?
Saving our future: multiministerial action guide
5.
Is there sufficient private sector and civil society participation in
the NAC?
6.
Has the NAC structure been decentralized and replicated at the
provincial and district levels?
(b) Planning strategies:
1.
Has a National AIDS Plan been developed for the country?
2.
Have HIV/AIDS concerns been integrated into national eco
nomic and development planning?
3.
Have HIV/AIDS concerns been integrated into impact assess
ments of major development projects?
(c) Budgetary strategies:
1.
Are allocations of the HIV/AIDS budget to ministries propor
tionate to their mandates in national development, and priority
areas in the National AIDS Plan?
2.
Has the allocation of the HIV/AIDS budget been mainstreamed
into the existing planning and budgeting process in each minis
try ?
HOW to respond?
The responses suggested below include those aimed at assisting the
Office of the Head of Government/Head of State to continue to
achieve goals and fulfil its functions in the context of changing
societal needs. It also shows how the Office could take action to
reduce HIV spread.
The way forward
39
(a) Political and organizational strategies:
1.
40
Ensure that:
•
Sufficient political authority at national, provincial and local
levels is exercised to drive multiministerial participation;
•
A coordinated and effective response is achieved through
supportive organizational structures;
•
National and provincial strategies are based on a realistic
situation assessment and response analysis.
2.
Set up a National AIDS Committee (NAC) with a wide member
ship spanning all relevant government ministers.
3.
Ensure high-level ministerial representation in the NAC.
4.
Provide adequate resources to the NAC secretariat to enable
effective coordination.
5.
Ensure the participation of civil society and the private sector in
the NAC.
6.
Establish provincial and district AIDS Committees to decen
tralize action for a more effective national HIV/AIDS response
and bring in the active participation of diverse departments and
sectors.
7.
Ensure a full response to the gender dimensions of the epi
demic, through appropriate member selection and the inclusion
of women's organizations in the NAC and local-level HIV/AIDS
Committees. Implement an orientation programme on gender
sensitivity and HIV/AIDS for all NAC members and NAC
secretariat personnel. Use a checklist of gender-sensitive actions
to enhance a gender-sensitive response to HIV/AIDS.
8.
Include people living with, or affected by, HIV/AIDS in the
NAC and in local-level HIV/AIDS Committees, to provide
valuable insight into the nature of the epidemic.
Saving our future: multiministerial action guide
(b) Planning strategies
1.
Develop a National AIDS Plan under the aegis of the NAC and
involving all relevant ministries.
2.
Integrate HIV/AIDS concerns into the national social and
economic development plan.
3.
Ensure that HIV/AIDS issues are adequately reflected in
poverty reduction strategies.
Box 8. Strategies
The fact that more and more Prime Ministers and Presidents, or their Deputies, are leading National AIDS
Councils, Commissions, or similar bodies, reflects the increasing urgency with which these leaders view the
threat posed by AIDS to national development. Such high-level leadership not only demonstrates political
commitment, but it also encourages non-health ministries to develop activities to fight AIDS within their
regular programmes.
However, caution is called for. Careful management of political mobilization and policy-making requires the
avoidance of confusion among existing institutions that already implement AIDS-related activities.
Ministries of Health, for example, have traditionally taken the lead on AIDS programming, often through
National AIDS Control Programmes. One way to avoid possible conflict is by setting clear responsibilities for
coordination, advocacy and policy-making in a manner that does not undermine the mandate of Ministries
of Health or of other existing structures.
In Kenya, for example, the National AIDS Control Council takes the lead on coordination and evaluation of all
activities against AIDS, while the Ministry of Health manages the mainly health-related interventions. Largescale assistance efforts, such as the World Bank's Multi-Country AIDS Program for Africa, have provided
funds to both the National AIDS Control Council, to support coordination and to channel funds to non
health ministries and non-governmental actors, as well as to the Ministry of Health.
Source: UNAIDS, Report on the global HIV/AIDS epidemic (Geneva, 2002), pp. 176-177.
The way forward
41
4.
Ensure consistency between national and provincial priorities,
while reflecting local dimensions of the epidemic, as appropriate.
5.
Provide technical assistance to ministries as well as nationaland local-level HIV/AIDS Committees to help develop their
institutional capacities.
6.
Include pre-approval/implementation impact assessments of
major development projects in relation to HIV/AIDS
(c) Budgetary strategies:
42
1.
Support an increase in the government budget for HIV/AIDS, to
demonstrate collective commitment by all ministries.
2.
Ensure that the AIDS budget request is mainstreamed into the
regular budgeting process of each ministry to reinforce sustain
able implementation.
3.
Ensure that HIV/AIDS resources are distributed to ministries,
on the basis of the National AIDS Plan, thereby encouraging
participation in the national HIV/AIDS response.
4.
Request the Ministry of Finance to develop effective systems
that ensure that no bureaucratic delays occur in the disburse
ment of HIV/AIDS funds to ministries.
5.
Set up and operate an independent mechanism for the audit and
monitoring of resources deployed by ministries according to the
National AIDS Plan.
Saving our future: multiministerial action guide
Ministry of Health
STEPS DESCRIBED IN THIS SECTION
WHY?
Introduces the role of the Ministry of Health in
tackling HIV/AIDS
WHO?
Identifies key actors for national responses
I
WHAT?
Contains a checklist of questions that identifies priorities
I
HOW?
Suggests appropriate action responses
The way forward
43
If allowed to spin out of control, the HIV/AIDS epidemic will
reshape the demographic structures of societies in the form of
increased morbidity, declining life expectancy and population loss.
That, in turn, would affect birth rates, age structures and population
growth rates.
(7
Already, calculations made for four countries (Cambodia, India,
Myanmar and Thailand) show that they could expect 2.2 million
additional deaths due to HIV/AIDS in the period 2000-2005.
Adult death rates can be dramatically affected in the short term,
since HIV/AIDS disproportionately strikes young adults. Estimates
indicate that when the adult HIV prevalence rate reaches 4 per cent,
HIV/AIDS could account for one-third of all adult deaths. No
country in the ESCAP region has yet reached such a prevalence rate.
However, badly affected areas in several countries of the region, for
example, some provinces in northern Thailand, South-Central China
and some States of India, could soon experience HIV prevalence
rates of 4 per cent and higher, unless prevention efforts are further
stepped up very soon.
The spectacular progress in child survival achieved in the region is
also under threat. As the HIV/AIDS epidemic matures, mother-tochild transmission of HIV typically causes infant and under-5
mortality rates to rise.
Some projections for
Thailand, for example, warn that child mortality
in 2010 could be 30 per cent higher as a result of
AIDS.
A growing epidemic slows — and eventually can
even reverse —improvements in life expectancy.
By the period 2010-2015, life expectancy in
Cambodia is projected to be 59.2 years, that is,
5 years less than it would have been without
H1V/AIDS.
44
Saving our future: multiministerial action guide
HIV /AIDS is projected to reduce life expectancy at birth in Botswana
and Zimbabwe by approximately 36.1 and 33.6 years, respectively,
in 2000-2005. Based on the 45 countries for which such projections
are available, a 1 per cent increase in the national adult HIV preva
lence rate reduces life expectancy by approximately one year.
Impact on the health sector
The HIV/AIDS pandemic inflicts a high cost on the health-status of
societies. It also has a multiplier effect on other prevalent diseases.
By weakening and eventually destroying the immune system, HIV
increases people's susceptibility to a variety of opportunistic infec
tions, including active tuberculosis (TB). Indeed, people with TB
who become infected with HIV face a 30- to 50-fold increase in their
risk of developing active TB. It is estimated that most countries of
the Asian and Pacific region could expect an increase of 5 to 10 per
cent in HIV-related TB cases.
The HIV pandemic could have a dramatic impact on the capacity of
health systems, with associated costs. In recent years, in the provin
cial hospital in Chiang Mai, northern Thailand, HIV-positive patients
have occupied about half the beds. In 2002, Cambodia's health-care
system had no additional capacity to provide appropriate treatment
for the estimated 12,000 PLWHAs in need of care and support
(communication received from the Secretary-General, National AIDS
Authority, Cambodia, 22 February 2003).
HIV/AIDS poses occupational risks for health workers, who could
acquire the virus (e.g., through needlestick injuries) or contract other
opportunistic infections. It undermines morale in the absence of
prophylactic treatment, as workload and stress levels increase, and
as people experience the death of children, young adults and
colleagues. Furthermore, the loss of health professionals to the
pandemic may lead to a further deterioration of already strained
health services in many countries in the region.
The way forward
45
The Ministry of Health takes the lead in mobilizing the health
sector and has a key role in the coordination of a multisectoral
response, with the support of the Head of Government/Head of
State. It has a central role in coordinating the national HIV/AIDS
response within Government. It is also responsible, among others,
for HIV /AIDS surveillance, prevention measures in health-care
settings and providing care and treatment for PLWHAs.
WHO should take the initiative?
•
Minister of Health;
•
Secretary, Department of Health;
•
Focal point in the Ministry that coordi
nates with the National AIDS Commit
tee;
•
Non-government and community groups
involved in health-related work.
WHAT needs to be done?
Below is a checklist of questions that guide the
type of assessment that needs to be carried out
regarding the functions of the Ministry of
Health:
46
Saving our future: multiministerial action guide
(a) HIV prevention and health promotion
1.
What are the needs for HTV prevention strategies, including
education, especially among young people, empowerment of
women, condom provision and STI treatment?
2.
What should be targeted, in terms of vulnerable groups,
practices and risk situations, to reduce HIV transmission most
cost-effectively?
3.
Is there a clear understanding, at all levels of the health system,
of key requirements for successful HIV prevention programmes?
4.
Which other Ministries and development sectors have major
roles in HIV prevention?
5.
What resources are available for HIV prevention programmes?
6.
What are the bottlenecks and obstacles to effective HIV preven
tion programmes?
7.
What are the needs for prophylaxis and secondary prevention of
complications of HIV infection?
(b) Primary health-care (PHC) service provision
1.
What levels of increased utilization of PHC services are being
experienced and might be expected, with the spread of the
epidemic?
2.
What types of opportunistic infections and other HIV-related
medical needs are presenting at PHC services or could poten
tially be managed effectively by PHC services?
3.
What psychosocial needs would have to be met at the PHC
level?
4.
What is the current and expected impact of HIV/AIDS on
number of tuberculosis cases (TB) in the population served?
The way forward
47
5.
What counselling and HIV testing needs to exist at the PHC
level?
6.
Does the TB control programme have the capacity to address a
TB epidemic?
7.
What diagnosis and treatment protocols are needed at primary
facilities for common opportunistic diseases and conditions, and
STIs?
8.
Are PHC staff members adequately trained, experienced and
supported to address medical and psychosocial needs that arise
with the spread of HIV/AIDS?
9.
Does HIV/AIDS create, at the PHC level, a need for certain new
drugs, or more drugs, for example those for TB and STIs?
10. What needs for referral systems are created by HIV/AIDS that
PHCs would likely have to address?
11. What extra facilities and personnel are needed to improve PHC
accessibility for people living with HIV/AIDS, especially in poor
communities?
12. What are the expected roles of current PHC staff in supporting
home-based care?
13. Do they have the capacity to perform this role in addition to
their other regular duties?
48
Saving our future: multiministerial action guide
(c) Ensuring access to appropriate hospital care
1.
What are the current levels of HIV /AIDS-related hospital
utilization?
2.
What is the projected number of people with HIV-related
illnesses and AIDS?
3.
How many of these are expected to seek hospital care and at
what stage of their illnesses?
4.
What are future bed needs likely to be? Data on the average
number of admissions and average length of stay of people
at different stages of HIV/AIDS may be used to obtain the
estimates.
5.
What would be the capacity of hospitals, according to current
plans?
6.
Have those plans considered projected HIV/AIDS needs?
7.
What is the case mix of people currently hospitalized with HIV/
AIDS-related illnesses?
8.
What is the mortality rate among people admitted with various
conditions?
9.
What indications are there of trends in quality of care for people
living with HIV/AIDS and other patients (e.g., mortality and
admission rates)?
10. Which conditions have poor prognoses and may be most appro
priately treated with palliative care?
11. Which conditions can potentially be cared for in other settings,
e.g., home-based care?
12. What are the needs for chronic TB in-patient care, due to social
circumstances and multi-drug resistance?
