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Handbook: Summary report Prepared by Alexander Forbes Financial Services Namibia May 2011

Executive Summary

The Namibian Government is committed to provide services to the citizens of Namibia. Apart from the sector’s responsibility to deliver services by maintaining a healthy and productive workforce, the Government needs to sustain current practices, develop innovative approaches to future challenges, and maintain an institutional memory that sustains the employees and the services rendered to the population of Namibia.

HIV and AIDS is one of the factors that impact on the ability of the Public Sector to deliver services. An HIV and AIDS impact assessment has been conducted within the Public Service workforce, including a demographic impact analysis. This analysis provides estimates of HIV prevalence and incidence among the Namibian Public Service workforce and the potential cost impact associated with these estimates.

The specific objectives of the impact assessment are to:

Examine the workflow processes within O/M/As to determine constraints placed on service delivery as a result of absenteeism, family related leave requests and death resulting from HIV and AIDS and other causes,

Investigate the extent to which HIV and AIDS is contributing to productivity loss within O/M/As,

Assess the level of preparedness of the Public Sector to effectively address the development challenges posed by the epidemic,

Ascertain the extent of government financial expenditures (medical aid pay out and productive hours lost, cost of ARVs for public sector employees, man hours lost, cost of early retirement, funeral costs etc ) as a result of the epidemic,

Based on the findings, propose short and long-term policy recommendations for mitigating the impact of HIV and AIDS for an effective public service.

The legal and policy instruments reviewed reflect a commendable degree of commitment from the Government attenting to the HIV and AIDS epidemic and its management thereof. Specific mention has to go to policies like the National Policy on HIV and AIDS: March 2007 as a clear testimony of the importance with which the Namibian Government is determined to deal with HIV and AIDS. From this national policy all sectors of the economy are then expected to develop their own policies. The National Policy gives a guiding framework for the development of a harmonised sector-specific policy framework and to create a standardised approach to dealing with HIV and AIDS across the different sectors of the economy.

Literature on current HIV and AIDS workplace management plans and programmes has also been reviewed. There is certainly a lot of activity within the Public Sector in response to HIV and AIDS management, however, there is enough evidence to suggest that more still needs to be done. A variety of reasons have been identified as contributing to the sector not doing as much as it should be doing. These range from limiting financial resources to a challenge faced by the offices, ministries and agencies to properly mainstream HIV and AIDS management as a core element of their functions.

The policy environment has then been assessed against the actual Public Sector profile to gain an understanding of what the actual impact is and how it can be mitigated. Employee static data was collected from the Office of the Prime Minister for all Public Sector employees. Results of HIV prevalence projections were generated making use of the Deloitte Multi-State AIDS projection model, where the rates of new infections (incidence rates) were derived (by age, sex and calendar year) from the Actuarial Society of South Africa (ASSA) 2003 AIDS Model (with reference to the corresponding results produced by the Spectrum model), and the demographics of the workforce were incorporated. These HIV incidence rates were calibrated to the results produced by the Ministry of Health and Social Services (MoHSS) sentinel survey for ante-natal clinic attendees which is conducted every two years.

Based on our best estimate model results, we estimate the 2008 HIV prevalence to be 13.5% for all O/M/As combined. This is expected to decrease to 5% by 2015. These projections were carried out on the basis of assuming that there are selective entrants to the workforce (i.e. new entrants are healthier than existing employees) and that there are high rates of churn (based on the experience within the pension fund). The combination of these assumptions results in an HIV prevalence rate that is expected to drop rapidly over the projection period.

We have also modelled the case where there is no allowance for selective entrants which results in a higher rate of HIV prevalence. Removing the selective entrant assumption, we estimate the 2008 HIV prevalence to be 15.2% for all O/M/As. This is expected to decrease to approximately 8% by 2015. The resulting HIV prevalence is higher as employees leaving the workforce are replaced with employees of the same HIV status.

It is important to note that the prevalence estimates derived in this report differ to those reported by the MoHSS on HIV prevalence of ante-natal clinic attendees shown in the sentinel survey results (latest survey in 2008). The former prevalence rate reflects a workforce where allowance is made explicitly for entrants to and exits from the workforce. This implies that the workforce HIV prevalence should be lower.

The next stage in the investigation was to assess the additional cost in providing employee benefits and the business interruption costs that the Namibian Public Service could expect as a result of HIV and AIDS being a feature of the environment. The most significant costs arising from HIV and AIDS were the costs of lost productivity, including replacement and rehiring costs, and sick leave benefits. These HIV and AIDS additional costs are expected to add around 8.6% (of annual payroll) to the cost of operations over the next 10 years. These additional costs can be reduced by the availability of ART. Costs will fall by an average of 0.4% of annual basic payroll if Anti-Retrovial Therapy (ART) is introduced in 2008. It is noted that the bulk of this saving is as a result of a short term deferral in deaths/disabilities.

In valuing the benefits of ART above it is important to note that we have not considered indirect issues such as staff morale, cohesive workings of teams, institutional memory and other intangibles that clearly contribute to the well-being of a workforce. Also excluded is consideration of the broader positive effects that ART would have on the communities in which the workforce lives.

The following is a high level overview of the recommendations that could be considered by the OPM. The detail of key messages and recommendations have been done in each of the chapters:

The Office of the Prime Minister has not yet undertaken studies to measure productivity levels within the various O/M/As. We recommend that an exercise be undertaken to define productivity within the Public Sector.

We also recommend that the Government increases its annual HIV and AIDS allocation for workplace programmes from the current average of N$200 000 per O/M/A to an average depended on the employee size of the O/M/A using a rate of N$720.00 per employee per year.

The Public Service Sector Management Plan (2006-2009) of the OPM HIV and AIDS Unit aims to ensure that O/M/As have workplace programmes and that they mainstream HIV and AIDS into their core functions. There is a need to engage specialists to help O/M/As mainstream HIV and AIDS in their policies, practices, processes and strategic plans.

The extent to which the OPM as the lead-agency is equipped in terms of human skills to successfully discharge its co-ordinating roles and the authority with which it can enforce cooperation from O/M/As in the management of HIV and AIDS needs to be clearly spelt out with the objective of making it more effective.

The utilisation of the sick leave benefits requires proactive management. A process of verification and assessment of the validity of the sick leave applications may need to be done before any one employee is awarded excess sick leave days in any sick leave cycle. We further recommend that the sick leave capturing system be improved so that the collection, maintenance, update and analysis of sick leave taken and the resulting costs can be estimated more accurately.

PSEMAS currently does not have a HIV disease management programme for those beneficiaries of the scheme that require HIV and AIDS-related benefits. We recommend that the scheme implements an HIV disease management programme.

Access to the medical scheme risk pool is currently unrestricted in terms of eligibility requirements. This may pose entry constraints for the lower income earners. We recommend that the Public Sector as the employer assesses means by which to increase access to the medical scheme risk pool particularly for those currently uncovered lives where affordability is a barrier to access.

We also recommend that a much more effective and coordinated workplace programme for HIV and AIDS be implemented as part of an employee wellness programme. The workplace programmes should place a lot of emphasis on the availability of ART and the required supporting treatment, care and support. If the additional cost of providing Public Service Employees Medical Scheme (PSEMAS) membership to uncovered employees is greater than the 2.20% (of the uncovered employee’s annual payroll) required to provide ART directly, then we recommend that the Namibian Public Service provide ART through a workplace programme outside of the medical scheme. However, if the additional cost of providing PSEMAS membership to those uncovered employees is less than 2.20%, then it would be more cost effective to the Namibian Public Service to provide membership to PSEMAS, which would then allow those uncovered employees to access ART treatment through PSEMAS.

We recommend that the HIV prevalence modeling be re-calibrated every two years in order to reflect the results of the MoHSS ante-natal sentinel surveys that are conducted every two years.

Glossary of Terms

AIDS Acquired Immune Deficiency Syndrome

AIS Actuarial & Insurance Solutions

ART Anti-retroviral Treatment or Therapy

ASSA Actuarial Society of South Africa

CD4 Cluster of Differentiation 4

COIDA Compensation for Occupational Injuries and Disease Act

CTE Cost to Employer

EAP Employee Assistance Programme

GDP Gross Domestic Product

PSEMAS Public Service Employees Medical Aid Scheme

GIPF Government Institutions Pension Fund

GLM Generalised Linear Modelling

HIV Human Immunodeficiency Virus

HSRC Human Science Research Council

IEC Information and education campaigns

KABP Knowledge, Attitudes, Behaviour and Perceptions

MTCT Mother-to-Child Transmission

OMA Office, Ministry, Agency

PMB Prescribed Minimum Benefit

SHE Safety, Health, and Environment

SHI Social Health Insurance

STI Sexually Transmitted Infection

UNAIDS Joint United Nations Programme on HIV and AIDS

UNDP United Nations Development Programme

VCT Voluntary Counselling and Testing

WHO World Health Organisation

Table of Contents

Executive Summary

Glossary of Terms

PART I: QUALITATIVE DATA COLLECTION ................................................................ 8

Chapter One: Qualitative Data Collection and Methodology ..................................... 8

1.1 Methodology and Study Approach ...................................................................................................... 8

1.2 Sampling Approach and Survey Tools ................................................................................................ 8

1.3 Research Assumptions ........................................................................................................................ 9

1.4 Study Limitations ................................................................................................................................. 9

Chapter Two: Institutional Responses ...................................................................... 11

2.1 Strategic Responses ......................................................................................................................... 11

2.1.1 Policies........................................................................................................................................................ 11

2.1.2 Commitment ................................................................................................................................................ 11

2.1.3 Structure and Management ......................................................................................................................... 12

2.1.4 Budget......................................................................................................................................................... 12

2.2 Operational Responses ..................................................................................................................... 12

2.2.1 Perceptions ................................................................................................................................................. 12

2.2.2 Preparedness .............................................................................................................................................. 13

2.2.3 Effectiveness ............................................................................................................................................... 13

2.2.4 Focal Group Responses – HIV and AIDS Units/Committees ...................................................................... 13

2.3 Low Level Responses ....................................................................................................................... 13

2.3.1 Methodology ............................................................................................................................................... 13

2.3.2 Responses .................................................................................................................................................. 14

PART II: QUANTITATIVE DATA COLLECTION, METHODOLOGY AND MODELING RESULTS ...................................................................................................................... 15

Chapter Three: Quantitative Data Collection ............................................................ 15

3.1 Data Received ................................................................................................................................... 15

3.2 Data Analysis ..................................................................................................................................... 15

3.3 Average Age of Employees ............................................................................................................... 17

3.4 Age Distribution by Gender ............................................................................................................... 18

Chapter Four: HIV Prevalence Modelling Results ..................................................... 19

4.1 Overall HIV Prevalence Rates – No ART or Interventions ................................................................ 19

4.2 Overall HIV Prevalence Rates: Effect of New Entrant Assumption ................................................... 23

4.3 Overall HIV Prevalence Rates – Allowance for Interventions ........................................................... 24

4.4 Overall HIV Prevalence Rates – Allowance for Interventions and ART Introduction in 2004 and 2008 ................................................................................................................................................................. 25

4.5 Disease Staging................................................................................................................................. 26

Chapter Five: Cost Impact Analysis ........................................................................... 30

5.1 Economic Assumptions ..................................................................................................................... 30

5.1.1. Investment Returns and Inflation Assumptions .......................................................................................... 30

5.1.2.Proportion of Employees Starting Treatment .............................................................................................. 30

Resource Rich Assumptions ................................................................................................................................ 31

5.2 Assumptions relating to the benefit of intervening ............................................................................. 31

5.2.1. Pension Benefits ........................................................................................................................................ 31

5.2.2. Sick leave benefits ..................................................................................................................................... 33

5.2.3. Ancillary Insurance Benefits ....................................................................................................................... 34

5.2.4. Medical Aid Benefits .................................................................................................................................. 34

5.2.5. Maternity Benefits ...................................................................................................................................... 34

5.2.6. Retraining and Hiring Costs ....................................................................................................................... 35

5.2.7. Productivity Assumptions ........................................................................................................................... 35

5.3 Methodology ...................................................................................................................................... 36

Chapter Six: Costing Results Under Different Assumed Scenarios ....................... 38

6.1 The “No AIDS” Scenario .................................................................................................................... 38

6.2 The “With AIDS” Scenario ................................................................................................................. 39

6.3 The “With AIDS and ART” Scenarios ................................................................................................ 40

6.4 Summary of the Benefits of Providing ART ....................................................................................... 42

Chapter Seven: Costs of Providing Anti-Retroviral Therapy (ART) ........................ 44

7.1 Assumptions Relating to the Cost of Intervening .............................................................................. 45

7.1.1. Allowances for the Cost of Anti-Retroviral Therapy, Pathology Tests and Prophylaxis for Symptomatic Relief .................................................................................................................................................................... 45

7.1.2. Allowances for the Hospitalisation and Consultation Costs........................................................................ 47

7.2 Methodology ...................................................................................................................................... 47

7.2.1. Overall Costs of Providing ART, Pathology Costs and the Costs of Hospitalisation/Doctor Consultations ............................................................................................................................................................................. 48

7.3 The Cost and Benefit of Providing Anti-Retroviral Therapy .............................................................. 56

PART III: CONCLUSION ............................................................................................... 59

Chapter Eight: Conclusions and Recommendations ............................................... 59

8.1 Conclusions ....................................................................................................................................... 59

8.2 Recommendations ............................................................................................................................. 61

PART I: QUALITATIVE DATA COLLECTION

Chapter One: Qualitative Data Collection and Methodology

1.1 Methodology and Study Approach

Initial steps in carrying out an investigation of this magnitude is to carry out a desktop analysis of the strucuters of the Public Sector and HIV and AIDS literature. The analysis relates to reviewing the available documentation in the public and private domain. Key aims of this exercise are to;

Identify the key sub-sectors of the Public Sector e.g. the police service, teachers in the education sector, the medical fraternity etc. This is important since at the communication stage of the project the result of the exercise will need to focus on the key sub-sectors of the public service in great detail;

Identify the working environment and processes within the various sectors of the public service. An example would be rural working environment versus urban and office environment staff versus field staff;

Determine current constraints to service delivery and to what extent this could be attributed to the impact of HIV and AIDS;

Determine the HIV and AIDS programmes currently implemented in the different sectors, and

Assess how effective they have been and what needs to be done in order to improve their intended objective.

