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The economic burden of HIV and AIDS on households in Nigeria Michael A Adedigba , Sudeshni Naidoo , Albert Abegunde , Oluwafemi Olagundoye , Ebun Adejuyigbe & Ibiyemi Fakande Published online: 11 Nov 2009.
To cite this article: Michael A Adedigba , Sudeshni Naidoo , Albert Abegunde , Oluwafemi Olagundoye , Ebun Adejuyigbe & Ibiyemi Fakande (2009) The economic burden of HIV and AIDS on households in Nigeria, African Journal of AIDS Research, 8:1, 107-114, DOI: 10.2989/AJAR.2009.8.1.11.724 To link to this article: http://dx.doi.org/10.2989/AJAR.2009.8.1.11.724
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African Journal of AIDS Research 2009, 8(1): 107–114 Printed in South Africa — All rights reserved
AJAR
ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/AJAR.2009.8.1.11.724
The economic burden of HIV and AIDS on households in Nigeria Michael A Adedigba1*, Sudeshni Naidoo2, Albert Abegunde3, Oluwafemi Olagundoye1, Ebun Adejuyigbe4 and Ibiyemi Fakande5 1
Department of Preventive and Community Dentistry, Obafemi Awolowo University, Ile-Ife, Nigeria University of the Western Cape, Department of Community Oral Health, University of the Western Cape, Private Bag X1, Tygerberg 7505, South Africa 3 Urban & Regional Planning, Obafemi Awolowo University, Ile-Ife, Nigeria 4 Paediatrics Department, Obafemi Awolowo University, Ile-Ife, Nigeria 5 General Hospital, Ilesa, Nigeria * Corresponding author, e-mail: [email protected]; [email protected]
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The study estimates the economic burden of HIV and AIDS on households in a Nigerian population. The data derive from a cross-sectional survey of households affected by HIV or AIDS in Ife-Ijesa Zone, Osun State, Nigeria. The sample consisted of 117 purposively selected, consenting adult HIV patients attending a general and teaching hospital. Participants were asked to self-report monetary expenses for HIV-related care, loss of savings, and funeral costs. The data show a significantly sharp drop in the participants’ household income as a result of care for HIV-related illnesses, from the time of knowing one’s HIV status to the time of illness, among three occupational categories (artisans, civil servants and unemployed; p = 0.02). Mean income among those in the unemployed category fell by 84.1%, income among artisans dropped by 72.6%, and income among civil servants decreased by 44.4%. The monetary loss during the course of HIV-related illnesses was heaviest for the artisan group, followed by the unemployed and the civil servants. Those who had lost a substantial part of their savings to HIV-related care were most numerous among the unemployed, followed by artisans and civil servants. Out of 16 households, 11 (42.3%) had received support from relatives during a funeral ceremony. There was a significant association between the occupational group and working for more hours after illness (χ2 = 9.28, df = 4; p = 0.05). Nearly all orphaned children were distributed to the extended family following the AIDS death of a parent. Among all the occupational groups, borrowing from a cooperative society during the course of HIV-related sickness was the commonest form. The findings add to data showing that despite the extended family support system, adult deaths due to AIDS continue to undermine the viability of sub-Saharan African households. Keywords: Africa, family, financial impact, household behaviour, income, low-income communities, poverty
Introduction The number of people living with HIV continues to rise in many parts of the developing world despite the fact that effective preventive strategies exist. Sub-Saharan Africa remains the hardest hit region with very high HIV prevalence (UNAIDS, 2005). An estimated 3.9% of the population of Nigeria is HIV-positive (Federal Ministry of Health [FMOH], 2006). UNAIDS has reiterated the need to evaluate the economic and social impacts of the HIV pandemic and so to develop multisectoral strategies to address those impacts at the individual, family, community and national levels; in particular it has suggested accelerating the implementation of national poverty-eradication strategies that may lessen the impact of HIV and AIDS on households’ income, livelihoods or access to basic social services (UNAIDS, 2006). Households form the basic social and economic elements of sub-Saharan African societies and their viability is threatened by sustained crisis-level mortality in widely disseminated
HIV epidemics (Gregson, Mushati & Nyamukapa, 2007). HIV and AIDS cause a loss of income and lower productivity among household members. If an HIV-infected individual is the sole breadwinner, the impact to the household is especially severe. AIDS illness creates extraordinary care needs that must be met, usually by withdrawing other household members from work or school to care for the sick. AIDS illness also causes household expenditures to rise as a result of medical and related costs, while the loss of assets and productive workers severely affect households’ capacities to produce and purchase food. Poor households are in particular danger of losing their economic and social viability (Menon, Wawer, Konde-Lule, Sewankambo & Li, 1998; Arndt & Lewis, 2000; Grégoire, 2001; Whiteside, 2002). Furthermore, the prevalence of AIDS intensifies chronic food shortages, creating a vicious circle for communities as the shortage of good nutrition speeds up the progression of HIV disease in those who are infected. African households are undergoing new challenges as an immediate result of HIV and AIDS: older people frequently
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care for the sick, dying and orphaned; in many cases, children head up the household; and, after the death of parents, surviving children are often fostered by grandparents or other older female relatives, or are sent to live with extended family members. Due to the increased demands for physical, economic and social support for people living with HIV or AIDS (PLHIV), individuals in HIV-affected households have less time to pursue income-generating opportunities (Hilhorst, Van Liere, Ode & De Koning, 2006). An escalation in AIDS deaths in Africa has caused the loss of labour, reduced farming income and household assets, and lowered households’ food security (UNAIDS, 2005). The monetary cost of HIV or AIDS has been catastrophic for many households in developing countries (Russel, 2004). Bachmann & Bachmann & Booysen (2003 and 2006) has shown that in South Africa, household economies and HIV/ AIDS are dynamically related, as many HIV epidemics occur against a background of progressive poverty. A recent study in Zimbabwe reported that deaths occurred disproportionately in urban and lower-income households, with AIDS deaths more often resulting in the loss of the household head (Gregson et al., 2007). The median gross expenditure on healthcare and funerals was approximately US$25 and US$73, respectively, with households receiving substantial external contributions for funerals; households experiencing AIDS deaths spent more on healthcare and had more frequently dissolved or relocated than households experiencing non-AIDS deaths, and the members of urban HIV-affected households migrated disproportionately compared to affected households in rural villages (Gregson et al., 2007). A study of AIDS-affected households in Zambia showed that in two-thirds of the families where the father had died, monthly disposable income had fallen by more than 80% (Loewenson & Whiteside, 2001). An earlier study in Côte d’Ivoire found that mean income in AIDS-affected households was half that of the average household (Béchu, 1998). In Botswana, per-capita household income for the poorest households was expected to fall by 15% over ten years (UNAIDS, 2001a). In Thailand and Tanzania, the funeral-cost burden of death was often far greater than the cost burden of AIDS illness, as households in those two countries reported spending up to 50% more on funerals than on medical care (Pitayanon, Kongsin & Janjareon, 1997; Urassa, Boerma, Isingo, Ngalula, Ng’weshemi, Mwaluko & Zaba, 2001). There appears to be four coping strategies that are commonly adopted by financially strapped families: 1) using savings and/or selling household assets, which may include clothing, land, farm produce, automobiles and electronics (for instance, a study in Thailand revealed that 41% of AIDS-affected households resorted to selling their land: Pitayanon et al., 1997); 2) getting assistance from extended family members; 3) reducing the number of dependent adults and/or children by sending them to live with relatives (see Pitayanon et al., 1997; Menon et al., 1998); and, 4) taking loans from extended family members, the local community or a cooperative/money-lending institution (see Mathenge, 2003; Wyss, Hutton & N’Diekhor, 2004). In a study in Thailand, 46% of the respondents claimed
Adedgiba, Naidoo, Abegunde, Olagundoye, Adejuyigbe and Fakande