The way forward
49
13. What types of staff members are most cost-effective and feasible
to train on the scale required to meet HIV / AIDS-related needs?
14. What inefficiencies (e.g., extended length of stay, low occupancy
of some wards) may waste capacity to meet needs?
15. What guidelines and systems for clinical care, admission,
discharge and referral are in place?
16. Do they fit in with overall strategy on hospital care?
(d) Home-based and other non-hospital care strategies
*
50
1.
What are the priority medical and other needs of people in an
advanced stage of AIDS?
2.
What models of home-based or other terminal care may help
meet the needs of people in an advanced stage of AIDS?
3.
What are the current and projected numbers of patients who are
candidates for each type of care, in view of their social, eco
nomic and other circumstances?
4.
What are the financial and other costs, to the health service and
to households, of various models of care?
5.
What is the impact of HIV/ AIDS on the workload of staff mem
bers involved in various care strategies?
6.
What training and support do caregivers and health care staff
members need, to enable them to provide the requisite care for
people living with HIV/AIDS?
7.
What financial and staff capacity are, and would be, available
for these services?
Saving our future: multiministerial action guide
8.
Are referral systems to and from home-based care (HBC) and
other care points able to cope with the workload efficiently?
9.
Are care strategies, such as HBC, strengthened by good coordi
nation with NGOs, community-based organizations (CBOs) or
initiatives by Ministries of Welfare and Education, for example,
to create a continuum of care for people living with HIV/AIDS,
orphans and other dependants?
(e) Blood supply
1.
Is a regular supply of safe blood assured?
2.
What are the extra costs of assuring a safe blood supply, e.g.,
from testing, and discarding of infected blood?
(fi Stress and burnout among health-care personnel
1.
Is HIV/AIDS causing burnout and stress among health care
personnel, due to factors such as increased workload, high
mortality among young patients and illness of colleagues?
2.
Has stress, such as that related to workplace exposure to HIV
or exposure of infected staff to opportunistic infections, been
addressed?
3.
Has stress on all concerned staff members, including dieticians,
oral health and laboratory staff, been considered?
(g) Public-private partnership
1.
2.
To what extent is the private sector likely to be significantly
impacted by HIV/AIDS costs?
Alto
oo<
What are the consequences, if the private health sector preven
tion and care response is not efficient and equitable?
The way forward
45 - 2j7.
CD
51
3.
Is the private health care sector mobilized to respond to HIV/
AIDS in a cost-effective, sustainable and equitable way?
4.
Are strategies and mechanisms in place to ensure effective and
sustainable involvement of CBOs and NGOs in prevention and
care?
5.
Are traditional healers contributing to effective HIV/AIDS
prevention and care?
(h) Leadership and coordination
52
1.
Is the Ministry of Health (MoH) providing the necessary leader
ship and support for intersectoral HIV/AIDS responses?
2.
Are people living with HIV/AIDS adequately involved in
prioritizing the use of available resources?
3.
To what extent are planners and managers of hospitals, PHC
and other health system components involved in adequate
mobilization and coordination around HIV/AIDS?
4.
Are other sectors mobilized and committed to addressing HIV/
AIDS issues?
5.
Are health information and other MoH systems giving adequate
information and technical inputs to guide health- and inter
sectoral initiatives, e.g.:
•
Statistics on the epidemic and its impact?
•
Economic evaluations?
•
Counselling standards?
•
Condom quality assurance?
•
Post-exposure prophylaxis policies?
Saving our future: multiministerial action guide
6.
Are demands for inputs into the inter-sectoral response leading
to adequate focus and capacity for effective health sector
strategy development and implementation?
(i) Policy and legislation
•
Do any current or planned policies and legislation related to the
sector:
1.
Increase or decrease the rate of spread of HIV infection?
2.
Actively reduce stigma and discrimination against people
living with HIV/AIDS or people affected by it, to encourage
disclosure to strengthen prevention and impact manage
ment?
3.
Need adaptation to meet new challenges to implementation
because of HIV/AIDS? For example, strengthening staff
capacity to meet HIV/AIDS care needs may require change
to staffing norms and job descriptions, to facilitate more
rapid and cost-effective training and employment.
HOW to respond?
The responses suggested show how the Ministry
can take action to reduce the spread of HIV.
Some responses may actively address impact.
Others may include more detailed research on,
and planning of, specific issues. It is important to
prioritize responses that are most critical and
feasible in specific situations. The appropriate
participation of key stakeholders is likely to be
important for effective prioritization and buy-in.
The way forward
53
(a) Prevention and health promotion
1.
Evaluate and refine existing prevention programmes.
2.
Use innovative routes and messages so that HIV/AIDS informa
tion and education continuously have credibility and maintain a
high profile. For example, radio and TV drama, agricultural
extension officers and popular personalities have been used. So
too have schools, post-offices, temples, mosques and churches.
3.
Develop plans to provide for health promotion items such as
budgets, staff, training and drug supplies.
4.
Ensure that programmes go beyond education and information,
and actually empower people to change their behaviour for HIV
prevention.
5.
Develop specific strategies to target vulnerable groups, as well
as high-risk behaviours and situations.
6.
Strengthen skills, understanding and support materials for
health personnel to participate fully in HIV prevention activities.
7.
Ensure adequate systems for reliable, easy access to free or
subsidized condoms.
8.
Set standards for condom distribution and use and monitor
condom quality.
9.
Mobilize other sectors to ensure effective roles in HIV preven
tion.
10. Ensure that STI services are user-friendly, can be accessed by
those who need them, and are effective.
11. Investigate and implement effective and appropriate use of
prophylaxis and secondary prevention.
54
Saving our future: multiministerial action guide
(b) Ensuring access to primary health care (PHC)
1.
Ensure that PHC services are effective in playing a key role in
HIV/ AIDS responses, especially by being more accessible to
local communities, and in preventing and treating illnesses
before they become so serious as to require hospital care.
2.
Identify and monitor the impact of HIV/AIDS on PHC services.
3.
Clarify realistic strategic and operational roles of PHC services
in HIV/AIDS care, to reduce reliance on hospital care.
4.
Ensure that PHC planners and staff members understand, and
are committed to, their role in the HIV/AIDS response.
5.
Ensure that all PHC services provide effective, accessible STI
services.
6.
Prioritize the effectiveness of TB services and programmes.
7.
Develop PHC guidelines for diagnosis and treatment of HIV/
AIDS-related conditions, and evaluate their implementation.
8.
Train PHC staff members, as necessary, in effective diagnosis
and treatment of TB, STIs and other HIV/AIDS-related condi
tions, and ensure follow-up support and monitoring.
9.
Review, streamline and monitor referral systems.
10. Develop counselling and support skills and the capability of
PHC service providers to meet psychosocial needs arising from
the spread of HIV/AIDS.
11. Develop a voluntary counselling and testing strategy and
systems.
12. Ensure the commitment of other sectors, e.g., welfare, and
proper coordination, to provide support for people living with
HIV/AIDS and their households.
The way forward
55
13. Invest in facilities and personnel, as necessary, to ensure
equitable and accessible PHC services for people living with
H1V/AIDS.
14. Review PHC service staffing to ensure adequate capacity.
(c) Ensuring access to appropriate hospital care
56
1.
Identify and monitor HIV/AIDS impact on hospitals.
2.
Ensure that hospital planners, managers and staff members
recognize the need to develop strategic plans to manage HIV/
AIDS care needs.
3.
Develop efficient coordination mechanisms with planners,
managers and staff members of PHC, welfare and community
based care.
4.
Define guidelines for a "core package" of hospital care, to
be provided to people living with HIV/ AIDS and terminal
illnesses.
5.
Develop guidelines for clinical management, admission, dis
charge, and referral to and from other services, in line with the
strategic plan.
6.
Develop counselling capacity in hospitals, to facilitate more
efficient testing and care planning with clients and caregivers.
7.
Develop capacity to undertake viral load testing and monitor
ing, or to facilitate convenient access to that service.
8.
Address key bottlenecks and inefficiencies related to hospital
staffing, care processes and capacity use.
9.
Ensure timely expansion of hospital capacity based on projected
needs, options for care, costs and available resources.
Saving our future: multiministerial action guide
Box 9. Health-care - just 75 cents away!
At a time when most governments around the world are privatizing their public health-care systems and
cutting back on expenditure, Thailand is showing that state-sponsored universal health-care is still possible.
Since February 2001, Thailand has been experimenting with a novel national health programme that provides
medical services, including surgery, to Thai citizens at just Baht 30 (equivalent to US$0.75) per visit to a hospital.
Patients from low-income families do not have to pay anything.
The programme builds on Thailand's various health insurance schemes, which by 1998, covered up to 80.3 per
cent of the country's over 60 million people. The remaining people who have been given insurance cover now
are typically among the poorest in society. They include slum dwellers, subsistence farmers, rural workers and
the very low-income self-employed.
Under the new system, the Government compensates health care service providers according to the number of
registered patients they have. In addition to an allowance of Baht 1,200 (equivalent to US$30) per patient,
resource-strapped hospitals can draw on a US$122 million contingency fund and claim fees for referral
patients.
At present, the service package includes most health services except cosmetic care, obstetric delivery beyond
two pregnancies, drug addiction treatment, haemodialysis, organ transplant, infertility treatment and other
high-cost interventions. Initially, Thailand's thousands of people living with HIV/AIDS were only eligible for
treatment of opportunistic infections. Following pressure from PLWHA groups, there are now plans to include
more expensive ARV treatment in a step-by-step process.
There has been criticism about aspects of the Baht 30 health scheme. Most notably, the criticism points to the
poor quality of medical services provided in rural areas and the consequent pressure on better-equipped
urban hospitals when they are flooded with out-of-town patients.
Although the Thai experiment is still in its early stages, its importance lies in the following:
(a)
The political commitment shown by the Government of Thailand to bring public health to the top of the
national agenda;
(b)
Investing significant funds into universal health-care, even though Thailand is just recovering from a
severe economic downturn;
(c)
Evolving a viable model for other middle-income countries on how to deal with unequal access to health
care and its impact on poverty.
Source:
Adapted from Nutta Sreshthaputra, "The Universal Coverage Policy of Thailand: An Introduction", paper prepared for
the Asia-Pacific Health Economics Network (2001).
The way forward
57
(d) Implementing home-based and other non-hospital care
1.
Clarify types and scale of needs to be met, different models of
care, cost and capacity issues.
2.
Pilot and evaluate various models of care.
3.
Ensure efficient systems for referral and for support of health
care service staff involved in home- based or other forms of
care.
4.
Ensure adequate numbers and skills of staff to provide informa
tion, training and support to caregivers.
5.
Develop protocols and systems to provide information and basic
training to caregivers, before people living with AIDS are
discharged from hospitals.
6.
Ensure the availability of a key package of medical supplies for
home-based and other types of care.
7.
Develop quality assurance mechanisms for each type of care.
8.
Develop policies and mechanisms to support effective and
sustainable roles for non-governmental and community-based
organizations involved in care and support.
9.
Ensure that Ministries of Welfare and Social Development rein
force community and household capacity to cope with care and
non-medical needs.
(e) Blood supply
•
58
Develop or refine systems to ensure safe blood supplies and
manage the costs of ensuring such supplies.
Saving our future: multiministerial action guide
(fi Stress and burnout among health care personnel
1.
Ensure effective policy, guidelines and implementation for pre
cautions to reduce occupational exposure to HIV, and exposure
of workers living with HIV/AIDS to opportunistic infections,
especially TB.
2.
Encourage open discussion of staff concerns, make counselling
available and support staff involved in counselling.
(g) Public-private partnership
1.
Develop a strategy and mechanisms to ensure sustainable and
cost-effective private sector HIV/AIDS prevention and care.
2.
Ensure effective private sector roles in addressing key public
health problems, such as HIV prevention, STIs and TB.
3.
Monitor delivery by industry clinics and other private sector
health service providers, to ensure adequate standards of care.
4.
Develop strategies and mechanisms to ensure effective and
sustainable involvement of CBOs and NGOs in prevention and
care, e.g., home-based care and counselling.
5.
Develop a strategy to involve qualified and reputable traditional
healers in prevention and support.
6.
Provide a conducive policy and regulatory environment for an
effective private sector response to HIV/AIDS.
(h) Leadership and coordination
1.