Based on the desktop analysis carried out the study then identified detailed data and information that needed to be collected for conducting the qualitative survey.

1.2 Sampling Approach and Survey Tools The magnitude of HIV and AIDS vulnerability and impact within the workplace depends on several factors. Consequently, for the purposes of this study, the 28 O/M/As have been classified into 7 categories. Size of O/M/A; perceived level of exposure to HIV infection within the workplace; perceived levels of mobility and geographical spread of employees; the strategic nature of the O/M/As in relation to HIV responses; existence of basic structures required in facilitating workplace programs; and geographical centrality of the O/M/A have been identified so as to ensure that O/M/As selected will reflect the different characteristics of the Public Sector. This criteria is further explained below. a. Size of O/M/A: refers to the category of O/M/As with 3,000 employees or more which are considered

to be relatively big; b. High exposure to HIV infection within the workplace: refers to the category of O/M/As whose work

environments are regarded as high risk environments in relation to HIV infection; c. High level of mobility: refers to the category of O/M/As whose mandate requires high levels of

travelling outside their usual place of work; d. Geographical spread of employees: refers to the category of O/M/As whose offices and employees

are fairly spread throughout the country; e. Strategic nature of O/M/A in relation to HIV responses: refers to the category of O/M/As whose

mandate has a significant impact on the Public Sector’s ability to implement sustainable HIV and AIDS response programs and the relationship of the O/M/A with the entire Public Sector;

f. Existence of basic structures required in facilitating workplace programs: refers to the category of O/M/As where the institutional structures required for the functioning of a good workplace program are perceived to exist; and

g. Geographical Centraity of the O/M/A: refers to the category of O/M/As whose operations are highly centralized in the national capital.

Table 1.1 gives a list of the different OMAs selected and interviewed for the current study. Classifications of the OMAs were based on the different categories outlined above.

Table 1.1: Classification of O/M/As into seven categories

Mobility Level - High

Geo- graphically

Spread

Centrally Domiciled

Strategically Positioned

Size - Very Big

Perceived Exposure

- High

Existence of Basic

Structures

MWT MoSS OPM MoF MoE MoHSS MFMR

MGECW MRLGHRD OP MTI MAWF

MME MoLSW Nat Assembly

MoFA

MLRR MoJ Nat Council

MICT MoHA MYNSSC

EC MET MoVA

ACC Source: Author’s Own Construct

Based on the above, 8 O/M/As, representing more than 80% of the total Public Sctor employees, have been selected from each of the 7 categories as samples for the study. It is however vital to note that these categorisations are not exhaustive and an element of overlap exists as some O/M/As perfectly fit into more than one category. The categorisation is only meant for the purposes of this study alone and should be treated as such. The O/M/As sampled are listed below. Table 1.2: O/M/As selected as a sample for the study

Criteria Selected O/M/A

Size – Very Big Ministry of Education and Ministry of Agriculture

Perceived Exposure - High Ministry of Health and Social Services,

Mobility Level - High

Ministry of Works and Transport

Geographically spread Ministry of Safety and Security

Strategically Positioned Ministry of Finance

Existence of Basic Structures Ministry of Fisheries and Marine Resources

Centrally Domiciled Office of the Prime Minister Source: Author’s own construct.

1.3 Research Assumptions A few issues have been assumed for the purposes of this study. For instance it has been assumed that there are particular characteristics that makes an O/M/A relatively more exposed to HIV and AIDS than others. It has also been assumed that the entire Public Sector can be clustered into 7 groups made up of O/M/As with common characteristics. Namibian geographical regions have also been assumed to directly influence the level of HIV and AIDS risks that the Public Sector employees domiciled in those regions find themselves exposed to. Further, age, gender, level of education, job grade and marital status have all been considered factors that influence the levels of HIV and AIDS risks that employees are exposed to.

1.4 Study Limitations By its very nature qualitative data is highly subjective. Every effort has been put to only obtain information from credible sources. This certainly has not been easy as defining what’s credible in itself is very depended on the situation at hand. Further, individuals are more naturally likely to express their personal opinion based on how they perceive their work environment in the context of HIV and AIDS. These personal opinions, although very much encouraged, may turn out to be inconsistent with the facts. A way to overcome this would be to phrase the same question in a variety of ways to one respondent in order to check for consistency. Also independent sources working within the same environments but with different operational mandates and authority were used for ensuring that the information collected does, with a high degree of probability, reflect the truth. Even where respondents strive to be as factual as possible there is an inherent risk of their perceptions of their HIV and AIDS environments being overshadowed by other socio-organisational issues. Ideally the study aims to single out the impact of HIV and AIDS on service delivery. Social ills like drug and alcohol

abuse as well as domestic violence might however have the effect of overshadowing the actual effects of the impact of HIV and AIDS. The study has ensured that the effects of these limitations are kept to a minimal.

Chapter Two: Institutional Responses

The survey made use of three data collection techniques, namely: (i) face-to-face interviews with top management; (ii) focus group discussions with mid-level management; and (iii) structured questionnaires with low-level employees distributed to the regions of the selected O/M/As. The analysis in this chapter summarizes the responses given by the respective respondents at each level. The different survey tools used in the survey are attached in the appendix of this report. The chapter is divided into sub-headings to reflect the sections covered at each level of management. The first section covers the strategic (top management) responses, the second section covers the operational (middle management) responses, while the last one covers the low-level employees’ responses.

2.1 Strategic Responses This section is divided into the following sub-sections based on the interview questions: policies; commitment; structure and management; and budget. The questions on policies are meant to find out: whether policies are in place and the efficiency of the respective offices responsible for drafting the policies within the O/M/As; whether there was a consultative process to drafting the policies; and the extent to which the institutional policies are drafted in line with the national policies on HIV and AIDS. The questions on commitment are meant to assess the level of leadership commitment towards HIV and AIDS management in the workplace i.e. whether HIV and AIDS have been mainstreamed in the strategic plans and the extent to which those activities are implemented. The questions on structure and management were to determine whether the O/M/As have created positions specifically for HIV and AIDS management. The authority of such office bearers in the Public Sector hierarchy is also assessed. The reason for addressing the above issues or questions is to measure the extent to which HIV and AIDS coordinators are empowered to influence decisions taken at management level. In addition, the question on Performance Management System (PMS) is to assess the level to which HIV and AIDS coordinators’ efforts are being recognized. However, since the OPM is responsible for implementing the PMS and it did not have it ready by the time the study was conducted, none of the other ministries had a functioning PMS.

2.1.1 Policies

There seem to be some guidelines or directives on how to manage HIV and AIDS in the workplace, but there are no functioning policies on HIV and AIDS for most of the O/M/As interviewed. For some, draft policies exist. Unfortunately implementation of programmes depends on final policies and not draft ones. For others they regard the guidelines for implementation as policies. Certainly this misunderstanding needs to be addressed quickly. It also appears that the OPM, which is expected to take the lead in enforcing rules and policies on HIV and AIDS Management within the Public Sector workplace, does not have a clear mandate to do so. This gives an indication that there is a need for a cabinet directive on HIV and AIDS management in the workplace within the Public Sector.

2.1.2 Commitment

Even though there seems to be a high level of commitment from the political leaders, a lot more needs to be done. There is a need to see top officers participating in voluntary HIV testing and to demonstrate that HIV and AIDS is just a disease like any other disease. This would encourage those infected and affected to approach and accept the impact of HIV and AIDS in a similar fashion that they view any other chronic diseases. The OPM is spearheading a process where all Permanent Secretaries (PS) are advised to have plans and allocate budgets for HIV and AIDS management in their respective workplaces. In the Third National Development Plan (NDPIII), mainstreaming of HIV and AIDS in all national development agenda of all O/M/As is a requirement. There are different forums where PSs are meeting to discuss HIV and AIDS related issues through the coordination of the United Nations Development Program (UNDP) and the OPM.

2.1.3 Structure and Management

Most of the HIV and AIDS Committees are chaired by the Permanent Secretaries or Directors of the respective O/M/As. In some the people responsible for implementing the programs (focal persons) are at the level of deputy directors and that helps facilitates the process as they form part of the institutional management team. In cases where the focal persons are at lower level positions, implementation of programmes through consultative efforts and support from top management becomes a challenge. Such focal persons lack the much-needed influential authority to effectively direct the management of HIV and AIDS within their O/M/As.

2.1.4 Budget

There is a need for a long term plan on how to manage HIV and AIDS as a chronic disease in the work place. This requires a co-ordinated and coherent plan to prepare for the future. According to the Ministry of Finance (MoF) the government allocated about N$886 million to the Public Service Medical Aid Scheme for the current fiscal year and project it to be about N$1 billion for 2010/2011 fiscal year, to cushion against the rising costs of medical care for civil servants. This is a significant allocation relative to the total annual budget of the MoF. In some cases the HIV and AIDS budget vote is centralized under the HIV and AIDS Unit, while in other cases each directorate submits its own budget request to deal with HIV and AIDS related matters in the workplace. Although most of the O/M/As have established centralized budget votes as required in the Third Medium Term Plan (MTPIII) those budget votes are mainly for HIV and AIDS awareness campaigns only such as pamphlets distribution and World AIDS Day celebrations. They are too small for case management, treatment, care and support in the workplace. There is lack of a standardised approach to HIV and AIDS management in the work place pausing great challenges in the implementation of any effective programmes within the sector. This leads to huge discrepancies in the amount of money allocated for HIV and AIDS management to different directorates. There is also no proper system of monitoring in place to ensure that money is put to the intended use. To a large extent directorates are not under any official mandate to submit audited financial reports of their budgeted activities on HIV and AIDS.

2.2 Operational Responses This section covers the responses from mid-level management. It includes questions for focal persons as implementers of programmes and also questions for chief control officers. The section is divided into perceptions, preparedness and effectiveness sub-headings.

2.2.1 Perceptions

The questions on perception were meant to find out whether staff members considered HIV and AIDS to be affecting performance and productivity in their areas. Responses to this question were mixed as some participants could not attribute the poor performance of their departments/directorates to HIV and AIDS alone, but rather to other factors, such as poor remuneration and recognition, low morale, lack of motivation, lack of resources, and illnesses like high blood pressure.

Perceptions of participants differed according to the level of progress achieved by their respective O/M/As with respect to the management of HIV and AIDS. The general view is that not much has happened to implement programmes geared towards the management of HIV and AIDS in the workplace within the Public Sector even though most O/M/As have established HIV and AIDS Units and Committees. Participants felt that the government has made significant progress to raise awareness at the national level but not much has happened within its own workplaces. As a result, people infected with or affected by HIV and AIDS do not really know what to do while they are on duty as they feel there are no structures for counselling, testing and treating HIV and AIDS employees within their O/M/As. Evidence shows that most of the O/M/As carry out activities with regard to HIV and AIDS such as celebrating World AIDS Day and distributing condoms but that seem to be all that the government is doing. According to the employees, the sources of information on HIV and AIDS are all external and do not come from within their workplaces. In most cases, only the focal persons of the HIV and AIDS Units

and, to some extent, the Human Resource Managers seem to be the only ones aware of the impacts of HIV and AIDS within their O/M/As as they are occasionally approached by those infected and affected seeking assistance. In rare cases, Human Resource Managers have very crude suspicions of the employees infected based on employee records on sick leave and general rate of absenteeism. HIV and AIDS is treated with a high degree of confidentiality among staff members. Employees do not feel free to release information about their HIV and AIDS status due to stigmatization. Confidentiality leaves managers with limited or no information to effectively manage the programmes making case management in the workplaces difficult. A need for a coherent programme, support and assistance has been emphasised quite strongly by the participants for better internal communication structures on HIV and AIDS matters.

2.2.2 Preparedness

The preparedness section was meant to determine whether policies and programmes are in place for effective management of HIV and AIDS within the Public Sector workplace. The majority of participants were aware of the draft national policy on HIV and AIDS for the Public Sector of 2008. Most of the internal policies are still in draft form as well. Participants were further aware of the Third Medium Term Plan (MTPIII), which outlines the role of each sector with respect to HIV and AIDS management at the workplace. HIV and AIDS is mentioned in the Strategic Plans of most O/M/As but little has been done to unpack the activities that deal with HIV and AIDS management into the day-to-day operations of the O/M/As. In terms of commitment of the O/M/As towards HIV and AIDS management in the workplace, some O/M/As assigned full time responsibilities to their HIV and AIDS Units to deal with HIV and AIDS matters in the workplace, while others are doing it on a part-time basis and regard their responsibilities towards HIV and AIDS issues as secondary. Again this non-standardised approach to dealing with HIV and AIDS within the Public Sector adds on to the reasons of why no major inroads have been made as yet in combating its impact within the sector.

2.2.3 Effectiveness

The effectiveness section was designed to evaluate the level of effectiveness of the policies and programmes in place. Since a majority of the O/M/As did not have functioning policies, with a few only having draft programmes, answers to these questions were not really in detail and hence no significant analysis could be conducted to assess the effectiveness of the policies.

2.2.4 Focal Group Responses – HIV and AIDS Units/Committees

The questions to the focal persons were basically targeted at finding out whether there are functioning HIV and AIDS Units and their roles in implementing the programmes to prevent, treat, give care, support and monitor HIV and AIDS cases at their workplaces. While other staff members were not much aware of HIV and AIDS programmes and their implementation, most of the focal persons seem to be doing something, even in the absence of proper guiding policies. Most of them however found our questions on how far they have gone with treatment, care and support and monitoring and evaluation to be quite advanced. The simple reason being that their budgetary allocations, lack of proper training and time would not allow them to fully roll out comprehensive workplace programmes.