to have borrowed from relatives, 23% from a cooperative or other type of local lending institution, and 23% from a moneylender (Pitayanon et al., 1997). A study in South Africa showed that deprived households used up to 21 months of their savings to offset medical and other healthrelated bills (Bachmann & Booysen, 2004). More than two-thirds (64.4%) of Nigerians are living below the poverty line of US$1 per day (UNDP, 2008); HIV and AIDS in no small way contributes to further reducing the already poor income of many households in Nigeria. Notwithstanding the research that has been done on various HIV-related economic impacts to households, there are gaps in empirical knowledge related to households’ coping strategies (Russell, 1996), especially in Nigeria. Some studies have focused on the impact of the disease on families that have experienced an AIDS death (e.g. Pitayanon et al., 1997 [Thailand]; Gregson et al., 2007 [Zimbabwe]), but this approach may overlook families that experience high expenditure on HIV-related care and treatment while not experiencing an AIDS death. There are two dimensions of HIV/AIDS-related impacts to the macro-economic environment: direct and indirect costs (Balyamujura, Jooste, Van Schalkwyk, Geldenhuys, Crew, Carstens et al., 2000). Direct cost refers to the cost of treatment associated with HIV-related symptoms. These costs can have serious consequences on a household’s healthcare financing due to disproportionate medical expenses in a resource-poor setting. Indirect costs refer to more difficult to measure parameters, such as costs relating to the value of production, loss of current wages, loss of present value of earnings, training expenditures for new staff, and the cost of absenteeism. There is an urgent need for baseline data to facilitate future intervention programmes to alleviate the economic impacts of HIV and AIDS in Nigeria and to better enable households’ socio-economic coping strategies. The aim of this study was to investigate the economic burden of HIV and AIDS on semi-urban households in Ife-Ijesa Zone, Osun State, southwestern Nigeria. Methods A cross-sectional study was carried out among people living with HIV or AIDS (PLHIV) in Ife-Ijesa Zone in Osun State (an inland state in southwestern Nigeria). This study site is a semi-urban area where the majority of people are engaged in a subsistent agrarian economy. The zone is also a referral centre for many neighbouring towns and villages in the management of HIV/AIDS-associated illnesses. After assuring individuals’ anonymity and confidentiality, written, informed consent was obtained from a sample of 117 out of 250 PLHIV approached who were attending an HIV/ AIDS clinic at the general and teaching hospital in the zone between January 2002 and July 2005. This number was above the expected, planned sample size of 65 individuals, based on an estimate of 4.4% HIV prevalence in Nigeria (see FMOH, 2004). A purposive sample of 117 PLHIV was chosen using selection criteria based on all consenting adult PLHIV choosing to participate in the study after the purpose of the
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research was explained. Ethical clearance was sought and obtained from the ethics committee at the teaching hospital. The data were collected by a trained home-based healthcare worker. All participants were ambulatory and none was an in-patient at the time of data collection. The calibrated questionnaire consisted of two parts: demographic information and an HIV-related economic impact assessment. Using recall, participants were asked to record the expenses and losses that their household had incurred for HIV-related care during the past three years of their living with the disease. Expenses included the cost of transportation to and from the hospital, medicines, medical examinations and hospital admission. Loss of assets during the period of the disease (i.e. from the time of diagnosis to time of illness) included household materials, land, household members, funeral costs, and reduced household savings and income per annum. These were computed into monetary values. Substantial loss of savings was regarded as losing more than 30% of a household’s savings. Monetary loss during the period was defined to the respondents as those losses occurring since the time of the first signs and symptoms of HIV-related illness. This was also the time when most of the study participants had presented at a hospital because of an illness, and which had consequently included testing for HIV. Family income was determined as the total income (e.g. regular monthly wages, revenue from other sources, gratuities) from the time the patient was first notified of their HIV diagnosis. Household income after the death of a spouse (for those respondents who had lost their spouse due to AIDS illness) was determined from the first day after such a death. A household’s monthly loss to care due to the respondent’s/ any household member’s illness involved total money lost from wages (due to inability to perform work optimally), the cost of medicines, hospital bills (e.g. consultation fees, the cost of examinations and/or hospital admission, transportation fees to and from the hospital, including bringing meals to the hospital), preparing special foods, running errands, accompanying an ill person to health facilities, and the cost of alternative care homes. ‘Unemployed’ as defined in this study also relates to a form of ‘disguised employment,’ meaning the participant may have been engaged in some form of making a living to keep body and soul together in the absence of a regular/ expected job. This may have involved working as a causal labourer in a factory, for a construction company, on a farm or other agro-allied establishment, or doing any menial job available. These unemployed or rather underemployed persons may have been holders of academic qualifications that could have made them eligible for a more skilled job. The cost of intangibles (e.g. pain, anxiety, loss of wellbeing) was excluded from consideration because of the difficulty of translating these into monetary terms (see Wyss et al., 2004). Income loss was calculated as the difference in the net household income before and after the participant’s HIV infection. The cost of antiretroviral medicines (ARVs) and some other medicines (such as cotrimoxazole, haematinics, acetylsalicylic acid and antimalarial drugs) were excluded. This is because the sample individuals were not on ARVs, and cotrimoxazole, haematinics,
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acetylsalicylic acid and antimalarial drugs were provided for free at the hospital’s clinic. The data were entered anonymously to achieve confidentiality, and then analysed using SPSS® software (Version 11). Simple proportions, percentages, summation analyses, chi-square for categorical variables, t-test, and one-way analysis of variance (ANOVA) for numerical variables were carried out. The level of significance was set at p ≤ 0.05. Results Of the 117 participants in the study, the majority were females (63.2%) (the percentage of males and females among the potential study population of 250 from where the sample was drawn was 35.8% and 64.2%, respectively). The participants’ ages ranged from 15 to 65 years (mean age 35.8 years). About two-thirds (62.4%) were married. About 5% had no formal education, but more than half (57.3%) had a primary or partial secondary education, and 37.3% had a secondary or tertiary education. The majority were categorised as artisans (54.7%), which included hairdressers, auto mechanics, iron-benders, barbers, carpenters and painters; 11.1% were categorised as unemployed (although some in this group worked informally), including another 4.3% who were retired; and civil servants formed 10.2% of the sample. The remainder did not share their occupational status (20%). Table 1 shows the participants’ reported sources of healthcare during the past one year before the survey. The majority (77.8%) made a government hospital their first choice; visiting a traditional healer was their second-mostcommon choice (34.2%). Just under one-third (28.2%) of the participants reported that they had lost one or more household members to AIDS; of these, 12.8% had lost a spouse and 8.5% had lost a child. Orphaned children were generally distributed to extended family members for care following a parent’s death. Figure 1 depicts the loss of household assets among the PLHIV studied. The loss of assets during the care of an HIV/AIDS patient was highest among the artisans, followed by the unemployed and the civil servants. There were no significant associations found between the occupational groups and the amount of assets sold as land (F = 0.22; p = 0.81), electronics (F = 0.25; p = 0.63), clothing (F = 0.03; p = 0.86), and other forms (F = 3.17; p = 0.08). The respondents’ household income had generally declined from the time before their household member’s HIV infection to the time of the death of a household member. There had been a significantly sharp drop in household income from the time prior to the participant discovering their own serostatus (HIV diagnosis) to the time of HIV-related illness (symptoms) among the various occupational groups (F = 4.64; p = 0.02). Figure 2 shows the estimated household monetary losses during the course of HIV-related illness in the respondents’ households based on the occupational groups. Artisans’ mean income dropped from approximately US$242 to US$66, or by 72.6%; for the unemployed it fell by 84.1%, and for civil servants it fell by 44.4%. The heaviest monetary losses during the course of HIV infection were reported in the artisan group, followed by the unemployed and the
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Adedgiba, Naidoo, Abegunde, Olagundoye, Adejuyigbe and Fakande