Ensure adequate technical support, and quality data from health
information systems and other sources, to guide HIV/AIDS
planning in health and other development sectors.
The way forward
59
2.
Ensure that people with HIV/AIDS have a strong role in defining priorities for use of available resources.
3.
Ensure coordination of HIV/AIDS-related planning and opera
tions among all relevant components of health services and
HIV/AIDS programmes.
4.
Mobilize other sectors to respond to needs for HIV prevention,
and care and support.
5.
Develop programmes to reduce stigmatization and discrimina
tion of people living with HIV/AIDS, to facilitate more effective
prevention and care.
Box 10. HIV/AIDS situation assessment in China
In 1997, the Ministry of Health, China, carried out an HIV/AIDS situation assessment with support from the
United Nations system and other national and international partners to map out the priorities and needs for
an effective response to the problem. The result was a national-level, medium- to long-term plan that set
out broad national objectives and strategies. These have to be reflected in specific provincial and local
government policies and strategies according to their respective situations. Given the size of China, these
situations are as different as they are complex and there has to be a strategic approach to planning at the
local level. The United Nations system and other agencies are collaborating with a core working group on
strategic planning at the central level and with local authorities to address these diverse and specific
situations. A pilot situation and response analysis was conducted in one province, Guangxi, at the provincial
as well as the more decentralized prefectural and county levels. These served to guide similar processes in
other provinces in 2000. In this way China is implementing its policy of planning its HIV/AIDS prevention
and care activities to match the diverse and changing determinants in provinces, counties and munici
palities.
Source: Adapted from Peter R. Lamptey and Helene D. Gayle eds., HIV/AIDS prevention and care in resource-constrained settings:
A handbook for the design and management of programs (Family Health International, Arlington, 2001) p. 16.
60
Saving our future: multiministerial action guide
Ministry of Finance
STEPS DESCRIBED IN THIS SECTION
WHY?
Introduces the role of the Ministry of Finance in
tackling HIV/AIDS
WHO?
Identifies key actors for national responses
WHAT?
Contains a checklist of questions that identifies priorities
HOW?
Suggests appropriate action responses
The way forward
61
er\
Projections for the Asian and Pacific region suggest that billions of
dollars and millions of lives could still be saved in this decade, if
Governments were to invest urgently in prevention measures. In a
2010 "costs-of-inaction" scenario, young, productive citizens would
be lost to the pandemic, business profits would slump, household
income and standards of living would plummet, and economies
would stagnate.
In the worst-affected countries of the world, HIV/AIDS is reversing
annual economic growth rates by as much as one to two percentage
points.
In some countries, if the epidemic were to remain
unchecked, economic wealth could decline substantially by 2020.
National studies of two African countries with adult HIV prevalence
rates higher than 30 per cent indicate that their economies would
grow by 2.5 and 1.1 percentage points less by 2015, respectively, than
they would have in the absence of AIDS. Higher morbidity and
mortality levels also drain national economies by reducing the
volume of available savings and changing the way in which savings
are used. Ultimately, this too affects economic growth.
Meeting the challenge of the HIV / AIDS pandemic is a long haul and
necessitates sustained investments. These investments have to be in
all development-related sectors, including elementary education,
health-care, social justice, and even defence and security.
The Ministry of Finance, as the fulcrum of the financial system,
exercises considerable power to raise resources and to influence
resource deployment, across ministries and sectors of the economy.
The ministry also has the power to provide fiscal incentives through
various subsidies.
When it comes to meeting the challenge of the HIV/AIDS epidemic,
the ministry's functions are pivotal and equipped for grappling with
issues such as the following:
62
Saving our future: multiministerial action guide
•
•
•
•
Allocating funds to mitigate poverty as a result of the epidemic;
Allocating funds for expanding HIV prevention;
Meeting home-based care needs of persons living with AIDS;
Addressing increased demands for health care services.
It is, therefore, imperative that the Ministry of Finance has a clear
understanding of what data and information are required from
different ministries and development sectors, to determine the
overall cost of meeting the HIV/AIDS challenge.
WHO should take the initiative?
•
Minister of Finance;
•
Secretary
Finance;
•
Focal point in Ministry of Finance that coor
dinates with the National AIDS Committee;
•
Business leaders, and representatives of
employees' associations.
(Expenditure),
Department
of
WHAT needs to be done?
The Ministry of Finance decides on the allocation of budgets
to the various ministries and development sectors. It is there
fore imperative that this ministry considers what information
it requires from those ministries and sectors in order to decide
on overall allocation, as well as specific funds to mitigate the
impact of HIV/AIDS impact and prevent new infections. In
this regard, critical questions need to be posed.
The way forward
63
Some external impact may already be experienced, but many would
be fully felt only in the medium- to long-term. The type of impact
assessment and responses to be decided on would depend on the
particular stage of the epidemic and the extent to which resources
have already been mobilized to address HIV/AIDS.
Key areas under the Ministry of Finance that would need rethinking
in order to tackle the HIV/AIDS epidemic include the following:
•
Macroeconomic policy and priorities;
•
Policy and legislation.
Below are examples of the type of assessment that needs to be done
with respect to both these areas:
(a) Macroeconomic policy and priorities
64
1.
What are the overall resources available for government spend
ing and how much flexibility is there likely to be, to meet new
needs as a result of HIV/AIDS?
2.
What are the current mechanisms for determining the allocation
of funds among sectors or sectoral clusters, and how much
flexibility is there likely to be to respond to new needs?
3.
What would be the key need and cost areas created by HIV/
AIDS?
4.
What is the magnitude of current and projected need, as a result
of HIV/AIDS spreading into the wider society?
5.
What are the cost implications within current practice?
6.
What is the regional variation of need and cost likely to be and
over what time frame?
Saving our future: multiministerial action guide
7.
Is current practice cost-efficient?
8.
What is the status of each sector's response to HIV/AIDS? For
priority sectors:
9.
(a)
Has the sector quantified the impact of HIV/AIDS on the need for
its services or functions?
(b)
Have strategic options been identified? These should include
prevention options and options to manage HIV/AIDS impact.
(c)
Have options that are affordable and sustainable, cost-effective
and that promote the public good, been identified and prioritized?
(d)
Have key efficiency improvements been identified?
Has a strategic plan been developed that takes HIV/AIDS issues
into account? Is it comprehensive? Does it deal with the inter
nal and external impact of HIV/AIDS on the sector?
10. Does the sector's strategic plan address equity concerns?
11. What is the status of inter-sectoral action?
12. How do sectors currently deal with overlap or gaps in respon
sibilities, to ensure planning for a multisectoral and integrated
response?
13. Can the responsibilities of various sectors
for managing the impact of HIV/AIDS be
identified? For example, what aspects of
the care of orphans would the Ministries
of Education, Health and Welfare coordi
nate, respectively, and how would func
tions undertaken by different Ministries be
integrated?
14. What is the impact of HIV/AIDS likely to
be on the total government revenue?
The way forward
65
(b) Policy and legislation
Do any current or planned policies and legislation related to the
sector:
1.
Increase or decrease the rate of spread of HIV infection?
2.
Provide the increasing numbers of people living with or affected
by HIV/AIDS adequate protection against discrimination?
3.
Require adaptation to meet new implementation challenges
because of HIV/AIDS?
HOW to respond?
Below are suggestions concerning the scope of possible responses
by Ministries of Finance. Some responses may actively mobilize
Government Ministries to address impact. Others may target mobi
lization and regulation of the private sector.
Whatever the response, involve all relevant stakeholders in both the
planning of impact assessment, and in its implementation.
Policies and priorities
66
1.
Promote the inclusion of specific HIV/AIDS objectives and
activities in all plans and budgets submitted to the Ministry of
Finance.
2.
Ensure that current expenditure reporting systems encourage
appropriate allocation of resources to HIV/AIDS.
3.
Increase government spending in areas of major need.
4.
Give priority to expenditures that fund cost-effective inter
ventions or represent a strategic investment in planning and
capability-building to meet future increases in need.
Saving our future: multiministerial action guide
5.
Recognize the critical role of expenditure on broader social and
economic development, and in areas such as welfare, to combat
the spread of HIV and reduce vulnerability to impact.
6.
Communicate to planners and institutions, as soon as possible,
an indication of overall expenditure policy in response to HIV/
AIDS, and the scale of possible increases, to guide the planning
of responses.
7.
Ensure that projects, especially large-scale ones, include HIV/
AIDS impact assessment and prevention.
8.
Give active support to priority HIV/AIDS responses by the
private sector. Consider ways of awarding tax relief for innova
tive responses in prevention, support for community assistance
in orphan care, or contributing to the financing and running of
hospices and home-based care and support centres.
9.
Ensure that incentives and regulations, for example medical
scheme regulations, promote, with equity, adequate care of
people living with HIV/AIDS.
10. Optimize the role of the private health sector in HIV/AIDS care.
Issues which may be considered include the following:
•
Requirement that private medical schemes share with Govern
ment information on the sustainability and cost effectiveness
of various HIV/AIDS (and other high-cost) care options.
•
Development of mechanisms to ensure that private health
care patients do not drain scarce public sector care resources
intended for the poor, following cost-ineffective use of
private health-care funding.
11. Ensure that policies and procedures for preventing occupational
HIV infection are clear, draw on available resources, and include
coverage of hospitals, the uniformed services, transport sector,
and prisons.
The way forward
67
Costs of action
Trends show increased financial resources for HIV/AIDS. Globally,
total international donor disbursement to affected countries for HIV/
AIDS programmes grew significantly from US$ 297 million in 1996
to US$1.8 billion in 2002. In the same period, national governmental
and NGO spending in affected countries exceeded US$ 500 million.
In terms of geographic distribution, in both 1999 and 2000, the
largest share of international donor assistance for HIV/AIDS was
destined for sub-Saharan Africa, with the Asian and Pacific region
ranking second. Spending on HIV/AIDS has been increasing in
absolute terms. Between 1996 and 2002, spending on HIV/AIDS
from all sources is estimated to have increased from US$ 500 million
to approximately US$ 3 billion.
Resource need and availability
As the HIV/AIDS pandemic grows, available funding is not match
ing the needs of countries in its path. Significant new resources are
required to address the HIV/AIDS pandemic in low- and middle
income countries.
By 2007, prevention costs would represent 39 per cent of total
funding needs, ARV therapy-funding requirements would increase to
25 per cent, and treatment for opportunistic infections would be 8
per cent of total funding. It is estimated that, in 2005, US$10.5
billion, and in 2007, US$ 15 billion would be needed annually to
expand the global HIV/AIDS response to a point at which the
spread of the pandemic could be reversed and its impact signifi
cantly diminished. By 2007, low- and middle-income countries in
the ESCAP region would need US$ 7 billion, that is, almost one-half
of the total resource requirements. Such a funding level would
require a dramatic increase in global resources for HIV/AIDS.
68
Saving our future: multiministerial action guide
The US$ 10.5 billion
and US$ 15 billion esti
mates for 2005 and
2007, respectively, do
not include infrastruc
ture development costs.
The WHO Commission
on
Macroeconomics
and Health has esti
mated that, if infra
structure development
costs were to be in
cluded, US$ 13.6 billion
and US$ 15.4 billion
would be needed for
HIV/AIDS prevention
and care, respectively,
in 83 selected low- and
middle-income
coun
tries by the year 2007,
in addition to what
was currently spent.
Box 11. Global resources needed by region
16,000
||
14,000 -
12,000 -
5 10,000 o
I
8,000 6,000 4,000 2,000 -
Bw
2001
2002
2003
2004
2005
2006
2007
OU Sub-Saharan Africa
□ South & South-East Asia
□ East Asia & Pacific
■ North Africa & Middle East
□ Western & Eastern Europe & Central Asia
Latin America & Caribbean
Source:
UNAIDS, "Financial resources for HIV/AIDS programmes in low- and middle
income countries over the next five years" (UNAIDS/PCB(13)/02.5).
It is estimated that, already in 2003, it would take US$ 3.5 billion to
bridge the gap between total funding needs and funding availability
for fighting HIV/AIDS globally. As for the ESCAP region, conser
vative estimates suggest a resource gap of 80 per cent between
resource need and availability for mounting an effective HIV/AIDS
response.
The way forward
69
Ministry of Education
STEPS DESCRIBED IN THIS SECTION
WHY?
