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The Impact of the AIDS Pandemic on Health Services in Africa

Erosion of health services is highly correlated with increases in AIDS prevalence. Regions of countries that have light AIDS burdens have witnessed small or no declines in health care.

In the past twenty years, the AIDS crisis has had crippling effects on the health care systems of many countries. The pandemic has compromised the ability of health systems to deliver care, in part because health professionals have fallen ill or have chosen to leave for less risky assignments elsewhere. The nature of care offered by clinics and hospitals has also changed, with limited resources shifted toward those infected with HIV or full-blown AIDS. A recent World Bank evaluation also reports changes in its funding for health, nutrition, and population programs (HNP) over the decade from 1997 to 2007, noting that “while the overall levels of lending in HNP have not changed much over the past decade, the composition of the portfolio has shifted rather dramatically toward communicable disease projects, particularly AIDS…”

AIDS may also reduce the demand for non-AIDS related health services in Africa: prime-aged adults who fall ill may need to leave the labor force and other family members may find it necessary to change their work patterns in order to care for the sick. These costs of lost work, together with the financial costs of covering illnesses associated with AIDS, can drive families into poverty, reducing their ability to fund non-AIDS related care.

These strains on health systems and households have taken their toll, according to a recent study by NBER researchers Anne Case and Christina Paxson. In The Impact of the AIDS Pandemic on Health Services in Africa: Evidence from Demographic and Health Surveys (NBER Working Paper No. 15000), they use data on fourteen sub-Saharan African countries collected in Demographic and Health Surveys (DHS) to document the impact of the AIDS crisis on non-AIDS related health services. They find deterioration in a number of survey measures of health care, including the presence of trained attendants at birth deliveries, tests done as part of antenatal care, and rates of immunization for children born between 1988 and 2005.

The most recent DHS survey for each country collected data on HIV prevalence, so Case and Paxson are able to examine the association between HIV burden and health care. They find that erosion of health services is highly correlated with increases in AIDS prevalence. Regions of countries that have light AIDS burdens have witnessed small or no declines in health care, using the measures noted above. Those regions currently shouldering the heaviest burdens have seen the largest erosion in treatment for pregnant women and children. The authors date the beginning of the divergence in health services between high- and low-HIV regions to the mid-1990s.

The Demographic and Health Surveys are large, nationally representative household-based surveys conducted at approximately four to five year intervals in low- and middle-income countries. They focus primarily on population, health, and nutrition. Women aged 15 to 49 are asked about their fertility histories, including information on prenatal care, delivery assistance, and children’s immunizations. In some of the surveys, information on antenatal care is available for a woman’s most recent birth; in others, it is collected for all births that occurred within a particular time period.

The authors analyze data from 41 DHS surveys conducted between 1988 and 2006 in sub-Saharan Africa, including multiple surveys from eight West African countries where HIV prevalence rates are relatively low – Burkina Faso, Cameroon, Cote d’Ivoire, Ghana, Guinea, Mali, Niger, and Senegal – and six countries in East and Southern Africa where rates are higher – Ethiopia, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe.

-- Lester Picker