Table 1: The respondents’ sources of healthcare during the last year before the survey (n = 117 PLHIV)
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VALUE (US$)
8 000
1st choice n (%) 1 (0.8) 3 (2.6) 5 (4.3) 18 (15.4) 90 (76.9)
ESTIMATED COST (Nigerian naira)
Source Alternative medicine Religious source Traditional healer Private hospital Government hospital
Artisans Civil servants Unemployed
6 000 4 000 2 000
Land
Electronics Clothing ASSETS
2nd choice n (%) 2 (1.7) 36 (30.7) 40 (34.2) 27 (23.1) 12 (10.3)
20 000 15 000
Mean income before HIV infection Monetary loss since HIV diagnosis Income during the course of HIV illness Income after a spous’e death Monthly loss due to HIV related care Funeral related costs
10 000 5 000
Other
Artisans Civil servants Unemployed OCCUPATIONAL GROUP
Figure 1: Participants’ self-reported loss of household fixed and non-fixed assets during the three years before the survey (n = 117 PLHIV; US$1 = N130)
Figure 2: Participants’ self-reported estimated household monetary losses during the course of HIV diseases (n = 117 PLHIV; US$1 = N130)
civil servants, but the differences between the groups were not significant (t = –1.66, df = 6; p = 0.15). During funeral ceremonies, artisans’ households’ spent 134% above their mean income earnings than before the HIV infection. Even though the majority of all respondents (65.6%) reported a loss of a substantial part (>30%) of their household savings to HIV or AIDS care, there was no significant association between occupational group and loss of savings (χ2 = 8.6, df = 4; p = 0.07), although in this regard the unemployed (29.2%) and artisans (28.1%) were the majority, with civil servants (8.3%) reporting the least loss. The artisans reported having received the most financial support from family or friends. The respondent’s household’s income decreased from the time before the infection of their household member’s HIV infection to the time of the death of a household member. There had been a significant drop in household income from the time prior to the participants knowing their serostatus (HIV diagnosis) to the time of illness (symptoms) among the various occupational groups (F = 4.64; p = 0.02). There was a significant association between the respondents’ working hours since the onset of illness and occupational group (χ2 = 9.28, df = 4; p = 0.05). Artisans worked for more hours to make ends meet since the onset of HIV illness compared with the other occupational groups (Figure 3). Artisans reported receiving the most financial support from family or friends due to a funeral ceremony (χ2 = 9.85, df = 4; p = 0.04). Those who reported that friends or relatives had given food, goods or clothing to the
deceased’s family during a funeral ceremony was not significantly associated with the respondents’ occupational group (χ2 = 2.46, df = 4; p = 0.7). Nearly half of all the households had spent some money to care for relatives who attended funeral ceremonies (Figure 3). Table 2 lists the ratios for respondents’ total household assets lost due to HIV-related care in relation to total annual household income. The unemployed group had the highest ratio of assets lost due to care in relation to total annual income. Table 3 shows the participants’ borrowing patterns and the types of lending institutions used. Nearly a quarter (n = 22; 23.4%) of all respondents reported having to borrow money to cover the costs of treating and managing their HIV infection or AIDS illness. Artisans borrowed more than did the other occupational groups and mostly did so from a cooperative society (Table 3). Discussion There were more females available for interview in the present study. This could be because more females seek care than their male counterparts (Xu & Borders, 2003) or because more women in Nigeria are HIV infected or are surveyed (through antenatal clinics) (FMOH, 2004). (However, the percentages of males and females among the 250 study population from where the sample was drawn were 35.8% and 64.2%, respectively, which was similar to the study participants.)
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Many of the participants reported visiting one or more other sources of care, where their funds might have been depleted, before presenting at the hospital or concurrently with their attendance. This was in agreement with previous assertions made by Pitayanon et al. (1997, p. 32) that “fear has led many AIDS [patients] to turn to traditional healers and various kinds of herbs in the search for a cure. News about ‘magical’ drugs and healers is widespread among AIDS [patients] and the costs of these so-called drugs and
Increase in time spent working Loss of savings Financial support from friends/relatives Support from relatives for funeral event Money spent on relatives attending the funeral
45 40 PLHIV (%)
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35 30 25 20 15 10 5 Artisans
Civil servants Unemployed OCCUPATIONAL GROUP
Figure 3: Occupational groups’ experience of the economic impact of HIV or AIDS
healers are generally high…[resulting in] the difficulty of stopping desperate people with a terminal illness and no hope of a cure from conventional medicine from seeking alternative sources of care.” These options are generally believed to be relatively less expensive and readily available when compared with orthodox medical care, but this may not be accurate if considering the final outcomes and the possible complications from delays in seeking care at an orthodox healthcare facility. The level of household assets lost during HIV/AIDS care was highest among the artisans, followed by the unemployed and the civil servants (p > 0.05). Coping ability in response to economic challenges differs among PLHIV. This study revealed a pattern of selling fixed and non-fixed properties to cope with expenses due to HIV-related care, similar to the findings of other studies (e.g. UNAIDS, 2001b; Wyss et al., 2004; Hilhorst et al., 2006). More properties were sold among the unemployed in response to the management of HIV infection compared with the other occupational groups (Figure 1). In the present study, the mean expenditure for all occupational groups was US$358 for treatment of HIV/AIDS, which was well in excess of the mean income generated (US$203). The observed trend in drop in annual income since the time of HIV diagnosis was heaviest for the unemployed and slightest for the civil servants. Civil servants earn a regular government-paid income, irrespective of sickness and hospitalisation (as long this does not exceed six months), enabling them to pay for healthcare services. Hence, the civil servants in this study best seemed to cope with the
Table 2: Occupational groups of the respondents versus an estimate of the fixed household assets (land) and non-fixed household assets (e.g. clothing, electronics) lost to HIV-related care (US$1 = N130)
Occupational group Artisans Unemployed Civil servants Total
Annual income n 25 16 6 47
(US$) 6 062 2 338 1 146 9 545
Fixed assets (land) lost n 1 7 2 10
(US$) 1 769 4 853 923 7 546
Non-fixed assets lost n 1 5 1 7
(US$) 10 281 6 899 2 308 19 487
Total assets lost (US$) 12 050 11 753 3 231 27 034
Asset loss/annual income ratio 1.99 5.03 2.82 2.8
Table 3: The respondents’ patterns of borrowing and lending versus their occupational group Artisans n (%)
Civil servants n (%)
Unemployed n (%)
Total n (%)
‘Have you borrowed money since your HIV diagnosis?’ (n = 94) ‘Yes’ ‘No’ Total
14 (14.8) 50 (53.2) 64 (68)
4 (4.3) 8 (8.5) 12 (12.8)
4 (4.3) 14 (14.8) 18 (19.2)
22 (23.4) 72 (76.6) 94 (100)
Lending body (n = 33)* Cooperative society Friends/extended family Moneylender Bank Total
8 (24.2) 4 (12.1) 2 (6.1) 1 (3) 15 (45.5)
2 (6.1) 2 (6.1) – – 4 (12.1)
7 (21.2) 4 (12.1) 3 (9.1) – 14 (42.4)
17 (51.5) 10 (30.3) 5 (15.2) 1 (3) 33 (100)
Parameter
* Some respondents borrowed from more than one source
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increasing economic burden of HIV disease. In contrast, among artisans working for themselves, the number of hours spent working determined their total income. Chronic and recurrent sicknesses that accompany HIV infection reduce the ability of PLHIV to work on a continuous basis. Among the study population, there was a marked drop in annual income since before diagnosis of HIV or AIDS to the time of illness or the death of a spouse (Figure 2), most prominently among the artisans and unemployed. Among all the participants, the amount of money spent for HIV-related care or treatment was about four times the total annual income. Similarly, Booysen, Van Tensburg, Bachmann, Engelbrecht & Steyn (2002) and Hilhorts et al. (2006) reported a drastic reduction in households’ savings. The economic effects of HIV and AIDS are felt most among the poorest households because resources to buffer the economic burden of the disease are grossly lacking (Barnett, Whiteside & Desmond, 2001). The role of women is generally a subservient one in Nigerian society. In southwestern Nigeria where this study was conducted, women have more liberty to be actively involved in money-making ventures than do women in northern areas. Most women do not own land, but they may be given access to farmlands by male relatives and in-laws in order to cultivate their own crops while still having to work the family fields. Because women generally have fewer assets, they are more likely to cultivate food crops (as opposed to cash crops). Households headed by single mothers are often involved in trading and processing agricultural produce to make a living; others may diversify to crafts (weaving traditional cloth, making ornaments) and other menial jobs (Hilhorst et al., 2006). The importance of this in the present study (and probably in the larger population) is that women and children (including foster children) will more likely suffer from the economic burden of HIV and AIDS. A key finding was the drastic reduction of the participants’ household income from the time before the onset of infection and during the course of the disease. The impacts of HIV and AIDS will differ during the different phases of the disease: namely, during the asymptomatic state, early illness, chronic illness, critical illness, and surrounding death and among a household’s survivors (Dirmie, 2002). Early sickness may lead to absenteeism from income-generating activities, which in turn leads to poorer income, while the already limited income may be further expended on (medical or traditional) healthcare bills. When the disease becomes chronic, the chances of the patient remaining involved in any economically productive activity may amount to none, and relatives (spouse, children) may have to abandon other activities to care for the ill. Time lost due to caring for an AIDS-sick household member will likely reduce the economic productiveness of an adult caregiving relative, or may cause a child to drop out of school. Thus, the poor become poorer. At this point, previously accummulated household savings may be expended and the sale of assets (such as land, clothing, livestock, and domestic goods like electronics) may follow in order to support the treatment or care of the sick individual. Finally, funeral events may overcome whatever household
Adedgiba, Naidoo, Abegunde, Olagundoye, Adejuyigbe and Fakande
assets remain. Thereafter, family survivors may be left with little or nothing to live on, as rights over some assets (such as land) changes over to others (Rugalema, 2002). As mentioned, the impacts of HIV or AIDS differ with different phases of the disease (Dirmie, 2002). A key finding of the present study was the drastic reduction of income in the participants’ households from the time before the onset of illness and during the course of the disease. From the phase of carrier state for HIV infection the patient progresses to the phase of symptoms (sickness), which can be early or late. The early stage of illness may lead to absenteeism and reduced income-generating activities. When the disease becomes chronic, the chance of the patient being involved in economically productive activity is greatly reduced, while relatives often need to leave work or school to care for the patient. Savings need to be tapped into to pay for healthcare (leading to substantial loss of savings) and the sale of fixed and non-fixed properties may follow, as observed in this study (Figure 1). Ultimately, funeral costs can consume a household’s remaining assets (Rugalema, 2002). Borrowing is an important coping strategy used by poor households affected by HIV/AIDS (Arndt & Lewis, 2000; Wyss et al., 2004; Hilhorst et al., 2006), as such households are not able to meet the costs of healthcare from their own resources (UNAIDS, 2001b). In this study, PLHIV reported borrowing money and selling household property (such as land, electronics, clothing, stored farm produce, livestock and jewellery) to pay for medical care, similar to the findings of other studies (e.g. Pitayanon et al., 1997; UNAIDS, 2001b; Wyss et al., 2004; Hilhorst et al., 2006). Thus, high household expenditures, the reduction of family incomes, and the loss of savings may result in the need to obtain loans. A large portion of civil servants in this study were able to secure loans, probably due to the fact that they were in full-time employment, had easier access to cooperative institutions and because their pension and gratuity could act as collateral should they default. Cooperative institutions are organised bodies of interested people pooling their monetary resources to support members with a low-interest loan. The loan interest varies between cooperative societies/ lending institutions (generally, in the study area an interest rate of 1% is common among cooperative bodies, 10% at banks, and higher if obtained from a money lender; the loans are paid back in instalments over a given period and defaulters are sanctioned according the rules laid down). In the present study, respondents in each of the occupational groups (including the unemployed who have least chance of repaying) reported having borrowed money due to HIV-related care, treatment or funerals. More than half the participants reported borrowing from a cooperative society, in agreement with the findings of previous studies in other developing countries (e.g. Pitayanon et al., 1997; Wyss et al., 2004). In Africa, the tendency to borrow from lending institutions has been shown to be adversely affected by individual’s (low) potential to repay loans (Mathenge, 2003), and stigmatisation also affects the HIV patient’s chances of borrowing (Hilhorst et al., 2006). The large amount of money spent on funerals reported by participants in this study was consistent with findings
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from studies among HIV/AIDS-affected households in low-income communities in Thailand, Tanzania and Nigeria (Pitayanon et al., 1997; Urassa et al., 2001; Hilhorst et al., 2006). The high expenditure is due to traditional funeral rites that require relatives and community members to come together at the house of the deceased (for as long as 1 to 2 weeks), to mourn and support the bereaved (MukizaGapere & Ntozi, 1995). The mourning period can be much longer for women than men, which can undoubtedly have untold economic effects on the surviving members of the household (Hilhorst et al., 2006). The economic burden of funerals among the study group reveals further depletion of the limited finances in poor HIV-affected households. However, the survey produced evidence of commendable support from extended family ties during the course of HIV illness or during a funeral event or mourning period, as demonstrated by the money, food and others items that respondents said had been given to them or their families. As good as the extended family network is in Nigerian populations (and as likewise observed elsewhere in sub-Saharan Africa), it has become seriously challenged by the social and economic impacts of the HIV pandemic (Nhongo, 2004; Hilhorst et al., 2006). Limitations of the study The present study did not take into consideration the length of a participant’s illness, which would have allowed comparisons between HIV-related costs and the duration of illness. Furthermore, the evidence that HIV disease or AIDS illness caused the reported monetary losses is weakened by the cross-sectional study design. A controlled longitudinal study would provide stronger evidence; therefore, the generalisations are limited to those for the study population. The study was designed to better understand and provide baseline data for future intervention programmes to alleviate some of the economic and social burdens of HIV and AIDS in low-income Nigerian communities. As more women than men acted as respondents in this study, the findings may more strongly reflect women’s opinions; a larger study involving more PLHIV would be more representative. Conclusions The findings support the suggestion that the economic impact of HIV and AIDS on households continues unabated in sub-Saharan Africa. In this study, artisans and the unemployed were the most economically affected by HIV disease. Poorer households require supplementary financial support to care for sick family members, as well as an enabling environment to do so. The diversion of assets, savings and earnings — lost to HIV-related care, treatment or funerals — affects the economic development among the study population. According to Balyamujura et al. (2000), HIV-prevention/control programmes may prove unsuccessful if poverty at the household level is not inhibited; they argue that poverty leads to a higher incidence of AIDS and vice versa. We suggest that despite the extended family support system, adult deaths continue to undermine the viability of Nigerian households, thus necessitating greater attention to economic issues among PLHIV in Nigeria.
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Acknowledgements — The authors express profound gratitude to the PLHIV from whom we have been learning a great deal and the staff of Living Hope Care (Nigeria) for their kind assistance during the time of data collection. The authors — Michael A. Adedigba is a consultant and lecturer in community dentistry; his professional activities focus on HIV/AIDS, quality of life issues, and dental infection and waste control. Sudeshni Naidoo is a professor of dental public health currently working in the field of HIV/AIDS and community dentistry. Albert Abegunde is currently working on household economic assessment in relation to health and disease. Oluwafemi Olagundoye is a senior registrar in preventive and community dentistry. Ebun Adejuyigbe is an associate professor focusing on paediatric HIV/AIDS. Ibiyemi Fakande is the director of Living Hope Care, an NGO helping to support PLHIV in Osun State, Nigeria.