Introduces the role of the Ministry of Edcuation in
tackling HIV/AIDS
WHO?
Identifies key actors for national responses
WHAT?
Contains a checklist of questions that identifies priorities
HOW?
Suggests appropriate action responses
70
Saving our future: multiministerial action guide
The impact of HIV/AIDS on communities served by the Ministry of
Education would be profound.
Furthermore, the Ministry is
uniquely placed to reduce the future HIV/AIDS epidemic as it can
influence the risk behaviour of large numbers , of young people,
many of whom are not yet infected.
School enrolments are likely to fall as students are taken out of
school to care for ill parents and family members. Poor families are
particularly likely to suffer this impact and would face increasing
difficulty in paying school fees and other related expenses. Girls, in
particular, are likely to be taken out of school to care for ill family
members.
High levels of new HIV infection among learners, while they are in
the education system and afterwards, would represent enormous
human costs, and "wasted investment" in education. The major
financial loss to education would usually be "waste" of basic state
subsidies of education for learners who later die of HIV/AIDS.
However, certain bursary or loan mechanisms may be vulnerable to
HIV/AIDS among beneficiaries and their families. Needs created by
HIV/AIDS in other sectors may limit budgets available for educa
tion. Exposure of certain learners (e.g., student nurses) to infection
during training may create liabilities for institutions, although the
main risk of infection would usually be through sexual activity.
Sickness and death in families and among friends
would affect many learners' morale, socialization
and performance. Many learners would have
new special needs.
Among them would be
children orphaned by the death of parents from
AIDS and learners who themselves are living
with HIV. HIV/AIDS would be a challenge to
education at primary, secondary and tertiary
levels.
The way forward
71
Many learners would themselves have been infected by HIV at birth,
or through sexual abuse, and sexual activity, including sex work.
Stigmatization of HIV/AIDS worsens all impact on learners.
HIV/AIDS may, over time, reduce the number of school entrants
and change the age structure of the population.
At the same time, AIDS may lead to a reduction in the number of
qualified teachers and administrators, and make it impossible for the
education system to fulfil its mandate and provide children with
quality schooling. The effects could be especially harsh in rural
areas where schools often depend on one or two teachers.
Unless adequate prevention and impact mitigation measures are put
in place, countries in the region that have reached high standards
of literacy and education could see some deterioration in terms of
quality and loss of skilled personnel. Those countries still striving to
reach the goal of providing quality education for all could see their
efforts stall in the face of HIV / AIDS.
WHO should take the initiative?
72
•
Minister of Education;
•
Secretary, Department of Education;
•
Focal point in Ministry that coordinates
with the National AIDS Committee;
•
Teachers' unions, school associations, non
governmental and community groups in
volved in education-related work.
Saving our future: multiministerial action guide
WHAT needs to be done?
Below is a checklist of questions that guide the type
of assessment that needs to be carried out regarding
the functions of the Ministry of Education:
(a) New HIV infections among learners
1.
What are the levels of HIV infection among learners and recent
graduates at various levels of the system?
2.
Are there HIV prevention initiatives in schools?
3.
Has the coverage and effectiveness of HIV prevention and life
skills programmes been evaluated?
4.
Have they been strengthened wherever appropriate?
5.
Are there existing or expected skill shortages, which may
worsen due to HIV/AIDS impacts on learners?
6.
Do curricula and courses at all levels help learners to reduce
behaviours associated with HIV risk and ensure returns on
investments in education?
(b) Ability to access basic education and new
special needs
1.
Is there evidence of reduced school enrolment and by how
much?
2.
Which States/provinces or regions are most affected?
3.
Is school attendance reduced due to HIV/AIDS?
4.
Is there evidence of an increased drop-out rate or repetition of
grades?
The way forward
73
5.
What are the characteristics of learners who drop out and who
repeat grades?
6.
Are these orphans? Girls/young women? Children from poor
households?
7.
Do educators have the understanding, skills and support to
recognize and respond to special needs created by HIV/AIDS?
8.
What is the extent of disruption of learning due to absenteeism
and attrition of teachers?
9.
Which provinces or regions are most affected by such disruption?
10. Does the design of buildings need to be modified to enable
schools to cope with special needs, e.g., increased need for sick
bays, counselling areas, and flexible classroom sizes?
(c) Future numbers of learners
1.
What is the expected number of learners at each level of educa
tion, given the HIV/AIDS epidemic?
2.
What are the implications for staffing and infrastructure
planning?
n c pf
1
74
Saving our future: multiministerial action guide
(d) Financial implications
1.
Is the sustainability of financial assistance programmes vulner
able to HIV/AIDS impact on beneficiaries?
2.
Are any learners at risk of exposure to HIV infection in the
course of their training?
3.
Are the training institutions involved ensuring appropriate
education and adequate supplies of protective equipment?
(e) Policy and legislation
Are any current or planned policies and legislation related to the
education sector likely to:
1.
Increase or decrease the rate of spread of HIV infection?
2.
Provide adequate protection against discrimination for the in
creasing numbers of people living with HIV/AIDS and affected
by it?
3.
Require adaptation to meet new challenges to implementation
because of HIV/AIDS?
HOW to respond?
The following are responses that the Ministry of Education could
take to reduce HIV spread.
(a)
New infection among learners
1.
Develop strategies to slow the rate of new infections in pupils:
these may include life skills programmes emphasizing HIV/
AIDS education.
The way forward
75
Box 12. Catching them early
In 1992, Thailand launched national strategies to reduce the vulnerability of
children, especially girls, at risk of entering the sex industry, and contracting
STIs and HIV.
The Ministry of Education (MOE) conducted a survey of Thai sex workers,
gathered data on villages with high HIV/AIDS rates, and collected informa
tion on the number of students who finished Grade 6, but who did not
continue their education. These were used as a basis for planning interven
tions.
Prevention measures were viewed as the most important strategy. How
ever, prevention, assistance, rehabilitation, and legal measures to eliminate
entry into the sex industry by children under 18 were also imperative.
These preventive measures identified guidelines for intervention that in
cluded those below:
•
The provision of 9 years of quality basic education and/or vocational
training for all children and youth;
•
Equal access for girls and boys to both formal and non-formal educa
tion;
•
Awareness-raising campaigns against child sex work;
•
Counselling and guidance services, in particular for solving family and
young people's problems and for job selection - in every school and for
out-of-school children and youth.
Source: UNAIDS, Summary Booklet of Best Practices: National strategies to reduce vulner
ability of Thai girls (Thailand) (http://www.unaids.org/bestpractice/summary/cyp/
natstrat.htm, 4 April 2003).
76
Saving our future: multiministerial action guide
2.
Use the findings and outcomes of programmes that are in
place to strengthen them, as appropriate, including through
effectiveness evaluations.
3.
Scale up interventions once these have been shown to be
effective.
4.
Consider fee exemption or bursaries for girls and young women
to reduce economic pressures to engage in sex work.
5.
Implement effective strategies to eliminate sexual abuse and
rape of learners in educational institutions.
(b) Ability to access basic education and new special needs
1.
Explore ways of providing bursary schemes for poor pupils:
consult with local communities to ensure bursary recipients are
able to attend school.
2.
Develop protocols and institute training to help teachers
respond to the special needs of all pupils and orphans whose
parents have died of AIDS.
3.
Include HIV/AIDS education for teachers in all in-service
training initiatives.
4.
Require teacher-tra ining institutions to provide HIV / AIDS
education.
5.
Liaise with other Government Ministries to develop a care
programme for children who have lost their parents to AIDS,
and decentralize implementation to the local level.
The way forward
77
Box 13. Going beyond the obvious: adapting education
AIDS makes it necessary to devise new ways of turning education against
the epidemic. School planners and policy-makers envision alternative forms
of schooling, such as schooling structured around modules and semesters
rather than around age-linked grades. With a project in 11 African countries,
the US Agency for International Development (USAID) helps schools
emphasize classroom-based prevention, life-skill messages, as well as
programmes for children who have dropped out of school to care for ailing
parents or because they must work to support the household. Among the
interventions is an interactive radio education programme that was piloted
in Zambia in order to provide an education for orphans and vulnerable
children. The AIDS Support Organisation (TASO) - a Ugandan group that
has traditionally provided support for people living with HIV/AIDS - found
that the major concern of parents caring for orphaned and vulnerable
children was the costs associated with attending school. TASO now
supports 232 primary, secondary and vocational education students by
providing school fees and teaching materials. The programme also trains
teachers in basic counselling skills and offers child/guardian workshops
so that guardians and children have a forum for discussing, and finding
solutions to, their problems. Calling on retired teachers offers another
means of coping with education systems strained as a result of AIDS.
Source:
UNAIDS, Report on the global HIV/AIDS epidemic (Geneva , 2002), p. 53.
(c) Future numbers of learners:
78
1.
How may staffing and infrastructure planning take into account
HIV /AIDS impact on the size and structure of the learner popu
lation?
2.
How may the impact of AIDS on attrition and absenteeism
among teaching staff be factored into planning?
Saving our future: multiministerial action guide
Ministry of Labour
STEPS DESCRIBED IN THIS SECTION
WHY?
Introduces the role of the Ministry of Labour in
tackling HIV/AIDS
WHO?
Identifies key actors for national responses
WHAT?
Contains a checklist of questions that identifies priorities
HOW?
Suggests appropriate action responses
The way forward
79
HIV/AIDS hits the world of work in numerous ways. In badly
affected countries, it cuts the supply of labour and reduces income
for many workers.
Increased absenteeism raises labour costs for employers. Valuable
skills and experience are lost. Often, a mismatch between human
resources and labour requirements is the outcome. Along with lower
productivity and profitability, tax contributions also decline, while
the need for public services increases. National economies are being
weakened further in a period when they are struggling to become
more competitive in order to weather the challenges of globalization.
Most countries impose an obligation on employers to do all in their
power to ensure that their employees are not put at risk of illness or
injury because of the nature of their work. The most clear-cut
examples of work-related HIV/AIDS risk are those situations in
which health-care workers are exposed to contaminated blood
or blood products.
Police and prison personnel may also be
exposed to HIV through human bites. In these instances, employers
are obliged to provide protective gloves and other equipment, and
education.
Misconceptions about work-related transmission may need to be
cleared up to prevent workers living with undue stress and preju
dice. Less clear-cut and more contentious as work-related exposure,
are situations that predispose employees to high-risk sexual encoun
ters, such as frequent and lengthy travel away from home. Trans
port workers, seafarers or construction teams are among such
vulnerable employees.
For workers already living with HIV/AIDS, early and appropriate
treatment can extend the length of working life and minimize
productivity impact. This extension of working years is to the
80
Saving our future: multiministerial action guide
advantage of the workers, their families, employers and the state.
As early treatment is dependent on early disclosure of HIV status,
non-discriminatory policies and access to counselling which facilitate
early disclosure need to be supported.
Early disclosure also gives employers the opportunity to mitigate
the impact of employee infections on the organization, such as
instituting multi-skilling, planning skills development and timely
recruitment of replacement staff. Training courses may be inefficient,
if HIV/AIDS affects recipients before they utilize skills.
Efforts to maintain stable and cooperative labour relations may be
undermined, if HIV/AIDS is poorly managed within companies.
The Ministry of Labour, together with unions and employer group
ings, may have a critical role in encouraging the formal and informal
sectors to manage HIV/AIDS issues appropriately.
HIV-positive individuals have the potential to lead productive lives
for many years. There is general agreement that pre-employment
testing is misguided, expensive and unfair. Even in situations where
pre-employment testing or pre-training testing is not conducted,
people thought to have HIV/AIDS may be discriminated against in
companies. This may be through employers not employing from
groups thought to engage in high-risk behaviours or denying HIV
positive people career advancement opportunities.
HIV/AIDS may affect the numbers claiming from any unemploy
ment protection fund or other benefit fund. Such funds may have
barriers to the chronically ill collecting benefits, thereby discriminat
ing against people living with HIV/AIDS.
