Foster, Susan Dwight (1997) The socioeconomic impact of HIV/AIDS in Monze District, Zambia. Doctoral thesis, London School of Hy- giene Tropical Medicine. Downloaded from: http://researchonline.lshtm.ac.uk/682244/ Usage Guidelines Please refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna- tively contact [email protected]. Available under license: Copyright the author THE SOCIOECONOMIC IMPACT OF HIV/AIDS IN MONZE DISTRICT, ZAMBIA Susan Dwight Foster Department of Public Health and Policy London School of Hygiene and Tropical Medicine 10 October 1996 A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy University of London ABSTRACT Zambia has one of the highest HIV seroprevalence rates in the world, estimated in 1995 at 17%. Rural Monze district in the Southern province, the site of the study, has high rates of HIV, estimated at 10-12% in 1991. During the study, the district was affected not only by AIDS but also by the 1991-92 drought and by a bovine epidemic of East Coast Fever. This study documents the impact of HIV and AIDS on the health services and on the district economy, and draws some long term implications for the national economy. At the district hospital, approximately 44% of inpatients and 30% of outpatients were HIV seropositive as were 18% of rural health centre patients. Tuberculosis, other respiratory infections, and diarrhoea accounted for the majority of days in hospital. The HIV epidemic was found to be affecting the hospital staff as well, with mortality at Monze and neighbouring Choma hospitals rising from 2 per 1,000 nurse years in 1980 to 27 in 1991 -a 13-fold increase. Measures to increase supply, reduce losses, and make better use of existing staff are proposed. _ The household survey found that while patients were better off overall than the district population, there was no appreciable difference in wealth between patients with HIV infection and those without. HIV-positive patients were younger than HIV-negative patients, and had fewer children. The loss of a member with HIV would cause a rise in the average household's dependency ratio of 16-17%. Production was affected by HIV disease, with an average of 94 days' loss of labour (patients plus carers) in the final year of life. Implications for policy include the need to decentralize care of patients with HIV disease to health centres, and to protect and make better use of the health human resources. The impact of HIV/AIDS on rural production, with approximately 1 in 3 district households having a member with AIDS, combined with external factors such as removal of subsidies, changes in marketing processes under structural adjustment, and long term drought, makes it increasingly difficult to eke out a living from farming. Combined with the lure of apparent employment opportunities in urban areas created by deaths due to AIDS, these factors may contribute to increased urbanization, making it difficult for Zambia to replace declining copper revenues with increased yields from agricultural production. PREFACE From the dark harbour soared the first rocket of the firework display organized by the municipality, and the town acclaimed it with a long-drawn sigh of delight.... While cataracts of coloured fire fell thicker through the darkness, Dr Rieux resolved to compile this chronicle, so that he should not be one of those who hold their peace but should bear witness in favour of those plague-stricken people; so that some memorial of the injustice and outrage done them might endure; and to state quite simply what we learn in time of pestilence: that there are more things to admire in men than to despise. Camus, ThePlague -Albert (tr. StuartGilbert) 4 ACKNOWLEDGEMENTS Many people helped in many ways with this research and with the preparation of this thesis. In Zambia, the staff and management of Monze Hospital were supportive from the start; I would like to make particular mention of Andy O'Connell, Dr Victor Mukonka, Dr Eileen Keane, and Dr Paul Kelly. My friend and colleague Anne Buve was there at every step of the way throughout the study. The late Maureen Zeko was crucial to the success of the study and she is much missed by the staff and patients of Monze Hospital. The ADZAM staff were responsible for collection of the data presented here, often in difficult and trying circumstances. Litrecy Himaambo, Martyn Mubanga, Catherine Mpafya, George Petros Jr, Wilfred Mweemba, Boniface Moonze, Leticia Virginia Hachoongo, Moses Ngoma, James Sakala, Margin Chilala, Churaa Munan'gandu, and Bentoe Mapulanga deserve special thanks for all the time and effort they devoted to this project, and for the good humour and sensitivity they brought to a difficult task. The support and interest shown in the study by the Ministry of health, in particular Dr Roland Msiska and the Honourable Katele Kalumba, Minister of Health, were very valuable and encouraging to the researchers in the field. Funding for the research was provided by the Overseas Development Administration (ODA). Back in London the support team was led by Charles Normand, who tried to ensure rigour in the analysis while running a large and expanding department of public health and policy. Support, advice and valuable insights were provided by the late Phil Strong who is also sorely missed in the School. Margaret Thomas and Donnette Neil provided constant support and friendship. My mother is amused and pleased by the exploits of her peripatetic daughter, and my father would have been very pleased to see this task completed. I owe a debt of gratitude to all of them. TABLE OF CONTENTS 1. THE ECONOMIC IMPACT OF AIDS AND HIV DISEASE: A REVIEW OF THE LITERATURE 13 ...... 1.1 INTRODUCTION 13 ....................................................................................................................................................... 1.2 THE ECONOMIC IMPACT OF HIV/AIDS 13 .............................................................................................................. 1.3 PREVIOUS WORK ON THE ECONOMIC IMPACT OF HIV/AIDS IN ZAMBIA 15 .................................................... 1.4 THE IMPACT OF HIV/AIDS ON THE HEALTH SERVICES 17 1.5 COPING WITH SERIOUS ILLNESS 19 ............................................................................................................................ 1.6 COPING IXTTH HIV DISEASE AND AIDS AT HOUSEHOLD LEVEL 22 .................................................................... 1.7 COPING PROCESSES AT COMMUNITY LEVEL 25 ........................................................................................................ 1.8 LESSONS FROM EARLIER EPIDEMICS 27 ..................................................................................................................... 1.9 WELFARE ECONOMICS AND HIV/AIDS IN AFRICA 29 .......................................................................................... 1.10 MIE APPLICATION OF WELFARE ECONOMICS 30 ................................................................................................... 1.11 DISSENTING VIEWS: APPLYING WESTERN ECONOMIC THOUGHT TO A TRANSITIONAL ECONOMY......... 33 2. STUDY DESIGN AND CONCEPTUAL FRAMEWORK 37 .................................................................... 2.1 INTRODUCTION 37 ....................................................................................................................................................... 2.2 CONCEPTUAL FRAMEWORK 37 ................................................................................................................................... 2.3 BRIEF DESCRIPTION OF STUDY COMPONENTS 38 .................................................................................................... 2.4 LOGISTICS OF THE STUDY 41 ...................................................................................................................................... 2.5 DETAILS OF STUDY COMPONENTS 43 ........................................................................................................................ 2.6 PROBLEMS ENCOUNTERED IN CARRYING OUT THE STUDY 50 .............................................................................. 3. ZAMBIA AND MONZE DISTRICT 51 .............................................................................................. 3.1 INTRODUCTION 51 ....................................................................................................................................................... 3.2 ZAMBIA'S ECONOMY 51 ............................................................................................................................................... 3.3 NATIONAL MAIZE PRICING 53 POLICY...................................................................................................................... 3.4 EPIDEMIOLOGY OF HIV AND AIDS IN ZAMBIA 54 ............................................................................................... 3.5 MONZE DISTRICT 57 .................................................................................................................................................... 3.6 THE 1991-92 63 DROUGHT.......................................................................................................................................... 3.7 HEALTH SERVICESOF MONZE DISTRICT 65 ............................................................................................................. 3.8 SummARY 67 .................................................................................................................................................................