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Rugalema, G. (2002) ‘HIV/AIDS and land issues: beyond proximate linkages.’ Opening remarks for the FAO/HSRC-SARPN Workshop on the Impact of HIV/AIDS on Land Issues, Pretoria, South Africa, 24–25 June 2002. Russel, S. (2004) The economic burden of illness for households in developing countries: a review of studies focusing on malaria, tuberculosis, and human immunodeficiency virus/acquired immunodeficiency syndrome. American Journal of Tropical Medicine and Hygiene 71(2 supplement), pp. 147–155. Russell, S. (1996) Ability to pay for health care: concepts and evidence. Health Policy and Planning 11(3), pp. 219–237. UNAIDS (2001a) AIDS Epidemic Update. December 2001. Geneva, UNAIDS. UNAIDS (2001b) Paying for HIV/AIDS Services. Lessons from National Health Accounts and Community-based Health Insurance in Rwanda, 1998–1999. Geneva, UNAIDS. UNAIDS (2002) Report on the Global HIV/AIDS Epidemic. Geneva, UNAIDS. UNAIDS (2005) AIDS in Africa: Three Scenarios to 2025. Geneva, UNAIDS. UNDP (2008) Human Development Indices 2007/2008. Human Development Report. New York, United Nations Development Programme (UNDP). Urassa, M., Boerma, J.T., Isingo, R., Ngalula, J., Ng’weshemi, J., Mwaluko, G. & Zaba, B. (2001) The impact of HIV/AIDS on mortality and household mobility in rural Tanzania. AIDS 15(15), pp. 2017–2023. Walker, C. (2002) ‘Ensuring women’s land access.’ Moderator’s comments at the Regional Workshop on Land Issues in Africa and the Middle East, Kampala, Uganda, 29 April–2 May 2002. Whiteside, A. (2002) Poverty and HIV/AIDS in Africa. Third World Quarterly Special Issue 23(2), pp. 313–332. Wyss, K., Hutton, G. & N’Diekhor, Y. (2004) Costs attributable to AIDS at the household level in Chad. AIDS Care 16(7), pp. 808–816. Xu, K.T. & Borders, T.F. (2003) Gender, health and physician visits among adults in the United States. American Journal of Public Health 19(11), pp. 79–86.
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The economic burden of HIV and AIDS on households in Nigeria Michael A Adedigba , Sudeshni Naidoo , Albert Abegunde , Oluwafemi Olagundoye , Ebun Adejuyigbe & Ibiyemi Fakande Published online: 11 Nov 2009.
To cite this article: Michael A Adedigba , Sudeshni Naidoo , Albert Abegunde , Oluwafemi Olagundoye , Ebun Adejuyigbe & Ibiyemi Fakande (2009) The economic burden of HIV and AIDS on households in Nigeria, African Journal of AIDS Research, 8:1, 107-114, DOI: 10.2989/AJAR.2009.8.1.11.724 To link to this article: http://dx.doi.org/10.2989/AJAR.2009.8.1.11.724
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ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/AJAR.2009.8.1.11.724
The economic burden of HIV and AIDS on households in Nigeria Michael A Adedigba1*, Sudeshni Naidoo2, Albert Abegunde3, Oluwafemi Olagundoye1, Ebun Adejuyigbe4 and Ibiyemi Fakande5 1
Department of Preventive and Community Dentistry, Obafemi Awolowo University, Ile-Ife, Nigeria University of the Western Cape, Department of Community Oral Health, University of the Western Cape, Private Bag X1, Tygerberg 7505, South Africa 3 Urban & Regional Planning, Obafemi Awolowo University, Ile-Ife, Nigeria 4 Paediatrics Department, Obafemi Awolowo University, Ile-Ife, Nigeria 5 General Hospital, Ilesa, Nigeria * Corresponding author, e-mail: [email protected]; [email protected]
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The study estimates the economic burden of HIV and AIDS on households in a Nigerian population. The data derive from a cross-sectional survey of households affected by HIV or AIDS in Ife-Ijesa Zone, Osun State, Nigeria. The sample consisted of 117 purposively selected, consenting adult HIV patients attending a general and teaching hospital. Participants were asked to self-report monetary expenses for HIV-related care, loss of savings, and funeral costs. The data show a significantly sharp drop in the participants’ household income as a result of care for HIV-related illnesses, from the time of knowing one’s HIV status to the time of illness, among three occupational categories (artisans, civil servants and unemployed; p = 0.02). Mean income among those in the unemployed category fell by 84.1%, income among artisans dropped by 72.6%, and income among civil servants decreased by 44.4%. The monetary loss during the course of HIV-related illnesses was heaviest for the artisan group, followed by the unemployed and the civil servants. Those who had lost a substantial part of their savings to HIV-related care were most numerous among the unemployed, followed by artisans and civil servants. Out of 16 households, 11 (42.3%) had received support from relatives during a funeral ceremony. There was a significant association between the occupational group and working for more hours after illness (χ2 = 9.28, df = 4; p = 0.05). Nearly all orphaned children were distributed to the extended family following the AIDS death of a parent. Among all the occupational groups, borrowing from a cooperative society during the course of HIV-related sickness was the commonest form. The findings add to data showing that despite the extended family support system, adult deaths due to AIDS continue to undermine the viability of sub-Saharan African households. Keywords: Africa, family, financial impact, household behaviour, income, low-income communities, poverty
Introduction The number of people living with HIV continues to rise in many parts of the developing world despite the fact that effective preventive strategies exist. Sub-Saharan Africa remains the hardest hit region with very high HIV prevalence (UNAIDS, 2005). An estimated 3.9% of the population of Nigeria is HIV-positive (Federal Ministry of Health [FMOH], 2006). UNAIDS has reiterated the need to evaluate the economic and social impacts of the HIV pandemic and so to develop multisectoral strategies to address those impacts at the individual, family, community and national levels; in particular it has suggested accelerating the implementation of national poverty-eradication strategies that may lessen the impact of HIV and AIDS on households’ income, livelihoods or access to basic social services (UNAIDS, 2006). Households form the basic social and economic elements of sub-Saharan African societies and their viability is threatened by sustained crisis-level mortality in widely disseminated
HIV epidemics (Gregson, Mushati & Nyamukapa, 2007). HIV and AIDS cause a loss of income and lower productivity among household members. If an HIV-infected individual is the sole breadwinner, the impact to the household is especially severe. AIDS illness creates extraordinary care needs that must be met, usually by withdrawing other household members from work or school to care for the sick. AIDS illness also causes household expenditures to rise as a result of medical and related costs, while the loss of assets and productive workers severely affect households’ capacities to produce and purchase food. Poor households are in particular danger of losing their economic and social viability (Menon, Wawer, Konde-Lule, Sewankambo & Li, 1998; Arndt & Lewis, 2000; Grégoire, 2001; Whiteside, 2002). Furthermore, the prevalence of AIDS intensifies chronic food shortages, creating a vicious circle for communities as the shortage of good nutrition speeds up the progression of HIV disease in those who are infected. African households are undergoing new challenges as an immediate result of HIV and AIDS: older people frequently
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care for the sick, dying and orphaned; in many cases, children head up the household; and, after the death of parents, surviving children are often fostered by grandparents or other older female relatives, or are sent to live with extended family members. Due to the increased demands for physical, economic and social support for people living with HIV or AIDS (PLHIV), individuals in HIV-affected households have less time to pursue income-generating opportunities (Hilhorst, Van Liere, Ode & De Koning, 2006). An escalation in AIDS deaths in Africa has caused the loss of labour, reduced farming income and household assets, and lowered households’ food security (UNAIDS, 2005). The monetary cost of HIV or AIDS has been catastrophic for many households in developing countries (Russel, 2004). Bachmann & Bachmann & Booysen (2003 and 2006) has shown that in South Africa, household economies and HIV/ AIDS are dynamically related, as many HIV epidemics occur against a background of progressive poverty. A recent study in Zimbabwe reported that deaths occurred disproportionately in urban and lower-income households, with AIDS deaths more often resulting in the loss of the household head (Gregson et al., 2007). The median gross expenditure on healthcare and funerals was approximately US$25 and US$73, respectively, with households receiving substantial external contributions for funerals; households experiencing AIDS deaths spent more on healthcare and had more frequently dissolved or relocated than households experiencing non-AIDS deaths, and the members of urban HIV-affected households migrated disproportionately compared to affected households in rural villages (Gregson et al., 2007). A study of AIDS-affected households in Zambia showed that in two-thirds of the families where the father had died, monthly disposable income had fallen by more than 80% (Loewenson & Whiteside, 2001). An earlier study in Côte d’Ivoire found that mean income in AIDS-affected households was half that of the average household (Béchu, 1998). In Botswana, per-capita household income for the poorest households was expected to fall by 15% over ten years (UNAIDS, 2001a). In Thailand and Tanzania, the funeral-cost burden of death was often far greater than the cost burden of AIDS illness, as households in those two countries reported spending up to 50% more on funerals than on medical care (Pitayanon, Kongsin & Janjareon, 1997; Urassa, Boerma, Isingo, Ngalula, Ng’weshemi, Mwaluko & Zaba, 2001). There appears to be four coping strategies that are commonly adopted by financially strapped families: 1) using savings and/or selling household assets, which may include clothing, land, farm produce, automobiles and electronics (for instance, a study in Thailand revealed that 41% of AIDS-affected households resorted to selling their land: Pitayanon et al., 1997); 2) getting assistance from extended family members; 3) reducing the number of dependent adults and/or children by sending them to live with relatives (see Pitayanon et al., 1997; Menon et al., 1998); and, 4) taking loans from extended family members, the local community or a cooperative/money-lending institution (see Mathenge, 2003; Wyss, Hutton & N’Diekhor, 2004). In a study in Thailand, 46% of the respondents claimed