The impact of HIV/AIDS includes the following:
•
Skills shortages in some areas (e.g., mines and other industries
that are reliant on migrant labour), with a rise in labour costs;
The way forward
81
•
Reduced supply of labour;
•
Loss of skilled and experienced workers;
•
Absenteeism and early retirement;
•
More people may need skills development;
•
Stigmatization of and discrimination against workers with HIV;
•
Increased labour costs for employers from health insurance to
retraining;
•
Reduced productivity in certain sectors and businesses, contract
ing tax base and negative impact on economic growth;
•
A threat to food security as agricultural workers are increasingly
affected;
"HIV/AIDS should be recognized as
a workplace issue, and be treated like
any other serious illness/condition
in the workplace. This is necessary not
only because it affects the workforce,
but also because the workplace, being
part of the local community, has a role
to play in the wider struggle to
limit the spread and effects of
the epidemic."
ILO, The ILO Code of Practice on HIV/AIDS and
the World of Work (Geneva, 2001)
82
•
Falling demand, investment discour
aged and enterprise development
undermined;
•
Social protection systems and health
services under pressure;
•
Increased burden on women to
combine care and productive work;
•
Loss of family income and household
productivity, exacerbating poverty;
•
Orphans and other affected children
forced out of school and into child
labour;
•
Pressure on women and young peo
ple to survive by providing sexual
services.
Saving our future: multiministerial action guide
WHO should take the initiative?
•
Minister of Labour;
•
Secretary, Department of Labour;
•
Focal point in the Ministry that coordinates
with the National AIDS Committee;
•
Trade unions, employers' associations,
non-government and community groups
involved in labour-related work.
WHAT needs to be done?
Below is a checklist of questions that guide the
type of assessment that needs to be carried out
regarding the functions of the Ministry of Labour:
(a) Employment planning, efficiency and productivity:
1.
What is the projected number of workers living with HIV/AIDS,
workers ill from HIV/AIDS, and AIDS-related deaths for
various sectors, industries, job categories and parts of a country?
2.
What sectors and institutions are at high risk of productivity
and efficiency losses?
3.
Which of these sectors are unlikely to cope with expected losses?
4.
What are future labour costs likely to be, given the loss of
skilled workers due to HIV/AIDS?
The way forward
83
5.
What are the labour costs for various job categories and
different planning areas likely to be?
6.
What are future levels of unemployment likely to be?
7.
What are the likely key skill shortages in the country and in
specific industries?
8.
How can the Ministry encourage companies to assess their
vulnerability to HIV/AIDS impact and to formulate appropriate
responses?
9.
How can employers and trade unions be encouraged to provide
access to counselling and safe entry points for HIV-positive
workers?
10. What health facilities are available to workers?
11. How may the Ministry of Labour promote early and appropriate
treatment of HIV-positive persons, in conjunction with the
health facilities available to workers?
(b) Labour relations
84
1.
What HIV/AIDS policy, legislation and guidelines are currently
available for employers, and are there any gaps in policy?
2.
Are there any indications as to how well HIV/AIDS workplace
policies are distributed?
3.
What sectors or parts of the country are poorly serviced by
labour policy and information?
4.
How do employers and trade unions currently approach HIV/
AIDS issues in the workplace? For example, do companies still
practice pre-employment screening? Are HIV-positive workers
barred from further training or promotion in some firms?
5.
How well would internal labour relations mediators and exter
nal consultants handle HIV/AIDS issues as they arise?
Saving our future: multiministerial action guide
(c) Employment equity
1.
Does current legislation ensure adequate protection for HIVpositive employees?
2.
Are there any mechanisms in place for implementation and
monitoring of good labour practice in relation to HIV / AIDS?
(d) Occupational health and safety
1.
What are policy and protocols for preventing work-related HIV
infection in hospitals and other at-risk institutions?
2.
Are these in line with good practice?
3.
How can employers be encouraged to decrease the exposure of
employees to high-risk situations?
4.
How can trade unions in high-risk industries be encouraged to
promote prevention and awareness initiatives?
5.
How can large employers and trade unions be encouraged to
provide effective counseling services for HIV-positive workers?
(e) Benefit packages
1.
What criteria are used to assess HIV/AIDS-related disability?
2.
Are these in line with good practice?
3.
Are HIV/AIDS disability criteria widely applied?
4.
Is there equity of access to any social security benefits?
5.
What are the current and on-going costs of benefit claims?
6.
What are future costs likely to be?
The way forward
85
(f) Policy and legislation
Do any current or planned policies and legislation related to the
labour sector:
1.
Increase or decrease the rate of spread of HIV infection?
2.
Provide, for the rising numbers of people living with HIV/AIDS
and affected by HIV/AIDS, adequate protection against dis
crimination?
3.
Require adaptation to meet new challenges to implementation
because of HIV/AIDS?
HOW to respond?
The Ministry of Labour is uniquely placed to impact profoundly on
the HIV/AIDS epidemic. It has the responsibility of programmes,
policies and legislation that target productive age adults, in the
prime of their lives, whose behaviours place them at high risk of
acquiring HIV and who are most affected by HIV/AIDS illness and
death.
(a) Employment planning and efficiency and productivity
86
1.
Use projections of HIV prevalence, illness and AIDS deaths by
sector and/or job category for planning and advocacy.
2.
Use labour cost projections in planning, if appropriate.
3.
Use skill audits in planning employment and training.
4.
Expand skills development programmes to meet future de
mands.
Saving our future: multiministerial action guide
Box 14. Reaching outside the formal economy
Workers outside the formal economy are too often ignored in public health efforts. Yet, in many low- and
middle-income countries, the informal economy employs far more people than do the public or formal
private sectors. These workers typically lack income security, health insurance and other benefits, and
seldom enjoy labour law protection. Owing to the obstacles to their entry into the formal job market,
women often represent the majority of those in informal work, making them even more vulnerable to the
economic effects of the epidemic. Enterprises in the informal economy are usually small and labourintensive, relying heavily on one or a few operators. When a worker falls sick and eventually dies, it can be
very difficult for these small enterprises to stay in business. The precarious nature of informal employment,
the lack of social protection and limited access to health services also worsen the impact of the epidemic
for individual workers. Workers in the informal economy are often organized into associations or groups,
and the ILO works with several of these. Increasingly, this assistance includes training for AIDS prevention
and social protection measures such as health insurance. Work among micro- and small enterprises includes
a business awareness programme for sex workers and the 'Start and Improve your Business' programme,
which is integrating HIV/AIDS into training in Africa. Other programmes offer technical support for the
setting up and strengthening of local micro-insurance schemes in order to increase access to heath-care.
A pilot project is under way in Burkina Faso to adapt this approach to HIV/AIDS-related needs.
Source:
UNAIDS, Report on the global HIV/AIDS epidemic (Geneva, 2002), p. 110.
5.
Develop, with stakeholders, policy and legislation that encour
age employers and trade unions in vulnerable sectors to conduct
effective workplace HIV prevention programmes.
6.
Disseminate information to employers in the most vulnerable
sectors or organizations concerning HIV/AIDS vulnerability.
7.
Disseminate resources and good practice case studies, which
describe actual responses to HIV/AIDS by some companies.
Case studies may include:
(a)
(b)
(c)
HIV prevention initiatives;
Managing ill health;
Human resource development and industrial relations;
The way forward
87
(d)
(e)
8.
Employee benefits and survivor support;
Monitoring and planning.
Plan innovative and non-coercive ways to encourage all compa
nies, or companies within specific sectors, to respond to HIV/
AIDS.
Introduce a Ministry award for good practice, arrange media
coverage and appropriate publicity.
10. Liaise with other government ministries, as appropriate, to
introduce a requirement that companies adhere to minimum
standards of good practice in HIV/AIDS, to qualify for govern
ment contracts.
11. Liaise with appropriate stakeholders to explore ways of award
ing tax relief for priority HIV/AIDS responses that exceed what
would ordinarily be expected. For example, such responses may
include actively assisting communities with orphan support or
contributing to the financing and running of terminal support
and home-based care support centres.
(b) Labour relations:
1.
Disseminate the ILO “Code of Practice on HIV/AIDS and the
World of Work" to employer groups, individual employers, and
trade unions, particularly sectors or parts of the country that are
poorly serviced by information.2
2.
Organize training courses for labour relations mediators on
HIV/AIDS issues, if applicable.
2 ILO, The ILO Code of Practice on HIV/AIDS and the World of Work (Geneva,
2001), electronic version available at (http://www.ilo.org/piiblic/english/protection/
trav/aids/code/languages/hiv_a4_e.pdf 2001).
88
Saving our future: multiministerial action guide
Box 15.
A model employer
The Haiha-Kotobuki joint venture became involved with the Viet Nam Chamber of Commerce and Industry
(VCCI), CARE International and the National AIDS Committee (NAC) in a project to promote business
partnerships to assist the efforts of the Government of Viet Nam to prevent and control HIV and AIDS. The
project attempts to do this by:
•
Increasing knowledge and awareness of the risk of HIV/AIDS and skills for protection within the business
community;
•
Piloting a model of HIV/AIDS education within the workplace; and
•
Developing policy with recommendations to encourage domestic and foreign companies to contribute
to HIV/AIDS programmes in their workplace.
Top management support was needed for such an initiative. VCCI identified a high-ranking and highly
committed member of the Haiha-Kotobuki joint venture. A large number of company staff were also willing
to be involved and trained in emerging social issues that impinge upon their business. Corporate leader
ship meant corporate responsibility in matters related to their staff, their families and the wider community.
One major activity undertaken by Haiha-Kotobuki was the development of an HIV/AIDS workplace policy.
The policy assists managers and workers in taking the initiative to protect themselves, their families and the
community against HIV/AIDS, as well as providing care and support for PLWHA in the company. HaihaKotobuki identified five major categories:
•
Implementation of prevention programmes;
•
Testing;
•
Confidentiality;
•
Preventing discrimination;
•
Flexible work conditions for HIV-positive staff.
Staff who may be living with HIV are treated equally and have access to all company benefits, including
holiday allowance, social and health insurance, emergency support and free lunch in the company cafeteria.
Source: Peter R. Lamptey and Helene D. Gayle eds., HIV/AIDS prevention and care in resource-constrained settings: A handbook for
the design and management of programs (Family Health International, Arlington, 2001) p. 16.
The way forward
89
(c) Employment equity
1.
Develop pilot mechanisms to monitor good labour practice in
relation to HIV/AIDS.
2.
Consider ways to encourage female participation in the labour
force.
(d) Occupational health and safety
1.
Ensure that good practice procedures for preventing workrelated exposure to HIV, and procedures for HIV prophylaxis in
the event of exposure, are in place in relevant institutions.
2.
Encourage trade unions in high-risk sectors to conduct HIV
prevention programmes.
3.
Assist trade unions to source condoms and to develop HIV/
AIDS education materials.
4.
Facilitate, with relevant stakeholders, the development of HIV
prevention through peer educator strategies in the workplace.
5.
Mobilize resources for developing training materials, such as
videos, slide shows and resource directories, that may be used
by peer educators.
Encourage employers to provide counseling services for HIV
positive workers, where feasible.
6.
(e) Benefit packages:
1.
2.
3.
4.
90
Facilitate the development and dissemination of functional
criteria for HIV/AIDS disability.
Ensure the removal of any barriers that the chronically ill may
face in collecting benefits.
Consider ways of protecting informal sector labour that may be
at risk of HIV, but have poor access to benefits.
Plan for future costs of unemployment insurance, where relevant.
Saving our future: multiministerial action guide
Ministry of Welfare
STEPS DESCRIBED IN THIS SECTION
WHY?
Introduces the role of the Ministry of Welfare in
tackling HIV/AIDS
WHO?
Identifies key actors for national responses
WHAT?
Contains a checklist of questions that identifies priorities
HOW?
Suggests appropriate action responses
The way forward
91
The impact of HIV/AIDS on households is potentially disastrous,
especially in a region where over 800 million people are estimated to
live below the poverty line of less than US$ 1 per day. Those most
likely to acquire the virus are generally in the prime productive age
group of 15 to 49 years, who are often at the peak of their earning
capacity.
M
As people living with HIV/AIDS succumb to illness, their income
earning abilities weaken. At the same time, household or family
incomes shrink, when family members have to adapt their work
lives to care for the ill. Studies show that the incomes of households
with a person living with HIV/AIDS can fall by as much as 80 per
cent.
As incomes become depleted, household savings are often tapped to
meet health-care costs associated with HIV/AIDS, Studies in the
region suggest that over half of all households affected by HIV/
AIDS reduced their consumption of goods and services by 40 to 60
per cent, in order to help meet health-care costs.