2.3 Low Level Responses

2.3.1 Methodology

The low level employees included clerks and general labourers in all the thirteen regions of Namibia. They were given structured questionnaires to get their views on HIV and AIDS impact in the workplaces. The total number of questionnaires sent to all the regions was 7,100 and 1,520 questionnaires were returned giving a response rate of about 21.4%, which was relatively lower than expected. About 32% of the

respondents were male employees, while 58% were female employees and 10% of the respondents did not indicate their gender. All thirteen regions of the country were covered and respondents indicated from which region they were responding. There were 14 questions in total with three options to choose the answers from. The answers were one of either “No”, “Not Sure” or “Yes”. The questionnaire is attached in the appendix for details.

2.3.2 Responses

With regard to the knowledge of HIV and AIDS and its causes, about 92% of the respondents indicated that they know what HIV is and what causes it, 2% were not sure and the other 2% said they did not know. On the question of openness about HIV and AIDS with their colleagues, about 76% of the respondents indicated that they talk openly about HIV and AIDS with their colleagues, but 15% of the respondents felt that they do not talk openly about HIV and AIDS in the workplace. Relatively more female employees talk more about HIV and AIDS than their male colleagues. The rest of the respondents did not indicate their answers. On their willingness to get tested, about 83% of the respondents indicated that they were willing to have an HIV and AIDS test conducted at their workplaces. With reference to their status, 81% of the respondents knew their HIV status, 11% did not know, while 4% were not sure. On the prevention of HIV and AIDS, about 87% of the respondents believed that HIV and AIDS can be prevented, 4% did not believe that, and the remaining 5% were not sure. About 68% of the respondents knew who to talk to on HIV and AIDS matters, 28% were either not sure or did not know of whom to talk to. A later question however revealed that the respondents know mostly only people and centres in the public domain to talk to on HIV and AIDS matters and not those from within their own O/M/As. About 90% of the respondents expressed a willingness to learn more about HIV and AIDS, 3% would rather not learn anything more about HIV and AIDS and 3% were not sure. There was a question on whether respondents would be willing to work with a colleague who is HIV positive, and about 81% indicated that they did not mind working with someone who is HIV positive, 10% were not sure, while only 5% of the respondent indicated that they would rather not work with an HIV positive person. With regard to whether they would lose their job if they go for HIV and AIDS testing, about 79% of the respondents did not think that they would lose their jobs if they tested positive, 8% believed they would and only 8% of the respondents were not sure whether or not they would lose their jobs if they were found to be HIV positive. Concerning the employees’ awareness of existing programmes in their O/M/As, about 49% of the respondents showed that they were aware of the HIV and AIDS programmes within their respective O/M/As, but 46% were either not sure or were not aware of anything at all. With reference to the question on whether PSEMAS provides benefits to HIV and AIDS patients, 43% of the respondents believed that PSEMAS’ benefits are available to those who are HIV positive. 43% were not sure if PSEMAS provides medication to those who are HIV positive, while 10% did not believe that benefits from PSEMAS are available to those who are HIV positive. With regard to the role of the respective employers, about 32% of the respondents believed that their employers were doing enough to address HIV and AIDS at the workplaces, another 32% felt that their respective O/M/As were not doing enough, while 31% were not sure if what’s being done is enough or if more could be done. On the role of workers unions, about 17% of the respondents believed that the Public Service Union talks about HIV and AIDS issues, 40% were not sure and 38% felt that the union does not talk about HIV and AIDS issues. With reference to the question on information sessions, 63% indicated that they were aware of the HIV and AIDS information sessions conducted in their respective O/M/As, 16% were not aware and only 17% were not sure whether or not there were any HIV and AIDS sessions conducted in their respective O/M/As.

PART II: QUANTITATIVE DATA COLLECTION, METHODOLOGY AND MODELING RESULTS

Chapter Three: Quantitative Data Collection

The following section presents the demographic profiles for each O/M/A for static employees from the Namibian Public Service.

3.1 Data Received The analysis that follows is based on data received from the Office of the Prime Minister regarding the Namibian Public Service Service static employees as at 31 January, 2008. The following data has been received on a per employee basis:

Employee number

Date of employment

Date of exit

Exit reason

Date of birth

Gender

Pay-point

Application type

Pensionable salary per annum

Basic salary per annum

Medical aid

Medical aid benefit option

Medical aid employer contribution

Medical aid employee contribution

Place of work

Marital status

Number of dependants

Grading

O/M/A Code

Band level

Salary grade

3.2 Data Analysis Table 3.1 gives a high level summary of the data provided (for all O/M/As combined). Cost to employer (CTE) values represent the gross payment to employees, which include the additional costs over and above basic salary e.g. employer pension contribution and employer medical aid contribution.

Table 3.1: High Level Summary of Data

Age profile Number Aggregate

annual CTE

Average CTE

per individual

0-19 6 0% 125,748 0%

20-29 8,032 13% 478,248,268 12% 59,543

30-39 18,316 31% 1,272,763,578 31% 69,489

40-49 22,227 37% 1,557,417,549 38% 70,069

50-59 10,128 17% 726,487,165 18% 71,731

>60 873 1% 60,262,095 1% 69,029

59,582 4,095,304,404

Gender Number Aggregate

annual CTE

Average CTE

per individual

Male 27,867 47% 1,930,008,563 47% 69,258

Female 31,715 53% 2,165,295,841 53% 68,274

59,582 4,095,304,404

Grade Number Aggregate

annual CTE

Average CTE

per individual

Grade 5 134 0% 51,148,011 1% 381,702

Grade 4 3,356 6% 609,288,529 15% 181,552

Grade 3 15,274 26% 1,518,588,013 37% 99,423

Grade 2 12,379 21% 900,076,877 22% 72,710

Grade 1 28,439 48% 1,016,202,974 25% 35,733

59,582 4,095,304,404

Source: Author’s own construct.

It can be seen that the majority of employees are between the ages of 40 – 49 (37%), are female (53%) and are in job grade 3 (26%). There are also a small proportion of individuals aged over 60 years (1%). We have allocated employees to different job grades for the purpose of measuring HIV risk.

3.3 Average Age of Employees Table 3.2 shows the average age of total employees and the average age of employees joining after January 2007, from each O/M/A. Table 3.2: Average Age of Total Employees and the Average Age of Employees joining after January 2007

O/M/A Average Age

(Total Employees)

Percentage of Employees joining after

January 2007

Average Age of Employees joining after

January 2007

Ministry of Foreign Affairs 43.9 3.5% 38.0

Ministry of Health & Social Services 42.9 14.6% 31.6

Ministry of Environment & Tourism 42.6 4.2% 30.2

Ministry Of Works and Transport 42.0 8.0% 31.4

Ministry of Agriculture, Water And Forestry 41.7 6.2% 32.3

National Assembly 41.3 5.1% 34.3

Ministry of Safety & Security 41.2 3.2% 26.9

Ministry of Regional & Local Government & Housing & Rural Development

41.0 8.4% 31.7

National Council 40.7 3.4% 36.0

Ministry of Home Affairs and Immigration 40.6 10.0% 31.7

Office Of The Prime Minister 40.3 5.9% 30.4

Ministry of Education 40.2 8.8% 30.3

Ministry of Information Communication Technology

40.0 10.5% 30.1

Ministry of Lands & Resettlement 39.6 9.6% 29.6

Ministry of Gender Equality & Child Welfare 39.4 9.6% 33.1

Anti-Corruption Commission 39.3 9.5% 42.0

Ministry of Labour And Social Welfare 39.1 10.4% 31.9

Electoral Commission 39.0 10.0% 33.7

Ministry Of Youth, National Service, Sport & Culture

38.9 18.3% 32.5

Ministry of Fisheries 38.6 8.5% 29.9

Ministry of Mines & Energy 38.3 6.1% 29.5

Ministry of Trade & Industry 38.0 10.7% 27.8

Office Of The President 37.9 13.2% 30.2

Ministry of Veterans Affairs 37.5 57.4% 35.3

Ministry of Justice 36.8 12.1% 28.6

Ministry of Finance 36.4 7.5% 27.6

Total 40.8 8.4% 30.5

18

Analysis of Average Age of Employees As shown in table 3.2 it is evident that the average age of employees gaining employment in the public service since January 2007 is younger at 30.5 years compared to 40.8 years for current employees. The difference in these average ages is about 10 years indicating that the Public Service is attracting more younger employees than older ones. The Ministry of Foreign Affairs has the oldest employees on average (age of 43.9 years), whereas the Ministry of Finance has the youngest employees on average (age of 36.4 years). The Ministries of Education and Safety and Security have average ages of 40.2 and 41.2 years respectively. We can see that the Ministry of Veteran Affairs has the highest proportion (57.4%) of employees joining after January 2007. This is expected since this ministry was created recently in 2007. The Ministry of Safety and Security has the lowest (3.2%).

3.4 Age Distribution by Gender The distribution of age by gender as a percentage of the total workforce is shown in figure 3.1. Figure 3.1: Distribution of Age by Gender

0

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Nu

mb

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Age

Distribution of Age by Gender

Female Male

Analysis of Age Distribution by Gender The majority of the workforce are females between the ages of 35 and 54 years. It is evident that there is a slightly higher number of males than females in age groups older than 54 years. Overall, the workforce consists mainly of older females.

19

Chapter Four: HIV Prevalence Modelling Results

The HIV prevalence modelling results have been determined by allowing for no growth in the workforce, where existing members exiting the workforce are replaced by new entrants of the same current demographic profile. As shown in the assumptions section, we have used the decrement rates provided by the GIPF. We have also assumed that there are selective entrants into the workforce.

4.1 Overall HIV Prevalence Rates – No ART or Interventions The curve below summarises the projected HIV prevalence rates for all O/M/As combined, allowing only for maintaining the population size and not allowing for further expected increases or decreases. These rates make no allowance for the provision of ART or interventions. We have also included comparative point estimates of prevalence rates from various public sources, including the prevalence rates for Namibia (UNAIDS), as well as individual Namibian company prevalence rates (Nampower and Namdeb). We have included a best estimate curve as well as low and high estimate curves, based on these comparative point estimates. Figure 4.1: Modelled HIV Prevalence in All O/M/As (with comparative point estimates) – No interventions, No ART

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

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HIV

Pre

va

len

ce

Year

Modelled HIV Prevalence in All O/M/A's

(with comparitive point estimates)

No ART (Best estimate) No ART (High estimate)

No ART (Low estimate) UNAIDS Global Report 2006 Data

UNAIDS, 2000 UNAIDS, 2002

UNAIDS, 2004 Report on the Global AIDS Epidemic Nampower Press Release, 2002

Namdeb, 2001

The point estimates taken from the Joint United Nations Programme on HIV and AIDS (UNAIDS) were based on sero-surveillance for antenatal care attendees. This may explain why the estimates are higher than the modelled prevalence, as the model takes into account both male and female workers, while the UNAIDS estimates are based solely on pregnant women, who tend to have higher HIV prevalence rates. The point estimates for both Nampower (Namibia’s national power utility) and Namdeb (largest diamond mining company in Namibia) were based on voluntary tests of employees. This could have lead to an underestimate of the actual prevalence, as employees who were HIV+ may not have volunteered to take part in the testing. In the overview of HIV and AIDS section of this report WHO/UNAIDS estimate that HIV prevalence within Namibia has remained at approximately 15% from 2001 to 2007. According to our model, HIV prevalence for the Namibian Public Service has decreased gradually from 17.2% in 2001 to 14.9% in 2007. This is a result of the differences in the

demographic profile of Namibian Public Service employees compared to the entire Namibian population. When modelling the HIV prevalence within the workforce, our model makes use of several factors, including salary grade as an indication of skill level. The curve below shows a comparison of our projected HIV prevalence rates for all O/M/As combined, to those shown in the Ministry of Health and Social Services’ Report on the 2008 National HIV Sentinel Survey. It can be seen that the curve for the HIV prevalence for O/M/As peaks at a similar point in time to the peak for the HIV Sentinel Survey results (approximately 2002), albeit at a lower level as expected given the differences in the demographic characteristics of the underlying populations. Figure 4.2: Modelled HIV Prevalence in All O/M/As (with 2008 National HIV Sentinel Survey comparative point estimates) – No interventions, No ART

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

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HIV

Pre

va

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ce

Year

Modelled HIV Prevalence in All O/M/A's

(with comparitive point estimates)

No ART (Best estimate) No ART (High estimate)

No ART (Low estimate) National HIV Sentinel Survey (2008)

HIV prevalence is defined as the proportion of individuals in the population who are infected at a given point in time. The number of HIV infections is driven by the incidence rate, which is the frequency of occurrence of new infections. From the graph, we can see that the prevalence rates increase initially as the incidence rates increase. The gradual decrease in the incidence rates, combined with the HIV associated deaths, results in the downward shape of the curve after 2002. For the 3-year period from 2008 to 2010, the prevalence rates decrease from 13.5% to 10.7%, as a result of the decrease in incidence rates and increase in number of deaths. The modelling process as demonstrated above was then repeated for each O/M/A. The three graphs below show the prevalence rates by O/M/A separated into three range categories; low, medium and high. These categories were formed relative to the prevalence rate for all O/M/As combined (which is shown in all three graphs) for illustrative purposes. If an O/M/A had a maximum prevalence rate lower than the maximum prevalence rate for all O/M/As combined, it was classified as low prevalence. If the O/M/A had a maximum prevalence rate much higher than the maximum prevalence rate for all O/M/As combined, it was classified as high prevalence. All other O/M/As with prevalence rates similar to the overall prevalence rates were classified as medium prevalence.