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to have borrowed from relatives, 23% from a cooperative or other type of local lending institution, and 23% from a moneylender (Pitayanon et al., 1997). A study in South Africa showed that deprived households used up to 21 months of their savings to offset medical and other healthrelated bills (Bachmann & Booysen, 2004). More than two-thirds (64.4%) of Nigerians are living below the poverty line of US$1 per day (UNDP, 2008); HIV and AIDS in no small way contributes to further reducing the already poor income of many households in Nigeria. Notwithstanding the research that has been done on various HIV-related economic impacts to households, there are gaps in empirical knowledge related to households’ coping strategies (Russell, 1996), especially in Nigeria. Some studies have focused on the impact of the disease on families that have experienced an AIDS death (e.g. Pitayanon et al., 1997 [Thailand]; Gregson et al., 2007 [Zimbabwe]), but this approach may overlook families that experience high expenditure on HIV-related care and treatment while not experiencing an AIDS death. There are two dimensions of HIV/AIDS-related impacts to the macro-economic environment: direct and indirect costs (Balyamujura, Jooste, Van Schalkwyk, Geldenhuys, Crew, Carstens et al., 2000). Direct cost refers to the cost of treatment associated with HIV-related symptoms. These costs can have serious consequences on a household’s healthcare financing due to disproportionate medical expenses in a resource-poor setting. Indirect costs refer to more difficult to measure parameters, such as costs relating to the value of production, loss of current wages, loss of present value of earnings, training expenditures for new staff, and the cost of absenteeism. There is an urgent need for baseline data to facilitate future intervention programmes to alleviate the economic impacts of HIV and AIDS in Nigeria and to better enable households’ socio-economic coping strategies. The aim of this study was to investigate the economic burden of HIV and AIDS on semi-urban households in Ife-Ijesa Zone, Osun State, southwestern Nigeria. Methods A cross-sectional study was carried out among people living with HIV or AIDS (PLHIV) in Ife-Ijesa Zone in Osun State (an inland state in southwestern Nigeria). This study site is a semi-urban area where the majority of people are engaged in a subsistent agrarian economy. The zone is also a referral centre for many neighbouring towns and villages in the management of HIV/AIDS-associated illnesses. After assuring individuals’ anonymity and confidentiality, written, informed consent was obtained from a sample of 117 out of 250 PLHIV approached who were attending an HIV/ AIDS clinic at the general and teaching hospital in the zone between January 2002 and July 2005. This number was above the expected, planned sample size of 65 individuals, based on an estimate of 4.4% HIV prevalence in Nigeria (see FMOH, 2004). A purposive sample of 117 PLHIV was chosen using selection criteria based on all consenting adult PLHIV choosing to participate in the study after the purpose of the
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research was explained. Ethical clearance was sought and obtained from the ethics committee at the teaching hospital. The data were collected by a trained home-based healthcare worker. All participants were ambulatory and none was an in-patient at the time of data collection. The calibrated questionnaire consisted of two parts: demographic information and an HIV-related economic impact assessment. Using recall, participants were asked to record the expenses and losses that their household had incurred for HIV-related care during the past three years of their living with the disease. Expenses included the cost of transportation to and from the hospital, medicines, medical examinations and hospital admission. Loss of assets during the period of the disease (i.e. from the time of diagnosis to time of illness) included household materials, land, household members, funeral costs, and reduced household savings and income per annum. These were computed into monetary values. Substantial loss of savings was regarded as losing more than 30% of a household’s savings. Monetary loss during the period was defined to the respondents as those losses occurring since the time of the first signs and symptoms of HIV-related illness. This was also the time when most of the study participants had presented at a hospital because of an illness, and which had consequently included testing for HIV. Family income was determined as the total income (e.g. regular monthly wages, revenue from other sources, gratuities) from the time the patient was first notified of their HIV diagnosis. Household income after the death of a spouse (for those respondents who had lost their spouse due to AIDS illness) was determined from the first day after such a death. A household’s monthly loss to care due to the respondent’s/ any household member’s illness involved total money lost from wages (due to inability to perform work optimally), the cost of medicines, hospital bills (e.g. consultation fees, the cost of examinations and/or hospital admission, transportation fees to and from the hospital, including bringing meals to the hospital), preparing special foods, running errands, accompanying an ill person to health facilities, and the cost of alternative care homes. ‘Unemployed’ as defined in this study also relates to a form of ‘disguised employment,’ meaning the participant may have been engaged in some form of making a living to keep body and soul together in the absence of a regular/ expected job. This may have involved working as a causal labourer in a factory, for a construction company, on a farm or other agro-allied establishment, or doing any menial job available. These unemployed or rather underemployed persons may have been holders of academic qualifications that could have made them eligible for a more skilled job. The cost of intangibles (e.g. pain, anxiety, loss of wellbeing) was excluded from consideration because of the difficulty of translating these into monetary terms (see Wyss et al., 2004). Income loss was calculated as the difference in the net household income before and after the participant’s HIV infection. The cost of antiretroviral medicines (ARVs) and some other medicines (such as cotrimoxazole, haematinics, acetylsalicylic acid and antimalarial drugs) were excluded. This is because the sample individuals were not on ARVs, and cotrimoxazole, haematinics,
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acetylsalicylic acid and antimalarial drugs were provided for free at the hospital’s clinic. The data were entered anonymously to achieve confidentiality, and then analysed using SPSS® software (Version 11). Simple proportions, percentages, summation analyses, chi-square for categorical variables, t-test, and one-way analysis of variance (ANOVA) for numerical variables were carried out. The level of significance was set at p ≤ 0.05. Results Of the 117 participants in the study, the majority were females (63.2%) (the percentage of males and females among the potential study population of 250 from where the sample was drawn was 35.8% and 64.2%, respectively). The participants’ ages ranged from 15 to 65 years (mean age 35.8 years). About two-thirds (62.4%) were married. About 5% had no formal education, but more than half (57.3%) had a primary or partial secondary education, and 37.3% had a secondary or tertiary education. The majority were categorised as artisans (54.7%), which included hairdressers, auto mechanics, iron-benders, barbers, carpenters and painters; 11.1% were categorised as unemployed (although some in this group worked informally), including another 4.3% who were retired; and civil servants formed 10.2% of the sample. The remainder did not share their occupational status (20%). Table 1 shows the participants’ reported sources of healthcare during the past one year before the survey. The majority (77.8%) made a government hospital their first choice; visiting a traditional healer was their second-mostcommon choice (34.2%). Just under one-third (28.2%) of the participants reported that they had lost one or more household members to AIDS; of these, 12.8% had lost a spouse and 8.5% had lost a child. Orphaned children were generally distributed to extended family members for care following a parent’s death. Figure 1 depicts the loss of household assets among the PLHIV studied. The loss of assets during the care of an HIV/AIDS patient was highest among the artisans, followed by the unemployed and the civil servants. There were no significant associations found between the occupational groups and the amount of assets sold as land (F = 0.22; p = 0.81), electronics (F = 0.25; p = 0.63), clothing (F = 0.03; p = 0.86), and other forms (F = 3.17; p = 0.08). The respondents’ household income had generally declined from the time before their household member’s HIV infection to the time of the death of a household member. There had been a significantly sharp drop in household income from the time prior to the participant discovering their own serostatus (HIV diagnosis) to the time of HIV-related illness (symptoms) among the various occupational groups (F = 4.64; p = 0.02). Figure 2 shows the estimated household monetary losses during the course of HIV-related illness in the respondents’ households based on the occupational groups. Artisans’ mean income dropped from approximately US$242 to US$66, or by 72.6%; for the unemployed it fell by 84.1%, and for civil servants it fell by 44.4%. The heaviest monetary losses during the course of HIV infection were reported in the artisan group, followed by the unemployed and the