As more and more people living with HIV progress to AIDS,
the financial and material burden of care tends to shift away from
hospitals towards family and friends, through home- and commu
nity-based care. AIDS deaths, following asset and wage losses, and
care costs, often push households deeper into poverty.
Forms of social relief available to the destitute
differ among countries of the region. The budget
ary implications of HIV/AIDS are obviously a
major consideration and the impact of HIV/AIDS
on eligibility for support and uptake would need
to be quantified. This is particularly important
in countries where statutory state support is
provided.
92
Saving our future: multiministerial action guide
In countries with severe epidemics, the most pressing welfare
concern that has been identified is that of the need to care for
children orphaned through parental death from AIDS. Large num
bers of AIDS orphans may be left unsupported, as extended family
structures and networks break down or household resources become
over-extended. There could be an increase in the number of home
less children, who themselves would become vulnerable to HIV
infection. Many children might be unable to attend school because
of household financial constraint.
In all countries with severe epidemics, the support of affected com
munities would help avert large-scale social problems. Overall need
and demand for welfare assistance could increase. In the long-term,
while the need for old age pensions might decrease, as fewer people
reach pensionable age, there might be more pensioners qualifying for
state assistance, as the proportion of people in the low-income
bracket increases as a result of the economic impact of HIV / AIDS on
households. The need in provinces or regions of a country would
differ: in some areas, HIV/AIDS-related need would be delayed,
while others might experience sustained need.
The statutory work load of state social workers could increase, with
higher eligibility for foster care grants and other social support and
increased numbers of foster homes that require supervision. There
could be increased referrals from local government and its housing
department for intervention in housing problems. Prevention and
community development activities may be swamped by statutory
work demands.
Welfare policies and programmes have the potential to foster
the creation of an environment in which the most vulnerable could
protect themselves from the full negative impact of HIV/AIDS.
Policies and programmes that support women and children who
otherwise might be vulnerable to pressure to engage in sex work as
a means of survival, and policies on orphan support, are critical to
The way forward
93
stemming a future epidemic, and to dealing with the impact of
the current one. Clear understanding of potential impact would
influence whether the welfare response is appropriate and effective
in meeting the needs of society and individuals.
WHO should take the initiative?
•
Minister of Welfare;
•
Secretary, Department of Welfare;
•
Focal point in Ministry that coordinates
with the National AIDS Committee;
•
Non-government organizations and com
munity groups involved in welfare-related
work.
WHAT needs to be done?
Below is a checklist of questions that guide the type of assessment
that needs to be carried out regarding the functions of the Ministry
of Welfare:
(a) Administration of social security grants and
other poor relief
i.
94
What is the expected impact of HIV/AIDS on eligibility and
uptake of social security grants or other forms of poor relief?
Saving our future: multiministerial action guide
2.
What are the budgetary implications of the welfare impact of
HIV/AIDS?
3.
What is the sub-national-specific impact of HIV /AIDS?
4.
How may data on impact be used to assist in sub-national
resource allocation and in channelling more resources to areas of
greatest need?
5.
What are the responsibilities of various sectors and other players
in contributing to safety nets for the most vulnerable?
6.
Are these resource-efficient and complementary?
7.
Are appropriate linkages in place?
8.
What are the gaps and overlaps in responsibility?
(b) Care of orphans and children affected by AIDS
1.
What are the projected numbers and provincial or regional
distribution of orphans (girls and boys)?
2.
What is the level of vulnerability of orphans?
3.
What are existing community care mechanisms for orphans?
4.
Has appropriate government policy been developed to address
the needs of orphans?
5.
What are the good practice examples or inno
vative models of care that could be adapted
or scaled up?
6.
What are the costs of current and desired
policies and programmes?
7.
How can sustainable funding be mobilized
for these?
The way forward
95
Box 16. Home and community care
In an attempt to address the growing problem of HIV/AIDS care in Cambo
dia, WHO started a joint pilot project in home and community care in 1997,
in collaboration with the Ministry of Health and local and international
NGOs. The project sought to develop ways to provide appropriate support
through government/NGO collaboration within the government policy of
health reforms. Using the framework of WHO's Comprehensive Care Across
the Continuum, eight home-care teams were established across the city of
Phnom Penh. Based in government health centres and working within
their boundaries, the teams formed a network of caregivers supporting
patients and families at home.
The following comprise the primary focus in health-care: At least two
members of each 5-person team are nurses. Social and emotional support
is given high priority, as well as raising general awareness about HIV/AIDS
within families and the community at large. Depending on need, 1 or 2
members of the team may make several visits a week, during which they
show the family how to manage symptoms simply and safely, and support
both family and patient as best they can. Although they carry simple drugs
and supplies and have some welfare funds, team members encourage the
family to buy essential items. Emphasis is placed on maintaining good
hygiene and nutrition. A team's activities may also include accompanying a
newly-diagnosed patient to a support group, educating monks concerned
about contamination on negotiating treatment options with a traditional
healer. Local volunteers assist the teams in their work - for example, in
finding a particular house in Phnom Penh's urban sprawl, or providing
liaison with community leaders.
Each team is made up of both government and NGO staff, all of whom
operate under the same terms and conditions. The project is coordinated
through a committee of members representing all partners, including the 7
NGOs and the health-centre managers. Monthly team activity reports are
submitted to the committee for discussion. Representatives from the
teams themselves meet weekly to exchange news, pass on referrals and
provide mutual support. Senior health workers and NGO staff carry out
96
Saving our future: multiministerial action guide
on-site supervision. Hospital doctors support the teams with regular medi
cal consultations at the homes of seriously ill patients unable or unwilling
to go to hospital.
The practice of sharing resources helped both the NGOs and the Govern
ment. Working on an equal footing towards a common goal enabled both
"sides" to share their different skills and experiences and learn from each
other. This has helped normalize relations between NGOs and Government,
which are sometimes strained. Some government staff members believe
that the lion's share of resources go to NGOs, which often adopt conflicting
and unsustainable approaches. NGOs, in turn, may complain of poorly
managed government facilities.
A new problem has emerged: Creating an equal team required supple
menting government staff salaries (normally between US$ 8 and US$ 15
per month) to a realistic level. The extent to which this creates a problem
needs further analysis. Low salaries are a constant source of frustration in
Cambodia. Until this is addressed, salary supplementation will be difficult
to avoid if the Government is to be included in innovative projects.
Source: Peter R. Lamptey and Helene D. Gayle eds., HIV/AIDS prevention and care in
resource-constrained settings: A handbook for the design and management of
programs (Family Health International, Arlington, 2001) p. 16.
O,^
The way forward
97
(c) Statutory work and community development
1.
What are the HIV/AIDS implications for equity of service
provision?
2.
How do equity concerns affect staff and infrastructure planning?
3.
Can grant application procedures be streamlined to be more
time-efficient?
4.
Would increased statutory work load and other forms of HIV/
AIDS-related impact lead to the neglect of community develop
ment and prevention activities under current service models?
5.
What partnerships could be developed with non-governmental
organizations and other bodies, for example local authorities?
(d) Policy and legislation
Do any current or planned policies and legislation related to the
welfare sector:
1.
Increase or decrease the rate of spread of HIV infection?
2.
Provide, for the increasing numbers of people living with HIV/
AIDS, and for those affected by it, adequate protection against
discrimination?
3.
Require adaptation to meet new challenges to implementation
because of HIV/AIDS?
HOW to respond?
The responses suggested show how the Ministry of Welfare could
take action to reduce HIV spread.
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Saving our future: multiministerial action guide
Box 17. Music brings the message
Over the past five years, the UNAIDS Secretariat and some of its cosponsors have worked closely with Music
Television (MTV) in an effort to reach out to young people and talk to them in their language about issues
that interest and involve them. This unique partnership has built on MTV's strengths as a global television
network and leading multimedia brand for young people, using their distribution platform and rightsfree distribution to other broadcasters to reach some 900 million households worldwide with HIV/AIDS
messages. The partnership has included the production of an award-winning series, 'Staying Alive', focusing
on the lives of individual young adults living with HIV/AIDS around the world. In addition to being shown
on all MTV channels, the series has been aired by many major networks, including China Central Television,
South African Broadcasting Corporation, TV Africa, Channel News Asia and RTR Moscow, to name a few.
Together with UNAIDS, MTV has encouraged many celebrities to record prevention messages that have
been widely distributed and used in public service announcements in many countries. A booklet for MTV
presenters and celebrities, entitled Talking about AIDS, has also been produced.
Source:
UNAIDS Report on the global HIV/AIDS epidemic (Geneva, 2002). p. 112.
(a) Administration of social security grants and
other poor relief
1.
Consider the feasibility of providing HIV/AIDS prevention
and care messages to social security grant recipients and house
holds.
2.
Seek increased budgets and adjust budget allocations in the light
of impact assessments and projections.
3.
Incorporate HIV/AIDS impact into poverty indicators.
4.
Adjust sub-national resource allocations, taking into account the
sub-national-level impact of HIV/AIDS on poverty.
5.
Ensure resources are directed towards poor relief and poverty
reduction in areas of greatest need.
The way forward
99
(b) Care of orphans and children affected by HIV/AIDS
*
UV'
*
1.
Prepare policy documents and projects to address the needs of
orphans, where appropriate, including streamlined provision
and support of foster care, bursary provision to assist education,
and provision of extra support for the schooling of orphans who
might have special education needs.
2.
Adapt and scale up innovative models of care that have been
proved effective.
3.
Mobilize and coordinate support for policy and project imple
mentation.
4.
Develop appropriate indicators and systems to monitor numbers
and circumstances of orphans and other children made vulner
able by HIV/AIDS.
5.
Liaise with Ministries of Education and Health, where relevant.
6.
Consider ensuring that any projects to address the needs of
orphans include HIV/AIDS prevention messages, if appropriate.
|0 o
(c) Statutory work and community development
Jr
1.
Ensure that staffing and infrastructure planning take into
account the demographic and economic impact of HIV/AIDS.
2.
Ensure that projects and programmes are directed to areas of
greatest need.
3.
Seek allocation of more social worker posts, if appropriate.
rm.
J
- 4.‘ -Streamline grant application procedures to be more time’
'efficient.
5. Consider the appropriateness of personnel assignment: for
•' r.example, dedicated personnel for statutory work and dedicated
. * personnel assigned to community development and prevention.
v
100
Saving our future: multiministeriai action guide
Ministry of Agriculture
STEPS DESCRIBED IN THIS SECTION
WHY?
Introduces the role of the Ministry of Agriculture in
tackling HIV/AIDS
WHO?
Identifies key actors for national responses
WHAT?
Contains a checklist of questions that identifies priorities
HOW?
Suggests appropriate action responses
08
§
The way forward
101
eatery
At first glance, HIV/AIDS may not appear to have a significant
impact on agricultural production and rural development at the
national level. However, by adversely affecting the livelihood, as
sets, income and productive capacity of a growing number of rural
households, HIV/AIDS could have a severe impact on the avail
ability, access to, and utilization of, food.
Differentials in HIV infection rates between urban and rural areas
can quickly be eroded when movement and interchange between the
two rise - in this manner, despite a common assumption to the
contrary, rural areas are not immune to the epidemic.
For example, the large-scale migration of mostly young rural people
to urban areas exposes them to high risk of HIV infection: long
absence from home, stressful living conditions and inducement to
engage in high-risk behaviour. On return to the rural areas, many
transmit the virus to their sex partners. Furthermore, they return to
their families for care, once the AIDS symptoms are manifest.
This could dramatically decrease the productivity of the agricultural
labour force. The impact of a serious epidemic might be more
pronounced where a large proportion of the labour force is em
ployed in the agricultural sector, for example in China, India and
Indonesia. In severe epidemics, food production and supplies, even
food security, could be threatened, as HIV/AIDS-related morbidity
and mortality worsen. For example, in Papua New Guinea, by 2020,
rural income is projected to decline by up to 8 per cent in a worst
case HIV/AIDS scenario. The effects on smallholder agriculture
could be even worse, with output projected to plunge by as much as
24 per cent over the same period.
Rural poverty, labour migration and the low status of women could
increase susceptibility to HIV. For example, men who have to
migrate or travel frequently, are more likely to change sex partners,
while young women in poverty may be compelled to trade sexual
favours for cash or other support.