21

Figure 4.3: Modelled HIV Prevalence – O/M/As with Low Prevalence

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20.00%

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HIV

Pre

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Modelled HIV Prevalence - O/M/A's with Low Prevalence

FA Vet Aff ACC

OPM EC Nat Assembly

Education Fisheries All O/M/A's Combined

Figure 4.4: Modelled HIV Prevalence – O/M/As with Medium Prevalence

0.00%

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4.00%

6.00%

8.00%

10.00%

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Modelled HIV Prevalence - O/M/A's with Medium Prevalence

Justice L & SW M & E

I & B L & R OP

Nat Council Finance R & LG & H & RD

All O/M/A's Combined

22

Figure 4.5: Modelled HIV Prevalence – O/M/As with High Prevalence

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25.00%

30.00%

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Modelled HIV Prevalence - O/M/A's with High Prevalence

H & SS T & I W, T & C

Y, NS, S & C GE & CW Saf & Sec

E & T HA & I AWF

All O/M/A's Combined

From figure 4.3 to figure 4.5 it can be seen that the demographics of each O/M/A are linked to the prevalence rates. The shape of the graph for each O/M/A is determined by a combination of factors, including gender composition, age distribution and salary grade composition. Those O/M/As with a higher proportion of female employees, a higher proportion of younger employees and lower average salary have a higher HIV prevalence rate, when compared to the other O/M/As. For example, if comparing the Ministry of Trade and Industry (T&I) and the Office of the Prime Minister (OPM), we can see that T&I has a higher proportion of women (51.6% versus 49.4%), a higher proportion of employees under age 30 (64.1% versus 53.6%) and a higher number of employees earning in the N$0 – N$50,000 range (33.3% versus 26.6%). This may explain why T&I is estimated to have a higher maximum prevalence rate than OPM (20.5% versus 14.0%). We also determined the prevalence rate by salary grade.

23

Figure 4.6: Modelled HIV Prevalence by Salary Grade – All O/M/As (No ART or Interventions)

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30.00%

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Pre

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Modelled HIV Prevalence by Salary Grade - All O/M/A's (No ART or Interventions)

All Low Med LowMed Med high High

From this graph, we can see that the higher salary grades have lower HIV incidence rates (the high salary grade has an incidence of about 1% in 2002 compared to 21% for the low salary grade). By comparing these curves to the curve for all combined, it becomes apparent that majority of the workers are in the medium-low salary grade.

4.2 Overall HIV Prevalence Rates: Effect of New Entrant Assumption In the assumptions section of the report, we set out that new entrants into the workforce are less likely to be as sick as existing employees. This is because we have assumed that an individual in HIV stage 4 would mostly likely be quite ill and may therefore struggle to be successful in getting a new job. If we remove this assumption and assume that the new entrants to the workforce have the same probability of getting a new job irrespective of HIV status, we have the following entrants per stage: Table 4.1: Modified New Entrant Bases (no selective entrants) – Likelihood of being in each HIV Stage

The resulting HIV prevalence rate of the workforce does not decrease as significantly in this case as the employees exiting the workforce are replaced with new entrants of a similar HIV status. Figure 4.7: HIV Prevalence in All O/M/As – Modified Entrant Assumption

HIV Stage 1 HIV Stage 2 HIV Stage 3 HIV Stage 4

Current Practice 100% 100%

100%

100%

Relative proportion of new entrants who are HIV+ (compared to an

identical current member) New Entrant Testing Protocol

0.00%

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HIV

Pre

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Modelled HIV Prevalence in All O/M/A's

No ART No ART (modified entrant assumption - no selective entrants)

For the remainder of the report we show results using the assumption for selective entrants; in other words, we assume that the profile of new entrants will be healthier than the existing employees.

4.3 Overall HIV Prevalence Rates – Allowance for Interventions The curve below summarises the projected HIV prevalence rates, both with and without the allowance for interventions. From this, we can see that the introduction of interventions causes the prevalence rates to decrease. This is driven by a decrease in the incidence rates. Allowing for interventions results in a decrease in the maximum prevalence rate (16.9% versus 17.5% at 2002), as well as a faster decrease in the prevalence rates thereafter.

25

Figure 4.8: HIV Prevalence in All O/M/As – Allowance for Interventions

0.00%

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HIV Prevalence in All O/M/A's

No ART No ART with Interventions

4.4 Overall HIV Prevalence Rates – Allowance for Interventions and ART Introduction in 2004 and 2008 Figure 4.9 below summarises the projected HIV prevalence rates based on the resource rich assumptions as defined by the WHO (ART commences when the CD4 count of an HIV-positive person drops below 350), with and without the allowance for interventions and ART introduction in 2004 or 2008. From these, we can see that the introduction of interventions, combined with the introduction of ART causes the incidence rates to decrease. Again, we see that the allowance for interventions results in lowering of the maximum prevalence rate. Figure 4.9: HIV Prevalence in All O/M/As – Allowance for Interventions and ART (Resource Rich Scenario)

0.00%

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HIV

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HIV Prevalence in All O/M/A's

2004 ART 2004 ART with Interventions

2008 ART 2008 ART with Interventions

From figure 4.9 above, we can see that after the introduction of ART, there is a period in which the prevalence does not decrease as rapidly as if there was no ART introduction. This is because, after the introduction of ART, those individuals who receive the treatment (HIV Stage 3 and HIV stage 4

individuals) are expected to live longer. Therefore, even though the number of new HIV cases is not increasing, those surviviors are included in the HIV prevalence rate. This explains why the decrease is not as pronounced as in the no ART scenario. It also becomes clear that allowing for interventions results in a quicker decrease in prevalence after the introduction of ART, than in the case with no interventions. Summary of the projected HIV prevalence rates based on the resource limited assumptions (ART commences when the CD4 count of an HIV-positive person drops below 200), with and without the allowance for interventions and ART introduction in 2004 or 2008 is shown in figure 4.10. Again, from these we can see that the introduction of interventions, combined with the introduction of ART causes the prevalence rates to decrease. We also see again that the allowance for interventions results in lowering of the maximum prevalence rate. Figure 4.10: HIV Prevalence in All O/M/As – Allowance for Interventions and ART (Resource Limited Scenario)

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HIV Prevalence in All O/M/A's

2004 ART (57% uptake) 2004 ART with Interventions (57% uptake)

2008 ART (57% uptake) 2008 ART with Interventions (57% uptake)

Comparing the resource limited graphs above (ART commences when the CD4 count of an HIV-positive person drops below 200) to their resource rich counterparts we can see that the maximum prevalence rates for the resource limited scenarios are slightly lower than those in the resource rich scenarios. This is because, under the resource limited scenario, employees receive treatment at a later stage (0% in Stage 3 and 57% in stage 4, compared to 60% in Stage 3 and 80% in Stage 4). This results in an increased number of deaths under the resource limited scenario, which reduces the prevalence rates. The introduction of ART as part of a work-place programme is generally done on the basis of a resource-rich setting, i.e. treatment from CD4 cell count below 350. This is in line with the recommended protocols adopted by medical aid schemes and many employer groups. On this basis, it can be seen that HIV-positive employees have better survival prospects and are therefore healthier and more productive.

4.5 Disease Staging We have considered both a resource rich and resource limited scenario. For the resource rich scenario, the disease is split into 6 distinct disease stages:

HIV stage 1

HIV stage 2

HIV stage 3

HIV stage 4 (AIDS)

ART stage 1 (first line treatment at HIV stage 3 – 200<CD4<350 with 60% uptake)

ART stage 2 (second line treatment at HIV stage 4 – CD4<200 with 80% uptake) For the resource limited scenario, the disease is split into 5 distinct disease stages:

HIV stage 1

HIV stage 2

HIV stage 3

HIV stage 4 (AIDS)

ART stage 1 (first line treatment at HIV stage 4 – CD4<200 with 57% uptake)

The results per disease stage are summarised in the graphs below. Figure 4.11: Prevalence per HIV Disease Stage for All O/M/As – No ART

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Prevalence per HIV Disease Stage for No ART - All O/M/A's

HIV stage 1 HIV stage 2 HIV stage 3 HIV stage 4

At most 4.0% of workers of the entire workforce are expected to reach HIV stage 3 (in 2004). With the availability of ART we expect that the proportion within this stage will reduce significantly over time as the infected workers begin ART. In the resource rich scenario modelling of this progression, we have assumed that 60% of workers in HIV stage 3 take up ART in each year. This is shown in figures 4.12 and 4.13, in which ART is introduced in 2004 or in 2008. Figure 4.12: Resource Rich Scenario: Prevalence per HIV Disease Stage for All O/M/As – Interventions and 2004 ART

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Prevalence per HIV Disease Stage for ART Introduction in 2004 with Interventions

HIV stage 1 HIV stage 2 HIV stage 3

HIV stage 4 Total HIV and ART1 Total HIV and ART2

Figure 4.13: Resource Rich Scenario: Prevalence per HIV Disease Stage for All O/M/As – Interventions and 2008 ART

0.00%

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12.00%19

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Prevalence per HIV Disease Stage for ART Introduction in 2008 with Interventions

HIV stage 1 HIV stage 2 HIV stage 3

HIV stage 4 Toatl HIV and ART1 Total HIV and ART2

From these graphs above, we can see that movements to the final stage of the disease (HIV stage 4 or AIDS) fall sharply after the introduction of ART (in both 2004 and 2008). The proportions in this stage are then expected to increase again as more HIV-positive workers deteriorate to this stage. Since treatment is expected to be administered in HIV stage 3 (60% in each year) and 80% of those in HIV stage 4, we expect a low proportion of workers to reach this stage. In the resource limited scenario modelling of this progression, we have assumed that 57% of workers in HIV stage 4 take up ART in each year. This is shown in the graphs below, in which ART is introduced in 2004 and 2008. Figure 4.14: Resource Limited Scenario: Prevalence per HIV Disease Stage for All O/M/As – Interventions and 2004 ART

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HIV stage 1 HIV stage 2 HIV stage 3

HIV stage 4 Total HIV and ART1

Figure 4.15: Resource Limited Scenario: Prevalence per HIV Disease Stage for All O/M/As – Interventions and 2004 ART

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Prevalence per HIV Disease Stage for ART Introduction in 2008 with Interventions (57% uptake)

HIV stage 1 HIV stage 2 HIV stage 3

HIV stage 4 Total HIV and ART1

Comparing the resource limited graphs above to their resource rich counterparts; we can see that after the introduction of ART (for both 2004 and 2008), the HIV Stage 3 prevalence rates for the resource limited scenarios are higher than those in the resource rich scenarios. This is expected as under the resource limited assumptions, there is no ART introduction for HIV Stage 3. Also, the HIV Stage 4 prevalence rates under the resource limited assumptions are also higher than their resource rich counterparts. This is because under the resource limited assumptions, only 57% of HIV+ individuals at this stage are receiving treatment, whereas under the resource rich assumptions 80% of HIV+ individuals are receiving treatment. Note that we are not looking at two roll out plans – only at one in 2004 (based on public health sector availability) or 2008 (based on employer provision).

30

Chapter Five: Cost Impact Analysis

In this section of the report, we set out the cost impact analysis for the Namibian Public Service. It is important to note that the results obtained in this section depend on the HIV prevalence results obtained in the previous sections of the report. Therefore, the cost results should be interpreted in the context of the HIV prevalence results generated.

5.1 Economic Assumptions

5.1.1. Investment Returns and Inflation Assumptions

We have assumed that the Namibian Public Service working capital or surplus funds earn a return of 12% per annum. This was based on the yield of the GC10 Namibian Capital Market Instrument (The Republic of Namibia Internal Registered Stock, reported by IJG Securities (November 2008)). We have assumed that standard price inflation (CPI inflation) amounts to 9.9%. This was based on an average of the year to date 2008 Namibia CPI values reported by the Namibia Economist. Furthermore, we have assumed that salaries grow by 10.9% per annum, and that medical costs rise by 11.4% pa. Note that it is not the absolute levels of these assumptions that are important, but rather the relationships between them.

5.1.2.Proportion of Employees Starting Treatment

As mentioned previously, we assume that employees have access to ART and we have allowed for: The potential that not all staff will register for the treatment, and for those that do, not all will manage to adhere to the treatment protocol, due to the high toxicity of some of the drugs. That those employees who are receiving treatment, are expected to remain alive for longer (than without treatment), and hence the proportion of employed staff who are HIV+, is expected to grow over time. We have performed our costing analysis under two different scenarios. The table below shows the assumptions for the first scenario, in which ART treatment is assumed to be available from 2004 onwards. Table 5.1: Resource Limited Assumptions - Proportion of Members Starting Treatment in each HIV State (2004)

Analysis of Table 5.1

Table 5.1 shows the assumption that 43% of individuals in HIV stage 3 are expected to start ART in each year. The corresponding amount for those in HIV stage 4 is 74%. These modified uptake rates were determined as follows: For HIV Stage 3: The proportion of employees on medical aid (71.8%) was applied to the 60% HIV Stage 3 ART uptake rate (according to WHO clinical guidelines in resource rich settings). This reflects the assumption that those employees who are on medical aid have access to ART treatment when

HIV Stage 1 HIV Stage 2 HIV Stage 3 HIV Stage 4

0% 0% 43% 74%

Proportion of members starting treatment in each HIV state

pa

Type of anti-retroviral therapy Average number of months

Triple Therapy 60

their CD4 count drops below 350, while those employees who are not on a medical aid scheme are not (resource limited scenario). For HIV Stage 4: The proportion of employees on medical aid (71.8%) was applied to the 80% HIV Stage 4 ART uptake rate (according to WHO clinical guidelines in resource rich settings), while the proportion of employees not on medical aid (28.2%) was applied to the 57% ART uptake rate determined previously in Section 5 of this report.

Resource Rich Assumptions

Table 5.2 shows the assumptions for the second scenario, in which ART treatment is assumed to be available from 2008 onwards.