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Adedgiba, Naidoo, Abegunde, Olagundoye, Adejuyigbe and Fakande
Table 1: The respondents’ sources of healthcare during the last year before the survey (n = 117 PLHIV)
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VALUE (US$)
8 000
1st choice n (%) 1 (0.8) 3 (2.6) 5 (4.3) 18 (15.4) 90 (76.9)
ESTIMATED COST (Nigerian naira)
Source Alternative medicine Religious source Traditional healer Private hospital Government hospital
Artisans Civil servants Unemployed
6 000 4 000 2 000
Land
Electronics Clothing ASSETS
2nd choice n (%) 2 (1.7) 36 (30.7) 40 (34.2) 27 (23.1) 12 (10.3)
20 000 15 000
Mean income before HIV infection Monetary loss since HIV diagnosis Income during the course of HIV illness Income after a spous’e death Monthly loss due to HIV related care Funeral related costs
10 000 5 000
Other
Artisans Civil servants Unemployed OCCUPATIONAL GROUP
Figure 1: Participants’ self-reported loss of household fixed and non-fixed assets during the three years before the survey (n = 117 PLHIV; US$1 = N130)
Figure 2: Participants’ self-reported estimated household monetary losses during the course of HIV diseases (n = 117 PLHIV; US$1 = N130)
civil servants, but the differences between the groups were not significant (t = –1.66, df = 6; p = 0.15). During funeral ceremonies, artisans’ households’ spent 134% above their mean income earnings than before the HIV infection. Even though the majority of all respondents (65.6%) reported a loss of a substantial part (>30%) of their household savings to HIV or AIDS care, there was no significant association between occupational group and loss of savings (χ2 = 8.6, df = 4; p = 0.07), although in this regard the unemployed (29.2%) and artisans (28.1%) were the majority, with civil servants (8.3%) reporting the least loss. The artisans reported having received the most financial support from family or friends. The respondent’s household’s income decreased from the time before the infection of their household member’s HIV infection to the time of the death of a household member. There had been a significant drop in household income from the time prior to the participants knowing their serostatus (HIV diagnosis) to the time of illness (symptoms) among the various occupational groups (F = 4.64; p = 0.02). There was a significant association between the respondents’ working hours since the onset of illness and occupational group (χ2 = 9.28, df = 4; p = 0.05). Artisans worked for more hours to make ends meet since the onset of HIV illness compared with the other occupational groups (Figure 3). Artisans reported receiving the most financial support from family or friends due to a funeral ceremony (χ2 = 9.85, df = 4; p = 0.04). Those who reported that friends or relatives had given food, goods or clothing to the
deceased’s family during a funeral ceremony was not significantly associated with the respondents’ occupational group (χ2 = 2.46, df = 4; p = 0.7). Nearly half of all the households had spent some money to care for relatives who attended funeral ceremonies (Figure 3). Table 2 lists the ratios for respondents’ total household assets lost due to HIV-related care in relation to total annual household income. The unemployed group had the highest ratio of assets lost due to care in relation to total annual income. Table 3 shows the participants’ borrowing patterns and the types of lending institutions used. Nearly a quarter (n = 22; 23.4%) of all respondents reported having to borrow money to cover the costs of treating and managing their HIV infection or AIDS illness. Artisans borrowed more than did the other occupational groups and mostly did so from a cooperative society (Table 3). Discussion There were more females available for interview in the present study. This could be because more females seek care than their male counterparts (Xu & Borders, 2003) or because more women in Nigeria are HIV infected or are surveyed (through antenatal clinics) (FMOH, 2004). (However, the percentages of males and females among the 250 study population from where the sample was drawn were 35.8% and 64.2%, respectively, which was similar to the study participants.)
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Many of the participants reported visiting one or more other sources of care, where their funds might have been depleted, before presenting at the hospital or concurrently with their attendance. This was in agreement with previous assertions made by Pitayanon et al. (1997, p. 32) that “fear has led many AIDS [patients] to turn to traditional healers and various kinds of herbs in the search for a cure. News about ‘magical’ drugs and healers is widespread among AIDS [patients] and the costs of these so-called drugs and
Increase in time spent working Loss of savings Financial support from friends/relatives Support from relatives for funeral event Money spent on relatives attending the funeral
45 40 PLHIV (%)
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35 30 25 20 15 10 5 Artisans
Civil servants Unemployed OCCUPATIONAL GROUP
Figure 3: Occupational groups’ experience of the economic impact of HIV or AIDS
healers are generally high…[resulting in] the difficulty of stopping desperate people with a terminal illness and no hope of a cure from conventional medicine from seeking alternative sources of care.” These options are generally believed to be relatively less expensive and readily available when compared with orthodox medical care, but this may not be accurate if considering the final outcomes and the possible complications from delays in seeking care at an orthodox healthcare facility. The level of household assets lost during HIV/AIDS care was highest among the artisans, followed by the unemployed and the civil servants (p > 0.05). Coping ability in response to economic challenges differs among PLHIV. This study revealed a pattern of selling fixed and non-fixed properties to cope with expenses due to HIV-related care, similar to the findings of other studies (e.g. UNAIDS, 2001b; Wyss et al., 2004; Hilhorst et al., 2006). More properties were sold among the unemployed in response to the management of HIV infection compared with the other occupational groups (Figure 1). In the present study, the mean expenditure for all occupational groups was US$358 for treatment of HIV/AIDS, which was well in excess of the mean income generated (US$203). The observed trend in drop in annual income since the time of HIV diagnosis was heaviest for the unemployed and slightest for the civil servants. Civil servants earn a regular government-paid income, irrespective of sickness and hospitalisation (as long this does not exceed six months), enabling them to pay for healthcare services. Hence, the civil servants in this study best seemed to cope with the
Table 2: Occupational groups of the respondents versus an estimate of the fixed household assets (land) and non-fixed household assets (e.g. clothing, electronics) lost to HIV-related care (US$1 = N130)
Occupational group Artisans Unemployed Civil servants Total
Annual income n 25 16 6 47
(US$) 6 062 2 338 1 146 9 545
Fixed assets (land) lost n 1 7 2 10
(US$) 1 769 4 853 923 7 546
Non-fixed assets lost n 1 5 1 7
(US$) 10 281 6 899 2 308 19 487
Total assets lost (US$) 12 050 11 753 3 231 27 034
Asset loss/annual income ratio 1.99 5.03 2.82 2.8
Table 3: The respondents’ patterns of borrowing and lending versus their occupational group Artisans n (%)
Civil servants n (%)
Unemployed n (%)
Total n (%)
‘Have you borrowed money since your HIV diagnosis?’ (n = 94) ‘Yes’ ‘No’ Total
14 (14.8) 50 (53.2) 64 (68)
4 (4.3) 8 (8.5) 12 (12.8)
4 (4.3) 14 (14.8) 18 (19.2)
22 (23.4) 72 (76.6) 94 (100)
Lending body (n = 33)* Cooperative society Friends/extended family Moneylender Bank Total
8 (24.2) 4 (12.1) 2 (6.1) 1 (3) 15 (45.5)
2 (6.1) 2 (6.1) – – 4 (12.1)
7 (21.2) 4 (12.1) 3 (9.1) – 14 (42.4)
17 (51.5) 10 (30.3) 5 (15.2) 1 (3) 33 (100)
Parameter
* Some respondents borrowed from more than one source