102
Saving our future: multiministerial action guide
These factors also make it more difficult for communi
ties and individuals to cope with the impact of existing
infections. HIV/AIDS may impact on the rural environ
ment through increasing demands for poverty relief,
through making some form of cropping and subsistence
agriculture unviable because of labour shortage, and
caring for sick family members may increase rural
women and children's work burden, leaving them little
time for skills development.
'v
Ministry programmes and policies relating to small-holder farmers,
tenant farmers and commercial agriculture may impact on HIV
spread. Further, HIV/AIDS may present overwhelming direct and
indirect costs to farmers and vulnerable organizations. Absenteeism,
recruitment and training are likely to form the bulk of costs to
organizations. HIV/AIDS-illness and mortality among the recipients
of loans might increase the number of defaulters on loan agreements.
Migrant labourers, seasonal labourers and immigrants may be at
particular risk and have few employee benefits. The low status
of women and their limited economic independence undermine
women's ability to protect themselves from HIV infection.
In fact, in macroeconomic terms, the majority of countries most
affected by HIV/AIDS are also those most heavily reliant on agricul
ture. The issue of HIV/AIDS is thus increasingly relevant to the
work of the Ministry of Agriculture and
the Ministry of Rural Development. Both
Ministries can design policies and strate
gies to stem the spread of the virus to,
and within, rural areas, as well as protect
and support rural households already
affected by HIV/AIDS.
The way forward
103
WHO should take the initiative?
•
Minister of Agriculture;
•
Secretary, Department of Agriculture;
•
Focal point in the Ministry who coordi
nates with the National AIDS Committee;
•
Members of local bodies, farmers' associa
tions, rural cooperatives, rural community
leaders, non-governmental organizations.
WHAT needs to be done?
Below is a checklist of questions that guide the type of assessment
that needs to be carried out regarding the functions of the Ministry
of Agriculture:
(a) Promotion of rural development, including poverty
reduction, provision for food security, and
empowerment of rural women
104
1.
What are the levels of HIV infection and AIDS deaths in rural
areas?
2.
What are the expected levels of infection and AIDS deaths in the
next 5 to 10 years?
3.
What kinds of rural households and communities are most
susceptible to HIV infection?
Saving our future: multiministerial action guide
4.
What is the current and expected impact of increased illness
and death on the nutritional status of pregnant and lactating
women, children under 5 and older persons in rural areas?
5.
Are there parts of the country whose viability would be
particularly adversely affected by large numbers of AIDS deaths
among adults in the productive age group?
6.
Are there HIV prevention programmes linked to current rural
development initiatives?
7.
Have their coverage and effectiveness been evaluated?
8.
Have they been strengthened, where appropriate?
9.
How may AIDS illness and death in the household affect
rural women's access to health services, education, and other
resources and support?
10. What are the special HlV/AIDS-related problems faced by
female-headed households in rural areas?
11. Do rural women face different problems in dealing with illness
and death in families from those that men face?
12. What is the effect of HIV/AIDS on migration patterns?
13. Would workers living with HIV/AIDS return to the rural areas?
14. What are the likely effects of such return on rural communities?
15. What is the role of employers and the state in supporting
workers living with HIV/AIDS in rural areas?
gygf / J? '
The way forward
105
(b) Creation of conditions favourable for small-holder
farmers, tenant farmers and commercial agriculture
1.
Are there any good practice partnerships or initiatives to reduce
HIV spread in rural areas or mitigate its rural impact, which
could be modified or replicated?
2.
What are current and potential governmental and NGO points
of entry for HIV prevention and mitigation in rural areas?
3.
Are these points of entry being fully exploited?
4.
Could farming systems or areas be classified according to how
vulnerable these systems would be to increased illness and
death, in the way that labour-intensive farming practices, low
food or credit surpluses and insecure land tenure make a system
more vulnerable.
5.
What is the need for, and feasibility of, expanding credit
availability for the poorest farmers?
6.
What are the numbers of orphans on farms and agricultural
enterprises?
7.
How many children on farms and agricultural enterprises
are likely to be orphaned in future years?
8.
What are the current policies and practices for orphaned
children and widows on farms?
9.
How would increased numbers of orphans and widows be
supported?
(c) Financial assistance and settlement of farmers
on state land
What is the likely impact of HIV/AIDS on current and future loan
portfolios?
106
Saving our future: multiministerial action guide
(d) Occupational health and safety strategies
1.
What enterprises, geographic areas and occupations are at high
risk of HIV/AIDS?
2.
What are the patterns and extent of migrant labour in the
agricultural sector?
3.
Are there any policies and programmes that inadvertently
encourage single-sex living arrangements, which might predis
pose to high-risk situations and behaviours?
4.
What is the feasibility and appropriateness of enlarging the
scope of activities undertaken by agricultural extension workers
to include HIV/AIDS activities?
(e) Rights of agricultural workers and rural dwellers
With regard to surviving children or widows having problems
retaining family land, housing or livestock:
1.
Do policies and legislation support gender equality and protect
the occupancy and inheritance rights of widows and orphaned
children?
2.
How could implementation of those policies and legislation be
monitored and strengthened, where appropriate?
(f) Other projects, schemes and services
Large concentrations of workers moving into an area for a defined
project could spread HIV into that area:
1.
What system exists to monitor projects that require movement
by many workers?
2.
How is the risk of HIV transmission related to projects and
schemes assessed?
The way forward
107
(g) Agricultural training
1.
2.
What are the levels of knowledge and awareness concerning
HIV/AIDS in training recipients?
What is the magnitude of need for prevention messages and
condom distribution?
(h) Policy and legislation
Do any current or planned policies and legislation related to the
agriculture sector:
1.
Increase or decrease the rate of spread of HIV infection?
2.
Provide adequate protection against discrimination for the in
creasing numbers of people infected or affected by HIV / AIDS?
3.
Require adaptation to meet new challenges to implementation
because of HIV/AIDS?
HOW to respond?
The Ministry of Agriculture has the responsibility of programmes,
policies and legislation that target those in the agriculture sector,
including adults in the prime of their lives, whose behaviours place
them at high risk of acquiring HIV and who are most affected by
HIV/AIDS illness and death.
(a) Promotion of rural development, including poverty
reduction, provision for food security, and
empowerment of rural women
i.
108
Consider using area-specific levels of HIV infection and
expected AIDS deaths to inform planning and target appropriate
rural development programmes.
Saving our future: multiministerial action guide
2.
Mobilize all rural development initiatives, whether public or
private, to include HIV prevention programmes, e.g., through
including HIV prevention in tender documents.
3.
Support appropriately targeted nutrition programmes for rural
children, pregnant and lactating women and older persons.
4.
Set up partnerships with other Departments or Ministries and
employers to find appropriate, cost-effective ways to assist ill
rural migrants and their families.
5.
Ensure that rural programmes and initiatives take into account
the vulnerability of farming systems and areas to increased
illness and death in working age adults.
6.
Integrate HIV education and condom distribution into agricul
tural support programmes and activities.
7.
Integrate information on the potential economic effects of HIV/
AIDS on farming systems into support programmes and activi
ties.
8.
Support initiatives to increase locally-generated incomes and
reduce the need for migration.
9.
Consider encouraging labour-economizing crop varieties and
labour-saving technologies and cultivation practices in areas of
high HIV prevalence.
The way forward
109
11. Support initiatives that would reduce the work burden of rural
women and children, e.g., access to fuel and water supply,
especially to benefit households with persons living HIV/AIDS
in need of their care.
12. Develop and implement unambiguous and consistent policies
that ensure land tenure is secured for widows and orphaned
children, to protect them from destitution following the death
from AIDS of husbands and fathers who were tenant farmers.
13. Document good practice case-studies and examples for use by
farmer organizations and community groups.
(b) Creation of conditions favourable for small-holder
farmers, tenant farmers and commercial agriculture
110
1.
Expand credit availability for the poorest farmers.
2.
Develop HIV awareness programmes to reduce risk behaviour
among small-holder and tenant farmers.
3.
Support labour-saving projects that benefit households with
persons living with HIV/AIDS.
4.
Introduce HIV/AIDS awareness programmes targeting com
mercial agriculture that include advice on how to mitigate the
impact of HIV and ensure employee benefits are sustainable.
5.
Encourage commercial farmer organizations and small-holder
farmers to develop a response to HIV/AIDS.
6.
Liaise with counterpart Ministry of Agriculture and the
agricultural sector in other countries to share sector-specific
lessons.
7.
Support inter-country cooperation to develop responses.
Saving our future: multiministerial action guide
(c)
Financial assistance and settlement of farmers
on state land
Include HIV/AIDS awareness messages with loan materials.
(d) Occupational health and safety strategies
1.
Identify agricultural enterprises, geographic areas and occupa
tions with high levels of vulnerability to HIV infection and AIDS
death, and liaise with appropriate Government Departments
and NGOs to undertake prevention programmes.
2.
Develop, with stakeholders, policies for farm worker illness
benefits.
3.
Review the tasks and beneficiaries of extension workers.
4.
Train frontline agricultural extension workers on HIV/AIDS
prevention and referral to treatment and care.
(e) Rights of farmers, agricultural workers and rural dwellers
1.
Develop policies and monitoring systems to ensure support for
destitute rural orphans, widows and older persons.
2.
Assess policies and legislation to ensure that there exists
adequate support for gender equality and protection of the
occupancy and inheritance rights of widows and orphaned
children.
(f) Other projects, schemes and services
1.
Include HIV in environmental impact assessment and include
HIV prevention in the planning stage of all agricultural and
rural development projects.
The way forward
Ill
2.
Advocate for the inclusion of HIV/AIDS-related prevention
activities in training and in the job descriptions of agricultural
extension officers.
3.
Include health measures in tender documents.
(g) Agricultural training
Include HIV/AIDS issues in the curriculum of agricultural
training colleges.
112
Saving our future: multiministerial action guide
O
U-
Q.
IXI
Actions common to all ministries
u
This checklist can help assess how effectively each ministry
has responded to HIV/AIDS - and what action still needs
to be taken. By determining what initiatives have not been
made, and which ones need clarification, this checklist can
assist any ministry in gauging its preparedness for the HIV/
AIDS epidemic
in
CO
Section
III
Basic steps for all
113
Yes
Action
No
Action
in Progress
Action being
planned
(A) HIV/AIDS Impact Assessment
Information management:
Is
information
about HIV/AIDS being collected, analysed, stored
and spread?
Assessment of target groups: Has there been
any assessment of the present impact of HIV/
AIDS on Ministry target groups? Is this informa
tion up-to-date?
Assessment of future impact on target
groups: Has there been any assessment on the
likely future impact of HIV/AIDS on Ministry tar
get groups?
Assessment of staff: Has there been an analysis
of how HIV/AIDS will impact the Ministry in
terms of direct/indirect costs due to illness and
loss of staff?
Assessment of operations: Has there been an
analysis of how HIV/AIDS will impact Ministry
operations, including policies and programmes,
in terms of direct/indirect costs?
(B)
Workplace Programmes on HIV/AIDS
Awareness
Programme implementation: Are programmes
currently in place to raise awareness of HIV/AIDS
among staff members?
Provincial staff outreach: Are programmes cur
rently in place to raise awareness of HIV/AIDS
specifically among provincial-ZState-level staff
members?
114
Saving our future: multiministerial action guide
Unsure
Yes
Action
No
Action
in Progress
Action being
planned
Staff working conditions: Are assessments of,
and changes to, working conditions of staff
exposed to high-risk situations that may render
them vulnerable to HIV infection (e.g., lengthy
trips away from spouses and partners)?
Access Do
condoms?
staff members
have
access
to
Participation: Are staff members of all positions
and departments included in the development
and implementation of HIV/AIDS prevention,
care and support programmes?
Appropriate materials: Have suitable HIV/AIDS
educational materials been developed, or made
available by outside service providers, to include
in workplace HIV/AIDS programmes?
Programme trainers: Have knowledgeable
and experienced trainers been located to
administer workplace programmes on HIV/AIDS?
(c)
Workplace Programmes for staff members
living with HIV/AIDS or affected by it
Eliminating discrimination: Are programmes
currently in place to eliminate, among staff
members, stigmatization and discrimination of
people living with HIV/AIDS or affected by it?
Access to counselling: Do staff members living
with or affected by HIV/AIDS have access to
counselling services?
Care and support: Does the Ministry have any
other specific care and support programmes for
staff members living with or affected by HIV/
AIDS?