Table 5.2: Resource Rich Assumptions - Proportion of Members Starting Treatment in each HIV State (2008)

Table 5.2 shows the assumption that 60% of individuals in HIV stage 3 are expected to start ART in each year. The corresponding amount for those in HIV stage 4 is 80%. These uptake rates reflect the scenario whereby treatment is made available according to WHO clinical guidelines in resource rich settings.

5.2 Assumptions relating to the benefit of intervening

5.2.1. Pension Benefits

The additional cost of pension benefits as a result of HIV and AIDS is a direct cost to the employer and the extent depends on the benefit structure offered to members and their dependents. A benefit structure that favours death benefits will incur higher cost impacts as mortality will rise as a result of HIV. On the other hand, a benefit structure that favours annuity benefits will incur cost reductions since the benefits will most likely be paid out for shorter periods. We were provided with the current Government Institutions Pension Fund (GIPF) rules. Members participate in a defined benefit scheme. Every member contributes to the Fund at a rate of 7.0% of his or her pensionable emoluments, with a further contribution coming from the employer. The latter amount is in essence a salary sacrifice out of the CTE. In the context of our calculations the impact of HIV and AIDS on the pension costs to the Namibian Public Service are indirect, with no additional cost, as the direct cost is borne out of CTE. HIV and AIDS could have a potential impact on the GIPF defined benefit scheme in the future. This would have to be determined in the next actuarial valuation of the GIPF Fund. We were also provided with the most recent (2006) Report on the Actuarial Valuation of the Government Institutions Pension Fund (GIPF). In this report, the authors stated that the Fund has an AIDS reserve, set at 8% of the Fund’s liability in respect to active members. This was determined using a statistical model to assess the impact of worsening HIV and AIDS experience in Namibia.

HIV Stage 1 HIV Stage 2 HIV Stage 3 HIV Stage 4

0% 0% 60% 80%

Proportion of members starting treatment in each HIV state pa

Type of anti-retroviral therapy Average number of months

Triple Therapy 60

According to the authors, at the valuation date the Fund was “fully funded”, with a funding level of 111.9%, and a surplus of N$2.292 billion. Given that the Fund was fully funded at the most recent actuarial valuation and that there has been an AIDS reserve set aside to provide for the liability arising as a result of the impact of HIV and AIDS on the Fund, we have assumed that for the purposes of this study, the cost impact of HIV and AIDS has already been allowed for within the contributions to the GIPF from both the employer and the employee. We have therefore not modelled this cost separately as it has already been allowed for implicitly within the cost of employment.

33

5.2.2. Sick leave benefits

The cost of sick leave benefits is a direct cost to the employer. We performed the sick leave analysis by O/M/A. Below is a summary of the average 2004 to 2007 actual sick leave days taken by the employees for each O/M/A. The total cost of these sick leave days taken was not indicated in the data provided, so an average or total cost of sick leave could not be determined. Table 5.3: Average Actual Sick Leave by O/M/A (2004 – 2007)

O/M/A 2004 2005 2006 2007 Average

Electoral Commission 10.81 13.11 9.83 8.31 10.52

Ministry Of Agriculture Water And Forestry 22.00 7.40 12.75 6.25 12.10

Ministry Of Education 1.00 1.00 1.00

Ministry Of Environment And Tourism 7.75 5.77 6.03 1.00 5.14

Ministry Of Finance 6.76 6.58 7.02 7.19 6.89

Ministry Of Fisheries & Marine Resources 4.47 2.00 3.24

Ministry Of Foreign Affairs 10.91 8.47 12.16 8.69 10.06

Ministry Of Gender Equality & Child Welfare 2.00 2.00 2.00

Ministry Of Health And Social Services 11.24 10.42 12.24 11.08 11.24

Ministry Of Home Affairs And Immigration 4.36 3.00 3.68

Ministry Of Information And Communication Technology 2.00 8.00 3.00 4.33

Ministry Of Justice 7.12 7.05 8.22 7.49 7.47

Ministry Of Labour And Social Welfare 6.73 7.82 6.76 7.89 7.30

Ministry Of Lands And Resettlement 11.82 11.20 10.92 12.24 11.54

Ministry Of Mines And Energy 11.11 12.02 15.70 15.20 13.51

Ministry Of Trade And Industry 8.00 2.00 2.00 4.00

Ministry Of Veterans Affairs 1.50 44.00 8.00 2.56 14.01

Ministry Of Works Transport And Communication 2.00 17.33 9.67

National Assembly 10.26 8.23 10.86 11.98 10.33

National Council 16.00 29.09 9.54 11.89 16.63

National Planning Commission Secretariat 10.08 7.09 11.44 5.91 8.63

Office Of The Auditor General 2.00 2.71 3.27 4.33 3.08

Office Of The President 10.55 9.08 9.00 8.38 9.25

Office Of The Prime Minister 8.61 5.83 8.89 5.00 7.08

All O/M/A's Combined - Weighted Average 12.23 8.09 11.10 8.30 9.65

34

From this table, we can see that an overall weighted average of 9.65 sick leave days have been taken per employee over the period 2004 to 2007. We were unable to determine which of these sick days were due to HIV complications as this is not reported. We have excluded the Ministry of Education in the overall weighted average calculation as we believe the data for this O/M/A is incomplete and would result in a significant underestimation of the actual average sick leave days taken. We have been informed by the Office of the Prime Minister that employees are afforded a maximum of 132 sick leave days on full pay and a further 132 sick leave days on half pay in any period of 36 months. On the basis of this leave allowance, we believe that the results derived above are significantly understated. The result of this is that the costs of sick leave benefits to the employer as a result of HIV and AIDS are under-stated. It is recommended that the Public Service conducts an investigation into sick leave experience in order to derive accurate estimates of the number of sick leave days taken (at full pay and at half pay) as well as the corresponding costs. We have therefore assumed that employees will take the following sick leave pa (by HIV state) based on full pay: Table 5.4: Assumptions: Paid Sick Leave by HIV Stage

HIV Negative 9.70

HIV Stage 1 12.00

HIV Stage 2 14.30

HIV Stage 3 16.50

HIV Stage 4 18.80

For Employees in Receipt of ART 12.00

HIV State Paid Sick Leave pa

We have also assumed that an individual takes 3 days sick leave if they become HIV+ (some individuals experience “sero-conversion illness” – where individuals experience cold-like symptoms on sero-conversion).

5.2.3. Ancillary Insurance Benefits

We have not allowed for group funeral benefits, as these are offered through the GIPF. In the context of our calculations, the impact of HIV and AIDS on these costs to the Namibian Public Service is indirect, as the direct cost is borne out of CTE.

5.2.4. Medical Aid Benefits

It is the employee’s decision whether or not to join PSEMAS. From our demographic profile analysis it was determined that 71.8% of the workforce belong to PSEMAS. Treatment for HIV and AIDS is included under the benefits of PSEMAS, albeit implicitly. We requested claims data from PSEMAS in order to conduct an analysis of the cost of claims as a result of HIV and AIDS. Unfortunately the data that we received was not sufficient to facilitate such an analysis as it requires access to detailed claims data. Given that PSEMAS does not have an HIV disease management programme in place and that there is no collection of data relating to HIV and AIDS related claims, there is little scope for the medical scheme to manage such costs or report on such impacts to the employer. We have therefore not been able to quantify the extent to which members’ contributions may be expected to change given the HIV and AIDS environment and other issues facing the industry. However, the Namibian Public Service should monitor how this environment changes to modify its strategy if appropriate.

5.2.5. Maternity Benefits

Maternity benefits are a direct cost for the employer. We have allowed for 3 month maternity benefits for all females. We have used the following fertility assumptions for females between the ages of 20 and 45. In the table below it can be seen that the fertility rate decreases as the job grade increases. In addition to this, the DHS 2006-07 report states that the preference for higher fertility is in the rural areas relative to the urban areas (4.3 versus 2.8 respectively).

Table 5.5: Assumptions: Fertility by Salary Grade

Fertility

Grade 1 4.50

Grade 2 4.00

Grade 3 3.00

Grade 4 2.00

Grade 5 2.00

STAFF CATEGORY (SALARY GRADE)Fertility Pre-AIDS

Source

1: Kalavakonda (2005)

We have also allowed for a reduction in fertility for women who are HIV-positive, which varies by age

2.

These age-specific assumptions about fertility are based on analyses of censuses on which the ASSA2003 model is based.

5.2.6. Retraining and Hiring Costs

Retraining and hiring costs are an indirect cost for the employer. In the event that an individual withdraws or dies, the company would need to replace the vacant position. Doing so results in a company incurring hiring costs (such as advertising costs/commission costs/HR costs etc), as well as retraining costs as new employees need time to “catch up”. We have summarised the assumptions made in relation to these costs in the table below. All figures are based on a multiple of one month’s salary. Table 5.6: Assumptions: Retraining and Hiring Costs

Expected

Withdrawals

Unexpected

Death/Disability

Grade 1 1.00 3.50 0.50 2.00

Grade 2 1.00 2.50 0.50 2.00

Grade 3 1.00 2.50 0.50 2.00

Grade 4 1.00 2.00 0.50 2.00

Grade 5 1.00 2.00 0.50 2.00

No of Months From

Multiple of Monthly Pay To Full Production

Replacement CostsRetraining CostsStaff Category

We have allowed for the fact that a voluntary withdrawal is usually preceded with notice, and hence a company may be able to hire and train the replacement without significant business interruption. Generally however, one would expect some business interruption to occur. Unexpected death/disability would result in a longer period of time before the replacement becomes productive. It is important to note that the table above reflects costs that are based on results derived from various studies. We were unable to obtain specific costs from the Office of the Prime Minister and therefore the actual costs incurred for retraining and hiring costs may be over-stated or under-stated.

5.2.7. Productivity Assumptions

The cost of lost productivity is an indirect cost for the employer. This is a significant assumption with respect to impact on costs. The cost to a company of an individual taking paid leave (for example) exceeds the cost of the individual’s salary. The true cost, represents the

1 Vijayasekar Kalavakonda (2005). Managing HIV/Aids Risk: An Enterprise Risk Management Model. World Bank

2 ASSA2003 Select Model. Actuarial Society of South Africa.

value of the lost productivity, (or the forgone “opportunity cost”) whilst the individual is not working. There are very few studies conducted in this field

3. The table below summarises the assumptions made by

employee category: Table 5.7: Assumptions: Productivity by Salary Grade

Staff Category

Ratio of Productive

Capacity to Salary

Grade 1 3.00x

Grade 2 2.50x

Grade 3 2.50x

Grade 4 2.00x

Grade 5 2.00x

The assumption is used when assessing the cost to the company as a result of lost productivity associated with voluntary withdrawal, death, disability and sick leave. For productivity, we have also referred to various studies conducted on productivity within different employers. Unfortunately we were not able to obtain specific productivity assumptions from the Office of the Prime Minister relating to lost productivity within the particular workforce. Therefore, the costs of productivity calculated in this study may be higher or lower than the actual costs. In order to verify this, the Office of the Prime Minister would need to undertake productivity studies in various O/M/As.

5.3 Methodology The next stage in the investigation was to assess the additional cost in providing employee benefits and the business interruption costs that the Namibian Public Service could expect as a result of HIV and AIDS being a feature of the environment. This was done in the following manner: Based on the demographic projections, we modeled all the benefits provided by the Namibian Public Service to their employees as well as any business interruption costs associated with the HIV and AIDS epidemic. The following factors were specifically considered and modeled for all current and new employees: The sick leave benefits provided by the Namibian Public Service; The maternity benefits provided by the Namibian Public Service; We also made allowances for the cost of retraining and costs associated with the hiring of new employees in the event of death/withdrawal of an employee; and Finally, allowances were also needed for the lost productivity associated with sick leave, and death/disability of the employee. When modeling the effects of AIDS, we compared the effects of all the above items, for a given employee. The computer model was run twice for each employee; under the first scenario the effect of AIDS was ignored, and under the second scenario the effects of AIDS were allowed for fully. The cost of AIDS to the employer (for the employee in question) was then taken as the differences between this scenario and the previously computed value. The total impact of AIDS was derived by summing the resultant costs for all current and new employees. When assessing costs we discounted all future employee benefit outgo and expected company costs, to derive a capitalised value as a percentage of basic payroll. Each employee was analysed and modeled separately. The curve below shows as an example, the projected demographic development for a 36 year-old female in Grade 2. The reader should note that we have not considered the costs for dependents of employees. This information was not available in order to perform the analysis. Therefore, should cover be extended to the families of employees, the total cost will need to be determined with reference to the number of dependents.

3 We have made reference to the following studies and interviews in the assessment of this assumption: Greener (1997); BIDPA

(2000); Groth and Maffessanti (2002); Dunn (2002); Morris (2000) and Rosen (2000)

The Namibian Public Service’s projected staff profile decreases as members die, retire and withdraw. We have assumed that the Namibian Public Service is expected to broadly maintain its staff complement, recruiting new members to replace those that leave/die. There are 3 main bases that can be used to allow for new members. These are: The Namibian Public Service does not test prospective employees in any way; The Namibian Public Service insists that all new employees pass an HIV test; and The Namibian Public Service naturally appoints new employees that are reasonably medically fit, but not necessarily HIV negative. The first option is highly unlikely to be followed, and whilst the second option will reduce the HIV sero-prevalence level amongst the Namibian Public Service’s staff substantially over time, this option is currently fraught with legal and moral problems. Hence we have assumed that the last option above is followed, as this is the most probable course of action. The total impact to the Namibian Public Service was derived by summing the resultant costs for all current and new employees, and weighting the results by salary.

38

Chapter Six: Costing Results Under Different Assumed Scenarios

Based on the projected development of the HIV epidemic by employee grade andthe method and assumptions used in this report, we were able to derive the impact of AIDS on the Namibian Public Service’s employee benefit provisions and internal operation. This impact was then re-assessed allowing for the provision of ART.