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increasing economic burden of HIV disease. In contrast, among artisans working for themselves, the number of hours spent working determined their total income. Chronic and recurrent sicknesses that accompany HIV infection reduce the ability of PLHIV to work on a continuous basis. Among the study population, there was a marked drop in annual income since before diagnosis of HIV or AIDS to the time of illness or the death of a spouse (Figure 2), most prominently among the artisans and unemployed. Among all the participants, the amount of money spent for HIV-related care or treatment was about four times the total annual income. Similarly, Booysen, Van Tensburg, Bachmann, Engelbrecht & Steyn (2002) and Hilhorts et al. (2006) reported a drastic reduction in households’ savings. The economic effects of HIV and AIDS are felt most among the poorest households because resources to buffer the economic burden of the disease are grossly lacking (Barnett, Whiteside & Desmond, 2001). The role of women is generally a subservient one in Nigerian society. In southwestern Nigeria where this study was conducted, women have more liberty to be actively involved in money-making ventures than do women in northern areas. Most women do not own land, but they may be given access to farmlands by male relatives and in-laws in order to cultivate their own crops while still having to work the family fields. Because women generally have fewer assets, they are more likely to cultivate food crops (as opposed to cash crops). Households headed by single mothers are often involved in trading and processing agricultural produce to make a living; others may diversify to crafts (weaving traditional cloth, making ornaments) and other menial jobs (Hilhorst et al., 2006). The importance of this in the present study (and probably in the larger population) is that women and children (including foster children) will more likely suffer from the economic burden of HIV and AIDS. A key finding was the drastic reduction of the participants’ household income from the time before the onset of infection and during the course of the disease. The impacts of HIV and AIDS will differ during the different phases of the disease: namely, during the asymptomatic state, early illness, chronic illness, critical illness, and surrounding death and among a household’s survivors (Dirmie, 2002). Early sickness may lead to absenteeism from income-generating activities, which in turn leads to poorer income, while the already limited income may be further expended on (medical or traditional) healthcare bills. When the disease becomes chronic, the chances of the patient remaining involved in any economically productive activity may amount to none, and relatives (spouse, children) may have to abandon other activities to care for the ill. Time lost due to caring for an AIDS-sick household member will likely reduce the economic productiveness of an adult caregiving relative, or may cause a child to drop out of school. Thus, the poor become poorer. At this point, previously accummulated household savings may be expended and the sale of assets (such as land, clothing, livestock, and domestic goods like electronics) may follow in order to support the treatment or care of the sick individual. Finally, funeral events may overcome whatever household
Adedgiba, Naidoo, Abegunde, Olagundoye, Adejuyigbe and Fakande
assets remain. Thereafter, family survivors may be left with little or nothing to live on, as rights over some assets (such as land) changes over to others (Rugalema, 2002). As mentioned, the impacts of HIV or AIDS differ with different phases of the disease (Dirmie, 2002). A key finding of the present study was the drastic reduction of income in the participants’ households from the time before the onset of illness and during the course of the disease. From the phase of carrier state for HIV infection the patient progresses to the phase of symptoms (sickness), which can be early or late. The early stage of illness may lead to absenteeism and reduced income-generating activities. When the disease becomes chronic, the chance of the patient being involved in economically productive activity is greatly reduced, while relatives often need to leave work or school to care for the patient. Savings need to be tapped into to pay for healthcare (leading to substantial loss of savings) and the sale of fixed and non-fixed properties may follow, as observed in this study (Figure 1). Ultimately, funeral costs can consume a household’s remaining assets (Rugalema, 2002). Borrowing is an important coping strategy used by poor households affected by HIV/AIDS (Arndt & Lewis, 2000; Wyss et al., 2004; Hilhorst et al., 2006), as such households are not able to meet the costs of healthcare from their own resources (UNAIDS, 2001b). In this study, PLHIV reported borrowing money and selling household property (such as land, electronics, clothing, stored farm produce, livestock and jewellery) to pay for medical care, similar to the findings of other studies (e.g. Pitayanon et al., 1997; UNAIDS, 2001b; Wyss et al., 2004; Hilhorst et al., 2006). Thus, high household expenditures, the reduction of family incomes, and the loss of savings may result in the need to obtain loans. A large portion of civil servants in this study were able to secure loans, probably due to the fact that they were in full-time employment, had easier access to cooperative institutions and because their pension and gratuity could act as collateral should they default. Cooperative institutions are organised bodies of interested people pooling their monetary resources to support members with a low-interest loan. The loan interest varies between cooperative societies/ lending institutions (generally, in the study area an interest rate of 1% is common among cooperative bodies, 10% at banks, and higher if obtained from a money lender; the loans are paid back in instalments over a given period and defaulters are sanctioned according the rules laid down). In the present study, respondents in each of the occupational groups (including the unemployed who have least chance of repaying) reported having borrowed money due to HIV-related care, treatment or funerals. More than half the participants reported borrowing from a cooperative society, in agreement with the findings of previous studies in other developing countries (e.g. Pitayanon et al., 1997; Wyss et al., 2004). In Africa, the tendency to borrow from lending institutions has been shown to be adversely affected by individual’s (low) potential to repay loans (Mathenge, 2003), and stigmatisation also affects the HIV patient’s chances of borrowing (Hilhorst et al., 2006). The large amount of money spent on funerals reported by participants in this study was consistent with findings
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African Journal of AIDS Research 2009, 8(1): 107–114
from studies among HIV/AIDS-affected households in low-income communities in Thailand, Tanzania and Nigeria (Pitayanon et al., 1997; Urassa et al., 2001; Hilhorst et al., 2006). The high expenditure is due to traditional funeral rites that require relatives and community members to come together at the house of the deceased (for as long as 1 to 2 weeks), to mourn and support the bereaved (MukizaGapere & Ntozi, 1995). The mourning period can be much longer for women than men, which can undoubtedly have untold economic effects on the surviving members of the household (Hilhorst et al., 2006). The economic burden of funerals among the study group reveals further depletion of the limited finances in poor HIV-affected households. However, the survey produced evidence of commendable support from extended family ties during the course of HIV illness or during a funeral event or mourning period, as demonstrated by the money, food and others items that respondents said had been given to them or their families. As good as the extended family network is in Nigerian populations (and as likewise observed elsewhere in sub-Saharan Africa), it has become seriously challenged by the social and economic impacts of the HIV pandemic (Nhongo, 2004; Hilhorst et al., 2006). Limitations of the study The present study did not take into consideration the length of a participant’s illness, which would have allowed comparisons between HIV-related costs and the duration of illness. Furthermore, the evidence that HIV disease or AIDS illness caused the reported monetary losses is weakened by the cross-sectional study design. A controlled longitudinal study would provide stronger evidence; therefore, the generalisations are limited to those for the study population. The study was designed to better understand and provide baseline data for future intervention programmes to alleviate some of the economic and social burdens of HIV and AIDS in low-income Nigerian communities. As more women than men acted as respondents in this study, the findings may more strongly reflect women’s opinions; a larger study involving more PLHIV would be more representative. Conclusions The findings support the suggestion that the economic impact of HIV and AIDS on households continues unabated in sub-Saharan Africa. In this study, artisans and the unemployed were the most economically affected by HIV disease. Poorer households require supplementary financial support to care for sick family members, as well as an enabling environment to do so. The diversion of assets, savings and earnings — lost to HIV-related care, treatment or funerals — affects the economic development among the study population. According to Balyamujura et al. (2000), HIV-prevention/control programmes may prove unsuccessful if poverty at the household level is not inhibited; they argue that poverty leads to a higher incidence of AIDS and vice versa. We suggest that despite the extended family support system, adult deaths continue to undermine the viability of Nigerian households, thus necessitating greater attention to economic issues among PLHIV in Nigeria.
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Acknowledgements — The authors express profound gratitude to the PLHIV from whom we have been learning a great deal and the staff of Living Hope Care (Nigeria) for their kind assistance during the time of data collection. The authors — Michael A. Adedigba is a consultant and lecturer in community dentistry; his professional activities focus on HIV/AIDS, quality of life issues, and dental infection and waste control. Sudeshni Naidoo is a professor of dental public health currently working in the field of HIV/AIDS and community dentistry. Albert Abegunde is currently working on household economic assessment in relation to health and disease. Oluwafemi Olagundoye is a senior registrar in preventive and community dentistry. Ebun Adejuyigbe is an associate professor focusing on paediatric HIV/AIDS. Ibiyemi Fakande is the director of Living Hope Care, an NGO helping to support PLHIV in Osun State, Nigeria.
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