Background Note Overseas Development March 2010 Institute Turning crisis into opportunity for children affected by HIV and AIDS: responding to the financial, fuel and food crises By Caroline Harper and Nicola Jones vidence suggests that the global financial been developed as part of a large research programme downturn has already had a negative impact on crisis and children (see Harper et al., 2009a) is pre- on HIV and AIDS service provision and fund- sented in Figure 1. ing and increased the vulnerabilities faced by Macro-level effects: Net financial flows to devel- Ethose living with the infection or caring for infected oping countries may fall by as much as $300 billion family members (UNAIDS, 2009). To date, however, in two years, equivalent to a 25% decline (Calì et there has been no comprehensive review of the al., 2008), resulting in reduced employment oppor- impacts of the crisis on children and caregivers in tunities, including for migrants. Aid volumes have this situation. This is critical, given that the mortality reduced, especially for major funding initiatives: the rate among infected children is disproportionate to Global Fund to Fight AIDS, Tuberculosis and Malaria that faced by adults, and that relatively fewer children (GFATM) and the US President’s Emergency Plan for have access to necessary antiretroviral therapy (ART). AIDS Relief (PEPFAR) have already suffered significant Moreover, many governments lack national policy budget cuts. These effects are being compounded strategies to address the child-specific dimensions of by a period of significant increases in food and fuel the HIV and AIDS epidemic, and there is, therefore, a prices in 2008 and continuing high prices. risk that children living with the disease or highly vul- Meso-level effects: The scale of macro-level effects nerable to infection will remain invisible in the crisis will determine the extent of meso-level impacts, unless they receive urgent policy attention. which will vary across and within regions, but may To understand how the macro-level changes include declining public service investment, less brought about by the Triple F crisis – financial, fuel access to credit, growing unemployment, increased and food – translate into meso- and micro-level poverty and heightened social exclusion. National effects on children living with, or vulnerable to, HIV government policy responses will shape the extent to and AIDS and their caregivers, it is important to under- which communities and households are able to cope stand the pathways by which changes in the global with these impacts. This is especially the case when it macroeconomic environment are filtered through comes to decisions to adopt a pro-cyclical or counter- country-specific policy and institutional frameworks cyclical approach to investments in basic services for at national and sub-national levels to impact com- HIV and AIDS and to maintain or scale up targeted munities, households and individuals. Interviews social protection programmes and child protection have been conducted with UN, Government and NGO services. The role of civil society actors who champion staff in Rwanda, Zambia, Mozambique, South Africa, the rights of families and children living with or vulner- Lesotho, Thailand, Paraguay and the Philippines. The able to HIV and AIDS may also play an important role conceptual framework that underpins this (and has in influencing policy outcomes. The Overseas Development Institute is the UK’s leading independent think tank on international development and humanitarian issues. ODI Background Notes provide a summary or snapshot of an issue or of an area of ODI work in progress. This and other ODI Background Notes are available from www.odi.org.uk This Background Note has been produced with the support of UNICEF UK (www.unicef.org.uk). Background Note Figure 1: Linkages between macro-level shocks and impacts on children living with or vulnerable to HIV and AIDS Financial Crisis – Impacts on Children vulnerable General regional and to or living with HIV and AIDS General regional and international macro- international macro- economic health economic health Dimensions of Trade and prices the macro- Financial Remittances (commodities Aid economic flows and services) environment Exchange Rates Fiscal space Meso-level Declining investment in public Rising unemployment, effects of Reduced access services (education, health, Declining social under-employment, the financial to credit nutrition, water and sanitation, capital; rising social declining working crisis housing, protection, care) violence conditions Policy responses Civil society Political Pre-existing and crisis-response investment in basic HIV and AIDS services Policy policy advocacy economy Pre-existing national plan on HIV and AIDS with focus on children responses + service dynamics provision Pre-existing social protection infrastructure and crisis- specific measures Household Protection Household consumption Reproduction, (physical & management Household Functions of the (food & services, nurture & emotional) & of assets time use household both quantity care promotion of & investments & quality) well-being Intra-household dynamics & household composition Child-specific vulnerabilities Deprivations of rights to survival, development, protection, participation Micro-level experiences: Households typically Impact on children: current, new HIV respond to periods of economic turmoil by economis- infections ing, reducing consumption in areas such as nutrition, The current economic crisis is likely to affect infants, education and health care. They may also resort to children and youth differently, through the follow- more negative coping strategies, such as the distress ing key variables, most of them products of the sale of assets or taking up risky and degrading forms economic risk and the intensification of poverty that of work. Children’s time is often used as a resource, households affected by HIV and AIDS face in times of and they may be withdrawn from school. Household economic downturn. functions also change under economic pressure, and a range of reactions may ensue, ranging from revised Food consumption resource allocations to increasing household violence The quantity and quality of food intake have suf- and mental illness. fered significantly as a result of the current crisis Although often neglected in discussions of the pov- (Hossain et al., 2009), because of lower household erty impacts of macroeconomic shocks, intra-household income, local currency depreciations and/or food conditions profoundly determine child wellbeing and price hikes. Economic downturns aggravate the vul- depend on both pre-existing gender and generational nerabilities of HIV-infected individuals, as they tend dynamics, and the ways in which they are affected by to suffer from more frequent and severe opportun- the crisis and related policy responses. For example, the istic infections because of their weakened immune position of women in decision-making roles and their systems (Kelly, 2000). level of education and efficacy are important for child New infections. Even a small decline in the quantity wellbeing, and this is a policy-sensitive arena. Cultural and quality of food may increase the risk of HIV infec- norms are also very important in influencing intra- tion for children and young people, as their vulnerabil- household decisions, such as son preference favouring ity to infection increases alongside malnutrition and medical treatment for boys over girls. the resulting dampening of their immune systems. 2 Background Note Health-seeking behaviour lighted as major impacts of HIV and AIDS on the lives of Although, ART is, in principle, free in many countries, children (Save the Children, 2006). There is evidence, patients still need to pay other costs, including bribes for instance, of guardians of orphans rejecting roles as for tests and services. Travel costs are cited repeatedly protectors and instead competing with their orphan (interviews conducted with UN and NGOs in Rwanda, charges for scarce land and property, forcing children Zambia, Mozambique, South Africa, the Philippines) to support themselves and defend their property as hindering access to clinics and drugs. The time and inheritance rights (Rose, 2006). Examples of the involved can be prohibitive for parents seeking treat- breadth of discrimination include the abandonment ment for children. Interruptions to care can occur even of children born to mothers living with HIV and AIDS in ‘committed’ households, when unexpected or sud- (CRIN, 2009). There are cases of infected pupils being den shocks make planned-for treatment too expensive refused admission to school in India, and in Romania, in terms of time or money. This can have detrimental legislation hampers the attendance of older children effects in terms of responsiveness to future wellbeing in school while younger children living with HIV and as a result of the development of viral resistance to AIDS are unable to access school because of long first-line drugs (UNAIDS, 2009). Furthermore, discon- periods of hospitalisation. Some nurses and doc- tinuing ART treatment can increase the risk of contract- tors in Ukraine have denied blood testing services to ing preventable HIV-connected diseases. infected children (CRIN, 2009). New infections. The effects of crisis can also result in increased HIV infections as carers cut back on seek- Loss of livelihood, risky strategies ing health care, compounded by potential cutbacks