6.1 The “No AIDS” Scenario The table below summarises the present value of future economic costs expected to be incurred by the Namibian Public Service (excluding pension provision) if AIDS was not a feature in Namibia. Amounts are shown as N$’000. Table 6.1: Projected Economic Costs – “No AIDS” Scenario

Year

Productivity

Costs

(000's)

Replace Rehire

costs

(000's)

Sick Leave

(000's)

Maternity

(000's)

TOTAL

Additional

Costs

(000's)

2008 295,975 27,832 150,471 26,730 501,008

2009 333,594 28,302 170,075 28,430 560,401

2010 368,729 29,497 188,167 28,956 615,349

2011 407,796 30,629 208,362 29,954 676,741

2012 451,091 31,848 230,731 30,336 744,006

2013 499,051 33,143 255,518 30,524 818,236

2014 552,311 34,344 282,927 28,745 898,327

2015 611,394 35,652 313,293 27,413 987,752

2016 677,084 37,218 346,965 25,633 1,086,900

2017 749,904 38,950 384,305 23,746 1,196,905

2018 830,556 40,856 425,717 22,134 1,319,262 This is summarised below (in thousands):

39

Table 6.2: Benefit Costs as a Percentage of Payroll – “No AIDS” Scenario

6.2 The “With AIDS” Scenario The following table allows for the impact of HIV/AIDS (in thousands). Table 6.3: Projected Economic Costs – “With AIDS” Scenario

Year

Productivity

Costs

(000's)

Replace Rehire

costs

(000's)

Sick Leave

(000's)

Maternity

(000's)

TOTAL

Additional

Costs

(000's)

Percentage

Increase Due

to AIDS

2008 709,139 74,820 174,992 19,025 977,976 95.2%

2009 767,276 73,562 193,050 19,730 1,053,618 88.0%

2010 827,029 75,463 212,823 20,181 1,135,495 84.5%

2011 888,033 76,938 234,530 20,964 1,220,465 80.3%

2012 951,304 78,307 258,411 21,313 1,309,335 76.0%

2013 1,017,556 79,543 284,729 21,540 1,403,367 71.5%

2014 1,081,481 79,514 313,453 20,438 1,494,887 66.4%

2015 1,148,096 79,272 345,153 19,683 1,592,204 61.2%

2016 1,219,846 79,160 380,239 18,565 1,697,810 56.2%

2017 1,298,094 79,068 419,128 17,343 1,813,633 51.5%

2018 1,384,025 79,073 462,262 16,326 1,941,685 47.2% This is summarised below (in thousands):

Year Salary Roll

(000's)

TOTAL Benefit

costs (000's)

Benefits costs

as % of payroll

2008 4,095,304 501,008 12.2%

2009 4,628,840 560,401 12.1%

2010 5,121,237 615,349 12.0%

2011 5,670,891 676,741 11.9%

2012 6,279,682 744,006 11.8%

2013 6,954,302 818,236 11.8%

2014 7,700,286 898,327 11.7%

2015 8,526,732 987,752 11.6%

2016 9,443,170 1,086,900 11.5%

2017 10,459,430 1,196,905 11.4%

2018 11,586,514 1,319,262 11.4%

Average discounted value over 10 years (p.a.) 11.8%

40

Table 6.4: Benefit Costs as a Percentage of Payroll – “With AIDS” Scenario

YearSalary Roll

(000's)

TOTAL Benefit

costs (000's)

Benefits costs

as % of payroll

Percentage

Increase Due to

AIDS 2008 4,095,304 977,976 23.9% 11.6%

2009 4,541,693 1,053,618 23.2% 11.1%

2010 5,036,737 1,135,495 22.5% 10.5%

2011 5,585,741 1,220,465 21.8% 9.9%

2012 6,194,587 1,309,335 21.1% 9.3%

2013 6,869,797 1,403,367 20.4% 8.7%

2014 7,618,605 1,494,887 19.6% 8.0%

2015 8,449,033 1,592,204 18.8% 7.3%

2016 9,369,978 1,697,810 18.1% 6.6%

2017 10,391,305 1,813,633 17.5% 6.0%

2018 11,523,958 1,941,685 16.8% 5.5%

Average discounted value over 10 years (p.a.) 20.4% 8.6% We can see that the presence of HIV and AIDS has added around 8.6% to the cost of doing business per annum over the 10 year time horizon. It is clear that the salary roll of the AIDS scenario differs from the non-AIDS scenario, due to the impact of AIDS. However, it is not the actual salary roll, but the benefits as a percentage of payroll that is important.

6.3 The “With AIDS and ART” Scenarios The table below allows for the impact of HIV and AIDS together with the provision of ART in 2004 (in thousands). Table 6.5: Projected Economic Costs – “With AIDS and 2004 ART” Scenario

Year

Productivity

Costs

(000's)

Replace Rehire

costs

(000's)

Sick Leave

(000's)

Maternity

(000's)

TOTAL

Additional

Costs

(000's)

Percentage

Change over

No ART

2008 708,796 41,369 174,992 19,025 944,181 -3.5%

2009 721,137 47,529 189,993 19,379 978,038 -7.2%

2010 787,159 56,752 209,245 19,411 1,072,567 -5.5%

2011 873,351 66,663 231,293 19,731 1,191,038 -2.4%

2012 969,684 76,307 255,855 19,650 1,321,496 0.9%

2013 1,071,782 84,482 282,991 19,493 1,458,747 3.9%

2014 1,169,123 89,372 312,620 18,544 1,589,658 6.3%

2015 1,264,202 92,082 345,130 17,916 1,719,330 8.0%

2016 1,356,969 93,447 380,870 16,968 1,848,255 8.9%

2017 1,449,186 94,113 420,257 15,928 1,979,485 9.1%

2018 1,543,377 94,670 463,762 15,074 2,116,882 9.0% This is summarised below (in thousands):

Table 6.6: Benefit Costs as a Percentage of Payroll – “With AIDS and 2004 ART” Scenario

YearSalary Roll

(000's)

TOTAL Benefit

costs (000's)

Benefits costs

as % of payroll

Percentage

Change Due to

ART2008 4,095,304 944,181 23.1% -0.8%

2009 4,541,693 978,038 21.5% -1.7%

2010 5,036,737 1,072,567 21.3% -1.2%

2011 5,585,741 1,191,038 21.3% -0.5%

2012 6,194,587 1,321,496 21.3% 0.2%

2013 6,869,797 1,458,747 21.2% 0.8%

2014 7,618,605 1,589,658 20.9% 1.2%

2015 8,449,033 1,719,330 20.3% 1.5%

2016 9,369,978 1,848,255 19.7% 1.6%

2017 10,391,305 1,979,485 19.0% 1.6%

2018 11,523,958 2,116,882 18.4% 1.5%

Average discounted value over 10 years (p.a.) 20.8% 0.3%

We can see that the benefit of providing ART in 2004 is to increase the cost to employer value by 0.3% (average discounted value over 10 years) (N$14,248,770). However, it is important to note that there is an actual cost savings in the short term, of 0.8% to 0.5% (between 2008 and 2011). This is a result of a decrease in replacement/retraining and economic costs (lost productivity costs), as employees are expected to live longer and be healthier. There is also a decrease in sick leave benefits, as employees are expected to take fewer sick leave days as they do not progress through the HIV stages as quickly. It is noted that the bulk of this saving is as a result of a short term deferral in deaths/disabilities, and this explains why savings begin to disappear and costs become more by year 2012.

The table below allows for the impact of HIV and AIDS together with the provision of ART in 2008 (in thousands).

Table 6.7: Projected Economic Costs – “With AIDS and 2008 ART” Scenario

Year

Productivity

Costs

(000's)

Replace Rehire

costs

(000's)

Sick Leave

(000's)

Maternity

(000's)

TOTAL

Additional

Costs

(000's)

Percentage

Change over

No ART

2008 708,752 37,081 174,992 19,025 939,850 -3.9%

2009 767,184 33,197 193,050 19,730 1,013,160 -3.8%

2010 826,930 34,669 212,823 20,181 1,094,602 -3.6%

2011 887,927 38,340 234,530 20,964 1,181,760 -3.2%

2012 951,189 44,298 258,411 21,313 1,275,211 -2.6%

2013 950,054 52,518 280,305 21,071 1,303,949 -7.1%

2014 1,033,834 62,465 309,003 20,006 1,425,308 -4.7%

2015 1,141,175 73,091 341,697 19,288 1,575,251 -1.1%

2016 1,258,342 83,161 378,031 18,213 1,737,747 2.4%

2017 1,380,632 91,079 418,190 17,033 1,906,934 5.1%

2018 1,505,406 96,021 462,496 16,052 2,079,974 7.1% This is summarised below (in thousands):

Table 6.8: Benefit Costs as a Percentage of Payroll – “With AIDS and 2008 ART” Scenario

YearSalary Roll

(000's)

TOTAL Benefit

costs (000's)

Benefits costs

as % of payroll

Percentage

Change Due to

ART2008 4,095,304 939,850 22.9% -0.9%

2009 4,541,693 1,013,160 22.3% -0.9%

2010 5,036,737 1,094,602 21.7% -0.8%

2011 5,585,741 1,181,760 21.2% -0.7%

2012 6,194,587 1,275,211 20.6% -0.6%

2013 6,869,797 1,303,949 19.0% -1.4%

2014 7,618,605 1,425,308 18.7% -0.9%

2015 8,449,033 1,575,251 18.6% -0.2%

2016 9,369,978 1,737,747 18.5% 0.4%

2017 10,391,305 1,906,934 18.4% 0.9%

2018 11,523,958 2,079,974 18.0% 1.2%

Average discounted value over 10 years (p.a.) 20.1% -0.4%

We can see that the benefit of providing ART in 2008 is to reduce the cost to company by 0.4% (N$15,380,359). Again, we can see that this is a result of a decrease in replacement/retraining, economic costs (lost productivity costs) and a decrease in sick leave benefits. If we compare this to the 2004 ART scenario, we can see that cost savings for the 2008 ART scenario are less in the first few years (0.9% versus 1.7% in 2009). This is a result of ART being introduced later, as the benefits of ART take time. However, the graphs clearly show that the cost savings last longer under the 2008 ART scenario (0.2% in 2015 for 2008 ART versus 0.5% in 2011 for 2004 ART).

6.4 Summary of the Benefits of Providing ART The graph and table below summarise the impact of HIV/AIDS on the benefits the Namibian Public Services provides to employees (including replacement/retraining costs and costs associated with lost productivity): Figure 6.1: Summary: The Cost of Benefits Provided to Employees, and Business Interruption Costs Over Time

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018A

nn

ua

l c

os

t a

s a

pe

rce

nta

ge

of

CT

E

Year

The Cost of Benefits Provided to Employees, and Business Interruption Costs Over Time

Without AIDS With HIV/AIDS

with HIV/AIDS & 2004 ART provided with HIV/AIDS & 2008 ART provided

Table 6.9: Summary: The Cost of Benefits Provided to Employees, and Business Interruption Costs Over Time

No AIDS With AIDS 2004 ART 2008 ART12.2% 23.9% 23.1% 22.9%

12.1% 23.2% 21.5% 22.3%

12.0% 22.5% 21.3% 21.7%

11.9% 21.8% 21.3% 21.2%

11.8% 21.1% 21.3% 20.6%

11.8% 20.4% 21.2% 19.0%

11.7% 19.6% 20.9% 18.7%

11.6% 18.8% 20.3% 18.6%

11.5% 18.1% 19.7% 18.5%

11.4% 17.5% 19.0% 18.4%

11.4% 16.8% 18.4% 18.0%

11.8% 20.4% 20.8% 20.1%Average Discounted Value

over 10 years (p.a.)

2013

2014

2015

2016

2017

2018

Year

2008

2009

2010

2011

2012

The graph and table provide us with the following insights: Without AIDS the cost of benefits (including replacement/retraining costs and business interruption costs caused by employees withdrawing or dying unexpectedly) is expected to be between 11.4% and 12.2% p.a. of CTE. With AIDS and assuming no ART intervention these costs rise by an average of 8.6% p.a. The increase is caused predominantly by increased replacement/rehiring costs, increased sick leave and less productivity. If we assume that ART is available then the Namibian Public Service can expect to save on costs. Costs will fall by an average of 1.1% (until 2011) of annual basic payroll if 2004 ART introduction is assumed. Costs will fall by an average of 0.8% (until 2015) of annual basic payroll if 2008 ART introduction is assumed (0.4% average discounted value over 10 years). It is noted that the bulk of this saving is as a result of a short term deferral in deaths/disabilities.

44

Chapter Seven: Costs of Providing Anti-Retroviral Therapy (ART)

The next stage in our investigation was to assess the cost of providing ART for the Namibian Public Service, based on the various HIV and AIDS stages. This was done by separating the employees into two distinct groups: employees who belong to the medical aid scheme (71.8% on PSEMAS), and employees who do not belong to the medical aid scheme (28.2% not on PSEMAS). A separate analysis was also performed on all employees (no separation into the above groups). This would allow us to determine the funding rate and cost benefit, assuming all employees are covered by the medical aid scheme (PSEMAS). The total projected cost of the antiretroviral therapy could then be ascertained by multiplying the number of employees assumed to be in each of the various HIV states to the projected cost of therapy (increasing with inflation) for each group. The cost of these drugs were then assumed to escalate over time (with medical inflation), and were applied to the number of lives who are projected to be in HIV stages 1 - 4 for each of the two groups (covered and uncovered). With these results and the projected Namibian Public Service salary roll for each group, we were able to assess the funding rate required to support the expected future costs incurred. For the covered group, the funding rate would be required by the medical aid scheme (PSEMAS). For the uncovered group, the funding would be required by the Namibian Public Service if they chose to cover the costs of those uncovered employees. Please note that the costings shown in this section exclude the costs expected to be incurred for dependents. This is because we do not have the number or profile of dependents to members in the medical scheme.