Basic steps for all
115
Unsure
Yes
Action
No
Action
in Progress
Action being
planned
(D) Human Resource Policies and Procedures
Social security: Are there alternative social
security options (e.g., health-care scheme, and
welfare fund) for staff members living with HIV/
AIDS?
Terms of leave: Have the terms for sick and unof
ficial leave been revised to take into account the
needs of staff members living with HIV/AIDS?
Care during travel: Are there provisions for
additional travel costs where staff members
living with HIV/AIDS need assistance during
travel on duty?
(E) HIV/AIDS Focal Point Team
Focal points: Has a team of departmental
focal points on HIV/AIDS been established?
Statement, guidelines, and action plans:
Has a Ministry mission statement, guidelines
and actions plans on HIV/AIDS been developed?
Assessment of staff awareness: Has there
been an assessment on the levels of staff aware
ness on HIV/AIDS issues?
(F) HIV/AIDS Task Force
Task force: Has an HIV/AIDS Task Force been
established for the Ministry?
Intra-Ministry action: Are existing mecha
nisms for HIV/AIDS intra-Ministry action in place?
Referral network: Has a referral network for
care and support services for staff members
been developed?
116
Saving our future: multiministerial action guide
Unsure
Action
Yes
No
Action
in Progress
Action being
planned
Representation: Is there Ministry representa
tion in the National AIDS Council/Committee?
Outside partners: Are any partners outside
government - such as UN agencies and NGOs involved in the Ministry's response to HIV/AIDS?
(G) Ministry Good Practices
Has your Ministry researched and explored
options for adapting relevant good practices
from other countries?
(H) Budget for HIV/AIDS Costs and Responses
Involvement: Is your Ministry actively involved
in the design and conduct of research on HIV/
AIDS?
Follow-up: Are there mechanisms in place to
follow up Ministry HIV/AIDS initiatives?
Indicator development: Have indicators been
established for measuring the progress of
Ministry initiatives?
(I) Ministry Ownership
Involvement: Is your Ministry actively involved
in the design and conduct of research on HIV/
AIDS?
Costs: Is there a budget allocated to cover
direct and indirect costs of HIV/AIDS on staff at
all levels and in all departments?
Responses: Is there a budget allocated to
cover immediate and effective responses to HIV/
AIDS, to be undertaken by the Ministry?
Basic steps for all
117
Unsure
Impact of HIV/AIDS within a ministry
Identifying the internal impact of HIV/AIDS within a ministry
involves understanding the extent and consequences of infection
among its employees.
While HIV/AIDS may severely compromise the ability of any
organization to deliver, the effects may be particularly pronounced in
Government, if it lacks the flexibility to respond to new pressures.
The impact of employee infections would be particularly severe for
ministries in the social sector, such as the Ministry of Education or
of Health because of the multiplier effect of personnel infections.
For example, for every teacher infected, the education of some 20 to
50 learners would be affected. The loss of key personnel in any
ministry would adversely affect the functioning of that ministry, with
a ripple effect in wider society.
Experience and research show that a ministry's vulnerability to
employee infection depends on several key factors such as the
following:
•
•
•
•
•
•
•
Number of employees living with HIV/AIDS;
Absenteeism and productivity;
Recruitment and training;
Morale;
Benefits;
Gender equality;
Capacity to respond.
Some of these areas of vulnerability may be the ultimate respon
sibility of a central body, such as the Ministry of Public Service
Administration, and individual sectors should liaise with that
Ministry. The type of assessment needed depends on the purpose
for which the data are to be used.
118
Saving our future: multiministerial action guide
Consider the following questions to help identify where your
ministry may be vulnerable to the impact of employee infection.
Review each area of action and consider which may be relevant to
your ministry.
1. Number of employees living with HIV/AIDS
The scale of the epidemic would result in considerable human
suffering for employees living with HIV/AIDS. In addition, the
ability of some ministries to fulfill their functions would be severely
impacted.
Estimates of the size and spread of the epidemic are available from
the Ministry of Health in most countries. It may be possible to use
these estimates to develop a rough idea of how many ministry
employees are currently HIV-positive. You may need to obtain
special projections of the expected scale of the epidemic in the
future: a growing number of people with HIV infections and AIDS
can be expected in many countries.
You may also expect that some categories of staff would be dispro
portionately affected. These would include younger people, those
who are mobile, such as migrants, and those who live in conditions
of social instability. Evidence suggests that skilled and affluent
people, mainly men, may have more opportunities for high-risk
behaviour, including unprotected sex.
•
What is the current level of infection?
•
How many new infections are expected each year?
•
What are future levels of infection, AIDS-related illness and
death likely to be?
•
Which categories of employees may be exposed to particularly
high-risk situations?
Basic steps for all
119
2. Issues and action points
(a) Absenteeism and productivity
(i) Issues
Absenteeism due to illness, compassionate leave and funerals can
impose large costs or inefficiencies on an organization. HIV/AIDS
among different categories of personnel may affect a ministry in
different ways. There may be people in key positions in the ministry
who would be difficult to replace in the event of illness or absentee
ism. There may be key work processes that are particularly vulner
able to unanticipated low productivity or absence of personnel.
•
Which work processes or occupations are particularly vulner
able to stoppages, absenteeism and difficulties in replacing
employees?
•
Are there effective systems to monitor absenteeism and asso
ciated impact?
•
What are the kinds and levels of costs or inefficiencies associated
with absenteeism?
•
Would estimation of future costs of absenteeism be useful?
•
Do attitudes and support mechanisms foster early disclosure of
HIV status to allow forward planning?
(ii) Action points
120
•
Consider appropriateness of adapting and reorganizing work.
•
Develop systems to incorporate HIV/AIDS impact on human
resource planning.
•
Consider strategies, such as multi-skilling, creating reserve pools
of labour and overtime arrangements.
Saving our future: multiministerial action guide
•
Create an enabling environment that would facilitate early
disclosure of HIV-positive status to allow forward planning and
succession management.
•
Streamline recruitment and appointment processes to be more
efficient and effective, if feasible;
•
Liaise with other appropriate ministries to achieve this.
•
Cooperate with the counterpart ministry in neighbouring coun
tries, to share sector-specific lessons.
(b) Recruitment and training
(i) Issues
HIV/AIDS within a ministry, as well as in wider society, may sub
stantially deplete the skills-base through illness and death among
trained personnel.
What are the levels and trends in staff turnover?
•
What are recruitment and training costs, and how significant
may they become?
•
Are training and recruitment efficiently designed to deal with
pressures created by HIV/AIDS?
•
Are systems in place for planning and monitoring around on
going skills requirements?
•
Can recruitment and appointment processes be streamlined to
ensure timely replacement of ill workers?
•
Which work processes within the ministry are most vulnerable
to AIDS impacts? What are potential skills shortages, where
replacement staff may be hard to come by?
Basic steps for all
121
(ii) Action points
•
Include HIV/AIDS prevention as a part of all training initiatives.
•
Include training on HIV/AIDS impact management where
appropriate.
•
Emphasize training that enables rapid payback of investment,
such as in-service training and short-course programmes.
•
Mobilize external training institutions to include HIV/AIDS
prevention in training courses and to consider, in course design
and number of student enrolments, HIV / AIDS impact.
(c) Morale
(i) Issues
Increased illness and death among family, friends and colleagues
may adversely affect employee morale.
•
What impact of HIV/AIDS on staff, co-workers and their
families may affect morale and productivity?
(ii) Action points
•
Develop systems to provide support in the workplace for those
living with and affected by HIV/AIDS.
(d) Benefits
(i) Issues
Employee benefits that are likely to be affected by HIV/AIDS
include medical insurance, sick and compassionate leave, loans,
retirement, coverage of disability, as well as death and funeral
expenses. For assessment of HIV/AIDS impact on certain benefits,
e.g., pensions, expert opinion may be required.
122
Saving our future: multiministerial action guide
•
What is the expected impact of HIV / AIDS on future claim levels
and costs for:
Medical insurance?
Sick leave?
Compassionate leave?
Death and disability cover?
Funeral benefits?
•
Is there any evidence of increased claims on benefits as yet?
•
Are there effective systems to monitor impact on employee
benefits?
•
Have all options for restructuring benefits to make them sustain
able and meet employee needs been considered?
Note: Collecting impact information on absenteeism, and impact on
benefits, may require the establishment of management information
systems. What is needed is a way to track impact over time.
(ii) Action points
•
Include personal financial planning and other planning issues in
HIV education programmes.
•
Revise employment frameworks to ensure that benefits are
sustainable and equitable and meet the needs of employees and
their dependents.
•
Develop health-care strategies to prolong productivity and
quality of life.
•
Encourage medical schemes to develop cost-effective treatment
protocols and policies.
•
Establish criteria for beneficiary eligibility.
Basic steps for all
123
(e) Gender
(i) Issues
HIV/AIDS tends to affect women disproportionately because of
biological susceptibility and because women tend to be disem
powered in sexual relations, as well as socially and economically.
•
What factors affect women staff members' ability to protect
themselves from HIV infection?
•
What factors affect women's and men's ability to deal with their
own illness or HIV/AIDS among household members?
•
Are assessments and intervention strategies sensitive to the
different needs and responses of men and women?
(ii) Action points
•
Ensure that HIV/AIDS prevention programmes address the need
for women's equality to negotiate safer sex.
•
Educate all levels of staff on gender sensitivity issues.
•
Ensure that no form of sexual harassment is tolerated in the
workplace.
•
Cooperate with other programmes that offer reproductive health
education and services.
(f) Capacity to respond
(i) Issues
A ministry's capacity to respond to employee infections is critical
to reduce the impact of these infections. Capacity issues include
appropriate dissemination of HIV/AIDS workplace policies, support
124
Saving our future: multiministerial action guide
services or employee assistance programmes, allocation of personnel
and resources for HIV/AIDS issues and HIV/AIDS impact monitor
ing systems.
•
Is there an HIV/AIDS policy in place?
•
Is the current HIV/AIDS policy adequate to protect employees
and the employer from unnecessary costs?
•
Do line and other managers feel confident in applying the policy
and managing HIV issues in the workplace?
•
What services are available to support affected or infected
employees?
•
Have committees, teams and/or persons responsible for HIV/
AIDS issues been identified?
•
Do they have adequate expertise and resources?
•
Are there effective systems to monitor impact on employee
benefits, absenteeism, and other costs?
(ii) Action points
•
Develop or review the ministry's HIV/AIDS workplace policy to
ensure that it is in line with the HIV/AIDS policy in other
government bodies, adheres to acceptable ethical standards,
preferably according to international guidelines.
•
Conduct information campaigns for human resource and line
managers on HIV/AIDS policy and other HIV/AIDS issues.
•
Establish management information systems to track the impact of
AIDS on at least the following:
-
Absenteeism;
Sick leave;
Death in service;
Benefits.
Basic steps for all
125
•
Identify persons responsible for HIV/AIDS responses within
the ministry and ensure that they have sufficient authority and
capacity to act.
•
Set up a dedicated HIV/AIDS committee to coordinate HIV/
AIDS activities.
•
Include HIV/AIDS as an on-going agenda item in relevant
management meetings.
•
Network with persons/task teams in other government minis
tries.
•
Insert HIV/AIDS as a line item in budgets, as appropriate.
•
Make confidential contact points with management available for
employees.
•
Ensure contact details for counselling and support services are
available and that these services are familiar with the ministry's
approach to HIV/AIDS.
3. Responses in areas of internal impact
Review each of the following areas of action and consider which
may be relevant to your ministry. Ensure the involvement of all
relevant stakeholders in planning action responses.
It would also be important to develop and disseminate an HIV/
AIDS policy, as this would help to guide response planning and
implementation.
4. Prevention of new infections
•
126
Implement effective workplace HIV prevention programmes that
include:
Saving our future: multiministerial action guide
Treatment of sexually transmitted infections;
Condom distribution;
Provision of education and information.
•
Evaluate existing prevention programmes to identify any defi
ciencies.
•
Strengthen workplace HIV prevention programmes, if needed.
•
Address situations that put employees at high risk of infection,
e.g., migrant labour, long periods away from home.
•
Ensure prevention programmes target key workers and workers
at high risk.
127
X
HIV/AIDS IN
X
ASIA AND THE PACIFIC
BYTES THAT MATTER
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