[stop-imf] Structural Adjustment and HIV/AIDS

[robert weissman]

http://www.icddrb.org/images/jhpn2302_potential-impact.pdf

J HEALTH POPULNUTR    2005 Jun;23(2):105-120 =A9 2005 ICDDR,B: Centre
forHealth and Population Research ISSN 1606-0997

Potential Impact of Adjustment Policies on Vulnerability of Women and
Children to HIV/AIDS in Sub-Saharan Africa

Roberto De Vogli1and Gretchen L. Birbeck2 1Department of Epidemiology
and Public Health, University College of London,  1-19 Torrington Place,
London WC1E6BTand 2African Studies Center and  Departments of Neurology
and Epidemiology, Michigan State University,  138 Service Road, A217,
East Lansing, MI 48824-1313, USA

ABSTRACT This paper evaluates the potential impact of adjustment
policies of the International Monetary Fund and the World Bank on the
vulnerability of women and children to HIV/AIDS in sub-Saharan Africa.
Aconceptual framework, composed of five different pathways of causation,
is used for the evaluation. These five pathways connect changes at the
macro level (e.g. removal of food subsidies) with effects at the meso
(e.g. higher food prices) and micro levels (e.g. exposure of women and
children to commercial sex) that influence the vulnerability of women
and children to HIV/AIDS. Published literature on adjustment policies
and socioeconomic determinants of HIV/AIDS among women and children in
sub-Saharan Africa was reviewed to explore the cause-effect
relationships included in the theoretical framework. Evidence suggests
that adjustment policies may inadvertently produce conditions
facilitating the exposure of women and children to HIV/AIDS. Complex
research designs are needed to further investigate this relationship.
Ashift in emphasis from an individual approach to a socioeconomic
approach in the study of HIVinfection among women and children in the
developing world is suggested. Given the potential for adjustment
policies to exacerbate the AIDS pandemic among women and children, a
careful examination of the effects of these policies on maternal and
child welfare is urgently needed.

...

CONCLUSION

Results of this analysis are complex to interpret. Certain components of
adjustment reforms, such as currency devaluation and trade
liberalization, may produce mixed effects on the vulnerability of women
and children to HIV/AIDS. Other reforms, such as financial
liberalization, removal of food subsidies, and introduction of userfees
for healthcare and education have a negative impact on the spread of the
epidemic among poor women and children. In most cases, adjustment
policies create synergies making it extremely difficult to identify
their net social effects. Clearly, there is, currently, no single study
capable of demonstrating a causal link between adjustment policies and
the exposure of women and children to HIV/AIDS. However, this analysis
provides some evidence that adjustment policies may inadvertently
facilitate societal conditions that increase the vulnerability of women
and children to HIV/AIDS in sub-Saharan Africa. Furthermore, our study
underestimates the impact of adjustment policies since it excludes men
from the analysis and does not discuss the effect of thesepolicies on
access to antiretroviral therapy among vulnerable and poor populations.

Findings of this review have been limited to sub-Saharan Africa for two
reasons. First, the African continent has been more impacted by
adjustment policies than other regions of the world. Second, in
sub-Saharan Africa, women account for 58% of adults living with HIV/
AIDS, and such percentage is much lower in other regions of the world
(e.g. 24% in East Asia and the Pacific) (7). However, these results may
be applicable to other developing regions provided that they have
similar proportions of women and children living in economic
marginalization.

Well-designed studies, combining public-health data and economic
indicators at the macro, meso and micro levels, are needed to further
test these hypotheses. HIV researchers should be encouraged to adopt a
broader approach in their evaluation of the spread of the epidemic in
the developing world, including the role of socioeconomic factors.
Evaluation of biomedical and behavioural indicators focusing on the
individual is largely insufficient to measure the determinants of
HIVinfection. An integrated and collective approach (whichconsiders the
macro-indicators reflecting social, economic and political factors) must
be developed for monitoring the HIVepidemic. Development economists
should broaden their analyses of adjustment policies to take into
account not only macroeconomic aggregates, but also micro-indicators at
the household levels. Appropriate social and health indicators must be
developedto examine the success and failure of the structural adjust
ment reforms (77). Rigorous study designs are neededto overcome the
methodological obstacles relating to measuring the health impact of
adjustment policies. Such studies must take into account the antecedent
factors and the need to specify the strata-specific effects that these
reforms have on different socioeconomic groups. Combined approaches and
methodologies that make use of both cross-sectional and longitudinal
designs, aggregated and disaggregated indicators, qualitative and
quantitative data gathering techniques are needed. Such analyses must
include inter-sectoral research activities involving different
disciplines and including the participation of civic society. To date,
the IMF has been resistant to supporting any type of evaluation or
public scrutiny regarding the social effect of its policies (78).
However, the World Bank has facilitated the active involvement of other
societal sectors and the public in the assessment of the social impact
of the adjustment policies. The launch of the SAPRI, in conjunction with
a network of NGOs, is a concrete example of such intention (79).

It must also be acknowledged that the World Bank is, at present, the
largest single investor in health in subSaharan Africa. Such investment
may reduce the HIV epidemic through some mechanisms. However, the
unintended consequences of adjustment policies may have greater negative
effects on the same health outcome. Given the potential for adjustment
policies to exacerbate the AIDS pandemic among women and children, there
is an urgent need to either demonstrate that such measures are not
harmful to maternal and child welfare or to modify policies. The present
buffering mechanisms designed to protect the most vulnerable segments of
the population during macroeconomic stabilization and structural
adjustment are not sufficient. The IMF and the World Bank need to
provide adequate scientific evidence demonstrating the effectiveness of
their policies. Failure to do so may undermine their international
credibility and further exacerbate the already tragic social conditions
of marginalized women and children at risk of HIV/AIDS in the developing
world.