45

7.1 Assumptions Relating to the Cost of Intervening

7.1.1. Allowances for the Cost of Anti-Retroviral Therapy, Pathology Tests and Prophylaxis for Symptomatic Relief

With the current debate around medication pricing it is very difficult to determine the likely cost of providing ART medication in Namibia. We have assumed that the recommendations put forward by the World Health Organisation (WHO) in 2003 for South Africa are followed, and that these costs would apply to Namibia as well (assuming an exchange rate of one to one). The 2003 costs of the WHO recommendations are shown in the table below. Table 7.1: Assumptions: Cost of Providing ART – WHO (2003)

CD4+ T-cell count >500 >500 Below 200 Below 200

In receipt of treatment? No Yes No Yes No Yes No Yes

Cost of Viral Load and

CD4+T Cell tests 32 32 49 49 49 144 49 144

Prophylaxis for

symptomatic relief 30 30 40 40 70 70 70 70

Cost of anti-retroviral

therapy per month Not Available Not Available Not Available Not Available Not Taken 900 Not Taken 900

Total monthly cost 62 62 89 89 119 1114 119 1114

Cost of WHO recommendations as an intervention strategy - per HIV+ employee, per month (2003)

Drug Protocol CostsHIV HIV

Stage 1

HIV

Stage 4Stage 2

Between 500 and 350 Between 350 and 200

HIV

Stage 3

These costs were then updated as follows:

The cost of doctor consultations, viral load and CD4+ T cell tests were updated using the 2008 National Health Reference Price List (NHRPL)

The cost of prophylaxes were updated using the 2003 to 2007 CPIX rates

The 2005 costs of ART treatment4 were updated using the 2005 to 2007 CPIX rates

The updated costs for 2008 are shown in the next table.

4 The ART treatment protocols provided by Calibre Clinical Consultants, April 2006 (R952.07 for ART 3 and R1,373.12 for ART 4)

Table 7.2: Assumptions: Cost of Providing ART – Updated for 2008

CD4+ T-cell count >500 >500 Below 200 Below 200

In receipt of treatment? No Yes No Yes No Yes No Yes

Cost of Viral Load and

CD4+T Cell tests 36 36 50 50 50 224 50 224

Prophylaxis for

symptomatic relief 38 38 51 51 89 89 89 89

Cost of anti-retroviral

therapy per month Not Available Not Available Not Available Not Available Not Taken 1092 Not Taken 1574

Total monthly cost 74 74 101 101 139 1405 139 1888

Between 500 and 350 Between 350 and 200

Cost of WHO recommendations as an intervention strategy - per HIV+ employee, per month (2008)

Drug Protocol CostsHIV HIV HIV HIV

Stage 1 Stage 2 Stage 3 Stage 4

47

7.1.2. Allowances for the Hospitalisation and Consultation Costs

We have taken an approach of costing all procedures on a per event basis. The salient assumptions are listed below: Table 7.3: Assumptions: Number of Doctor Visits/Lab Trips/Hospital Days per HIV Stage

AIDS State assumptions padoctor visits lab trips hospital days

HIV Stage 1 0.0 1.0 0.0

HIV Stage 2 2.0 2.5 2.0

HIV Stage 3 4.0 2.5 5.0

HIV Stage 4 4.0 2.5 7.0

ART 1 3.0 3.5 4.0

ART 2 3.0 3.5 4.0

ART 3 3.0 3.5 4.0

ART 4 3.0 3.5 4.0

Table 7.4: Assumptions: Cost of Doctor Consultations

Cost of consultations

Cost of consultation with doctor 191

7.2 Methodology This section deals with the costs of providing ART for the two groups, covered and uncovered, and separately for all employees combined (for the 2008 ART uptake assumptions – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake) using the HIV prevalence projections of the two groups (covered and uncovered) and all employees combined (shown below):

Figure 7.1: Comparison – HIV Prevalence for Uncovered, Covered and All Employees – Including Access to ART

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

HIV

Pre

va

len

ce

Year

Comparison - HIV Prevalence for Uncovered, Covered and All Employees

2008 ART (Employees on Medical Aid)

2008 ART (Employees not on Medical Aid)

2008 ART (All Employees)

The HIV prevalence rate is slightly greater for the uncovered group than the covered group (12.5% versus 12.3% in 2008). This is expected, due to the socio-economic implications of medical scheme membership (i.e. affordability), HIV prevalence levels in medical schemes are expected to be lower than the general population.The prevalence for all employees combined is slightly lower than for the uncovered group (12.4% in 2008). After the introduction of ART in 2008, there is a period in which the prevalence does not decrease as rapidly as if there was no ART introduction. This is because, after the introduction of ART, those individuals who receive the treatment (HIV Stage 3 and HIV stage 4 individuals) are expected to live longer. Therefore, even though the number of new HIV cases is not increasing, those surviviors are included in the prevalence. This explains why the decrease is not as pronounced as in the no ART scenario. In the summary that follows, we assume that those covered employees would obtain the ART drugs in the private sector, given the large scale provision through PSEMAS. For those employees without medical aid (uncovered), we have also assumed that ART drugs are obtained in the private sector, i.e. the uncovered group have similar access to treatment as the covered group, but that the costs would not have to be covered by the Namibian Public Service in the case of the uncovered group. We have also assumed costs for members only, and have excluded costs for dependents.

7.2.1. Overall Costs of Providing ART, Pathology Costs and the Costs of Hospitalisation/Doctor Consultations

We derive the following tables and graphs of projected costs for the covered and uncovered groups, and for all employees combined, for the 2008 ART assumptions, presented as a percentage of payroll. We have however not provided for any costs of administration.

49

Table 7.4: Projected Overall Costs: Covered Employees: ART Introduction in 2008 – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake

Salary Roll

per annum Anti-Retroviral Pathology Tests Prophylaxis for Hospitalisation Total Program Cost as a % of Smooth

Year (Basic Pay) per annum per annumsymptomtatic

ReliefDoctor/Nurse Costs pa annual Funding

member only member only member only Consultations

etc

basic pay rate

2008 3,167,835,610 32,408,922 6,979,515 4,414,647 2,322,450 46,125,534 1.46% 1.46%

2009 3,413,082,628 47,835,774 9,211,389 5,022,840 2,612,919 64,682,922 1.90% 1.67%

2010 3,684,050,882 59,776,893 11,002,208 5,662,594 2,961,529 79,403,224 2.16% 1.83%

2011 3,958,451,057 70,298,238 12,559,135 6,262,220 3,295,610 92,415,203 2.33% 1.95%

2012 4,242,697,306 79,141,407 13,822,338 6,764,812 3,577,576 103,306,133 2.43% 2.04%

2013 4,535,841,802 85,538,302 14,676,668 7,112,428 3,774,992 111,102,390 2.45% 2.10%

2014 4,822,131,102 88,666,751 15,005,142 7,246,887 3,856,484 114,775,264 2.38% 2.13%

2015 5,114,997,812 88,312,170 14,787,869 7,151,667 3,813,129 114,064,836 2.23% 2.14%

2016 5,403,672,798 84,749,780 14,077,559 6,840,939 3,652,594 109,320,873 2.02% 2.13%

2017 5,668,183,697 78,649,829 12,982,819 6,355,064 3,396,675 101,384,387 1.79% 2.11%

2018 5,906,762,633 71,179,423 11,684,255 5,770,210 3,086,282 91,720,169 1.55% 2.07%

Annual Cost of

50

Figure 7.2: Summary of Overall Costs: Covered Employees: ART Introduction in 2008 – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Cost of hospitalisation/consultation 0.073% 0.077% 0.080% 0.083% 0.084% 0.083% 0.080% 0.075% 0.068% 0.060% 0.052%

Cost of prophylaxis 0.14% 0.15% 0.15% 0.16% 0.16% 0.16% 0.15% 0.14% 0.13% 0.11% 0.10%

Cost of pathology tests 0.22% 0.27% 0.30% 0.32% 0.33% 0.32% 0.31% 0.29% 0.26% 0.23% 0.20%

Cost of anti-retroviral therapy 1.0% 1.4% 1.6% 1.8% 1.9% 1.9% 1.8% 1.7% 1.6% 1.4% 1.2%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

Covered Employees: Cost based on ART Introduction in 2008 – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake

For the covered employees, the average discounted value over the next 10 years works out at 2.07% of CTE for the 2008 ART assumptions. This smoothed funding rate would be required by the medical aid scheme (PSEMAS).

51

Table 7.5: Projected Overall Costs: Uncovered Employees: ART Introduction in 2008 – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake

Salary Roll

per annum Anti-Retroviral Pathology Tests Prophylaxis for Hospitalisation Total Program Cost as a % of Smooth

Year (Basic Pay) per annum per annumsymptomtatic

ReliefDoctor/Nurse Costs pa annual Funding

Non-member Non-member Non-member Consultations basic pay rate

only only only etc

2008 927,468,811 11,615,715 2,570,502 1,658,357 847,418 16,691,992 1.80% 1.80%

2009 1,028,562,911 17,114,488 3,377,683 1,889,187 958,519 23,339,878 2.27% 2.03%

2010 1,140,676,268 21,417,164 4,035,064 2,134,100 1,092,933 28,679,261 2.51% 2.19%

2011 1,265,009,982 25,216,877 4,608,255 2,362,868 1,222,128 33,410,128 2.64% 2.30%

2012 1,402,896,069 28,519,866 5,091,737 2,562,327 1,336,282 37,510,213 2.67% 2.38%

2013 1,555,811,740 31,020,088 5,438,161 2,708,588 1,421,866 40,588,703 2.61% 2.41%

2014 1,725,395,221 32,357,456 5,594,808 2,776,121 1,464,827 42,193,211 2.45% 2.42%

2015 1,913,463,301 32,624,794 5,580,388 2,770,592 1,467,927 42,443,700 2.22% 2.39%

2016 2,122,030,801 31,797,451 5,393,922 2,688,693 1,429,148 41,309,215 1.95% 2.35%

2017 2,353,332,156 30,143,020 5,078,265 2,547,084 1,357,323 39,125,693 1.66% 2.28%

2018 2,609,845,362 27,997,263 4,685,407 2,367,607 1,264,135 36,314,412 1.39% 2.20%

Annual Cost of

52

Figure `7.3: Summary of Overall Costs: Uncovered Employees: ART Introduction in 2008 – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Cost of hospitalisation/consultation 0.091% 0.093% 0.096% 0.097% 0.095% 0.091% 0.085% 0.077% 0.067% 0.058% 0.048%

Cost of prophylaxis 0.18% 0.18% 0.19% 0.19% 0.18% 0.17% 0.16% 0.14% 0.13% 0.11% 0.09%

Cost of pathology tests 0.28% 0.33% 0.35% 0.36% 0.36% 0.35% 0.32% 0.29% 0.25% 0.22% 0.18%

Cost of anti-retroviral therapy 1.3% 1.7% 1.9% 2.0% 2.0% 2.0% 1.9% 1.7% 1.5% 1.3% 1.1%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

Uncovered Employees: Cost based on ART Introduction in 2008 – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake

For the uncovered employees, the average discounted value over the next 10 years works out at 2.20% of CTE for the 2008 ART assumptions. This smoothed funding rate would be required by the Namibian Public Service if they chose to cover the costs of those uncovered employees.

53

Table 7.6: Projected Overall Costs: All Employees: ART Introduction in 2008 – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake

Salary Roll

per annum Anti-Retroviral Pathology Tests Prophylaxis for Hospitalisation Total Program Cost as a % of Smooth

Year (Basic Pay) per annum per annumsymptomtatic

ReliefDoctor/Nurse Costs pa annual Funding

All Employees All Employees All Employees Consultations basic pay rate

etc

2008 4,095,304,404 52,114,498 11,094,525 6,959,503 3,711,156 73,879,682 1.80% 1.80%

2009 4,541,692,586 78,363,343 14,929,563 8,066,995 4,254,878 105,614,779 2.33% 2.06%

2010 5,036,737,078 99,470,443 18,103,884 9,223,908 4,884,789 131,683,023 2.61% 2.25%

2011 5,585,741,420 118,843,434 20,980,683 10,352,936 5,507,718 155,684,772 2.79% 2.38%

2012 6,194,587,234 135,957,983 23,440,251 11,349,669 6,056,337 176,804,239 2.85% 2.47%

2013 6,869,797,243 149,422,963 25,274,243 12,116,777 6,477,969 193,291,952 2.81% 2.53%

2014 7,618,605,149 157,914,630 26,297,914 12,571,088 6,729,562 203,513,194 2.67% 2.55%

2015 8,449,033,098 160,945,189 26,454,506 12,669,915 6,788,206 206,857,816 2.45% 2.54%

2016 9,369,977,709 158,748,680 25,801,197 12,428,851 6,663,509 203,642,236 2.17% 2.50%

2017 10,391,305,273 152,477,783 24,525,136 11,918,459 6,393,719 195,315,096 1.88% 2.44%

2018 11,523,957,556 144,082,503 22,929,158 11,268,196 6,048,492 184,328,348 1.60% 2.37%

Annual Cost of

54

Figure 7.4: Summary of Overall Costs: All Employees: ART Introduction in 2008 – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Cost of hospitalisation/consultation 0.091% 0.094% 0.097% 0.099% 0.098% 0.094% 0.088% 0.080% 0.071% 0.062% 0.052%

Cost of prophylaxis 0.17% 0.18% 0.18% 0.19% 0.18% 0.18% 0.17% 0.15% 0.13% 0.11% 0.10%

Cost of pathology tests 0.27% 0.33% 0.36% 0.38% 0.38% 0.37% 0.35% 0.31% 0.28% 0.24% 0.20%

Cost of anti-retroviral therapy 1.3% 1.7% 2.0% 2.1% 2.2% 2.2% 2.1% 1.9% 1.7% 1.5% 1.3%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

All Employees: Cost based on ART Introduction in 2008 – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake

For all employees combined, the average discounted value over the next 10 years works out at 2.37% of CTE for the 2008 ART assumptions. This smoothed funding rate would be required by PSEMAS, assuming all employees are covered by the scheme.

55

The table below is a summary of the total ART cost (as a percentage of annual basic payroll for 2008 to 2018) for each of three groups: covered, uncovered and all employees combined. We can see that the total ART cost for the uncovered group is greater than that of the covered group for years 2008 to 2014, after which the total ART cost for the uncovered group is lower than that of the covered group. Figure 7.5: Total ART Cost as a Percentage of Annual Basic Payroll: ART Introduction in 2008 – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Covered Employees 1.46% 1.90% 2.16% 2.33% 2.43% 2.45% 2.38% 2.23% 2.02% 1.79% 1.55%

Uncovered Employees 1.80% 2.27% 2.51% 2.64% 2.67% 2.61% 2.45% 2.22% 1.95% 1.66% 1.39%

All Employees 1.80% 2.33% 2.61% 2.79% 2.85% 2.81% 2.67% 2.45% 2.17% 1.88% 1.60%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

Total ART Cost as a % of Annual Basic Payroll: ART Introduction in 2008 – 60% HIV Stage 3 and 80% HIV Stage 4 Uptake

Covered Employees Uncovered Employees All Employees

56

7.3 The Cost and Benefit of Providing Anti-Retroviral Therapy By considering a 10 year time horizon and using the results of the previous chapters and the section above we are able to compare the benefit of ART against the cost of the therapy. Table 7.7: Covered Employees: Cost Benefit Analysis

If Allowing Allowing

HIV/AIDS for AIDS for ART

were not a (current 2008

feature in scenario) Covered

Namibia

Cost of providing anti-retroviral

therapy pa

Cost includes administration,

pathology tests, prophylaxis and 2.07%

hospitalisation costs

Cost of benefits to employees

includes the costs of replacing,

retraining and hiring new employees 5.87% 10.15% 10.0%

as well as normal benefits

Impact of AIDS on costs 4.28%

As a percentage of payroll, pa

Benefit of anti-retroviral therapy

i.e reduction in the impact of AIDS 0.187%

Ratio of benefit of providing ART over the cost of ART 0.090

Cost benefit analysis

NB: all amounts are expressed as a

percentage of annual payroll over a 10

year time horizon

The cost benefit ratio was determined by taking the ratio of the cost savings resulting from ART (benefit of ART) to the cost of providing ART. The cost benefit ratio gives an indication of the effectiveness of ART on reducing the costs to the Namibian Public Service. It is also important to note that the above table represents the cost benefit analysis for employees who are members of the medical scheme (PSEMAS).

Table 7.8: : Uncovered Employees: Cost Benefit Analysis

If Allowing Allowing

HIV/AIDS for AIDS for ART

were not a (current 2008

feature in scenario) Uncovered

Namibia

Cost of providing anti-retroviral

therapy pa

Cost includes administration,

pathology tests, prophylaxis and 2.20%

hospitalisation costs

Cost of benefits to employees

includes the costs of replacing,

retraining and hiring new employees 5.9% 10.28% 10.1%

as well as normal benefits

Impact of AIDS on costs 4.33%

As a percentage of payroll, pa

Benefit of anti-retroviral therapy

i.e reduction in the impact of AIDS 0.189%

Ratio of benefit of providing ART over the cost of ART 0.086

Cost benefit analysis

NB: all amounts are expressed as a

percentage of annual payroll over a 10

year time horizon

Comparing the above cost benefit analysis for the uncovered lives to the cost benefit analysis for the covered lives, we can see that although the uncovered lives have higher HIV associated costs than the covered lives (2.20% versus 2.07% for the 2008 ART scenario), the benefits of ART is greater (0.189% versus 0.187% for the 2008 ART scenario). It is also important to note that we have not considered issues such as staff morale, cohesive workings of teams, institutional memory and other intangibles that clearly contribute to the well-being of a workforce. Also excluded is consideration of the broader positive effects that ART would have on the communities in which the workforce lives.

Table 7.9: : All Employees: Cost Benefit Analysis

If Allowing Allowing

HIV/AIDS for AIDS for ART

were not a (current 2008

feature in scenario) All Covered

Namibia

Cost of providing anti-retroviral

therapy pa

Cost includes administration,

pathology tests, prophylaxis and 2.37%

hospitalisation costs

Cost of benefits to employees

includes the costs of replacing,

retraining and hiring new employees 11.82% 20.43% 20.1%

as well as normal benefits

Impact of AIDS on costs 8.61%

As a percentage of payroll, pa

Benefit of anti-retroviral therapy

i.e reduction in the impact of AIDS 0.376%

Ratio of benefit of providing ART over the cost of ART 0.159

Cost benefit analysis

NB: all amounts are expressed as a

percentage of annual payroll over a 10

year time horizon

The above table shows that providing ART to all employees, results in a cost savings of 0.376%. If we assume that all employees are covered by the medical aid scheme and that the cost of ART treatment is covered by the scheme then the actual ratio of the benefit of providing ART over the cost of ART for the Namibian Public Service is much greater than the 0.159 shown. From the above tables, we can see that the greatest cost benefit results from the scenario in which all employees are covered.

59

PART III: CONCLUSION

Chapter Eight: Conclusions and Recommendations

8.1 Conclusions

The Government of Namibia as the policymaker has provided an enabling environment in which strategies can be implemented to manage the HIV and AIDS epidemic. Review of the published literature provides comprehensive evidence of the response to HIV and AIDS in the different Acts, Bills and Charters as well as Policies and Rules. The literature also reports on monitoring and evaluation systems, relevant policy frameworks, strategic plans and establishment of preventative programmes. It is thus quite evident that a lot of work has been done at a national level to create an enabling legal and policy environment for HIV and AIDS management.

This concluding chapter will provide recommendations on intervention strategies that will mitigate the impact of the HIV and AIDS epidemic in the workplace within the Namibian Public Sector. For the remaining twenty two years to achieve Vision 2030, the readiness of the Public Sector to help the nation attain the goals of Vision 2030 is very critical. Studies of a similar nature carried out elsewhere reveal that sound understanding of the epidemic and managing strategies by the Public Sector has positive impact across all sectors of the economy. It is in this spirit that this study has been carried out. It will however need to be treated as a baseline on which further studies of a similar nature will be carried out. To date, the effectiveness of the Government’s efforts to alleviate the impact of HIV and AIDS within the Public Sector are yet to be appreciated. The effects of the HIV and AIDS epidemic on the ability of the Public Sector to deliver services had never been quantified and the need to do so could not be over emphasized. This report not only assigns a monetary value to the impact of HIV and AIDS in the Public Sector but also provides a model to help O/M/As monitor the impact of the disease over a period of time. It needs to be stressed here that it is mandatory that the Namibian Government in its role as an employer needs to also be compliant with the same legislation, policy framework and strategic plans it has created as a policymaker. In order to meet the set targets for Vision 2030 there will be an additional and increased demand from the public for service delivery. The burden that HIV and AIDS will have on this increasing demand for Government services from the public of Namibia will have an accelerated effect on the demand for increased service delivery. In general it can be argued that the planning, monitoring and evaluation framework should be more integrated to focus on the achievement of measurable output on key service delivery. No literature could be found that describe the methodology and criteria that define the different service delivery outputs for the different occupational environments of the Government. No measurable outputs in terms of service delivery are described in any formal documents received for this analysis and review. It is vital to define such outputs in order to quantify the impact HIV and AIDS has had on the Public Sector as supplier of services to the people of Namibia. The measurement of productivity and performance management of the Public Sector is in need of improvement. The quantification of the HIV impact on the productivity can only be done effectively if there is a baseline against which it can be measured and compared. More and clearer definitions of productivity in the Public Sector context would have assisted the study in quantifying the impact of HIV and AIDS in a more realistic context. The Public Sector is a service-oriented sector. Its most valued resources are its employees. An analysis of the workflow processes within the O/M/As reveals that most operations across the entire Public Sector are manually driven. This doubles the reliance the sector has on its human resources. In that regard, a healthy civil service and its achievement and sustainance thereof instantly becomes a critical concern to any delivery-focused government. Studies like this one create a platform through which the Government can better understand the level of its dependence on human resources and the threats that it faces. Attempts to improve the delivery efficiences within the sector should therefore start with the improvement of the welfare of its employees. The literature reviewed highlighted the commitment of the Government to achieving this. The results are however yet to be realised as most of these efforts are still at infancy stages.

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Currently the government is only funding for about 25% of all the HIV and AIDS management annual requirements. The long term sustainability of external donor funding needs to be carefully assessed. Even in the intermediate term with the current global financial crisis and economic recession there is a real threat of donor funding levels to developing countries drastically getting reduced. Due to non-discriminatory principles HIV testing is not compulsory anywhere including at the workplaces. This limits the availability of prevalence data. The legal environment thus provides a challenge for implementation of any strategy to mitigate the impact of HIV as it requires the consent and participation of the employee without fear of discrimination and that the individual’s right to privacy is protected. This has the effect of impacting negatively on the effectiveness of any disease management programmes that might be put in place. Encouraging voluntary testing and getting employees to open up on their HIV status might be the only way of partially overcoming this challenge. The National Policy on HIV and AIDS, which serves as the overall reference framework, requires O/M/As to develop and align their institutional policies to it. It is circumstantially evident from the lack of reports and literature on this topic that very little has been achieved regarding the development and implementation of the institutional policies within O/M/As. This further made it difficult for the study to analyse the effectiveness of such policies, since they are either just non-existent or in a draft form not yet executable. Further, through the UNGASS Declaration, Namibia has committed itself to strengthen the response to HIV and AIDS in the workplace by establishing and implementing prevention and care programmes in public, private, and informal sectors. While this commitment might have been achieved for the other sectors, evidence of its achievement in the Public Sector is missing. It is commendable that the Ministry of Health and Social Services has provided a policy framework for incorporating HIV and AIDS for each of the Public Sector offices through the National Occupational Health Policy of July 2006. It must however be advised that for the successful achievement of the policy goals the primary responsibility of implementing, monitoring and maintenance of the policy should remain with the specific line ministries, offices and agencies. Although sentinel surveys and reviews carried out do not categorise civil servants separately, it is of concern that at national level the HIV prevalence rate is still very high (17.8% in 2008 amongst women aged between 15-49 years attending antenatal clinics). This continues to pause a danger to the Public Sector considering that it is from this highly infected population that it will have to draw its human resource capital. Hence, the need to manage the impact of the disease more effectively and efficiently remains absolutely necessary. Qualitative data collected through focal group discussions, interviews and questionnaire surveys revealed a handful of concerns from those through which the Government delivers – the employees themselves. Whereas it is generally agreed that there is a leadership commitment to managing HIV and AIDS at the workplaces it is felt that the impementaion of the policies and rules on the diseases is very poor. Co-ordination and communication of activities is poorly understood by those that it aims to benefit. The HIV and AIDS management structures that are there are yet to be formalised to create positions for substantive HIV and AIDS office bearers within the O/M/As. The budgetary allocations for programmes on the diseases can hardly last a month in any one given financial year. The focal persons have not received any formal training on HIV and AIDS and neither do they get any techinal guidance on most issues most of the times. In the eyes of the employees HIV and AIDS management within their workplaces has been relegated to a few annual campains in a year and condoms distribution only. Heads of Human Resources divisions concur with the HIV and AIDS Focal Persons that The Office of the Prime Minister needs to speedily finalise the Public Sector HIV and AIDS Policy. From a policy percepective this has been singled out as the sole reason why the management of the disease has not received a lot of attention from the O/M/As. They argue any initiatives they might have just lack proper policy guidance from the Office of the Prime Minister as the lead agency within the Public Sector. Quantitative data was collected through the Office of the Prime Minister and a demographic profile analysis of the Public Sector workforce (as at 31 January 2008) showed that majority of the 59,582 employees were employed in the Ministries of Education and Safety & Security (41.5% and 21.5%, respectively). The majority of all workers were female (53.2%), between the ages of 41-50 years (36.1%), earning an annual income between N$0 – N$50,000 (44.5%) and unmarried (66.7%), with most of them on the Government medical aid scheme (71.8% on PSEMAS).

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Statistical methods were used to identify the main factors affecting HIV prevalence, represented by an HIV prevalence magnitude indicator. The HIV prevalence magnitude indicator for females was on average 46.9% higher than for males. Further observations were that the lower the salary band, the higher the HIV prevalence magnitude indicator. Compared to the medium salary band, the medium-low salary band had an HIV prevalence magnitude indicator 87.6% higher and the low salary band 136.5% higher. The higher salary bands, medium-high and high, had HIV prevalence magnitude indicators lower than the medium salary band (81.3% and 96.5% lower respectively). The exposure weighted factor of age band (1.809) was the highest compared to the other analysis factors and was followed by gender (0.851) and salary band (0.755). This means that HIV prevalence is driven firstly by the age band the employee belongs to, followed by the employees’ gender and then salary.

The next stage in the investigation was to assess the cost in providing employee benefits and the business interruption costs that the Namibian Public Service incurs as a result of HIV and AIDS being a feature of the environment. Based on the demographic projections of HIV prevalence, we modeled the employee benefits provided by the Namibian Public Service to their employees, as well as business interruption costs associated with the HIV and AIDS epidemic. When assessing costs we discounted all future employee benefit outgo and expected company costs to derive a capitalised value as a percentage of basic payroll.

Based on our estimates, we were able to determine the cost impact of HIV and AIDS to the Public Sector over the next 10 years. The most significant costs arising from HIV and AIDS are the costs of sick leave benefits, maternity benefits, allowances for the cost of retraining and costs associated with the hiring of new employees in the event of death/withdrawal of an employee, and allowances for the lost productivity associated with sick leave, and death/disability of the employee. These HIV and AIDS additional costs are expected to add around 8.6% (of annual payroll) to the cost of operations over the next 10 years. The above costs can however be reduced by the introduction of ART. Costs would have fallen by an average of 0.4% of annual basic payroll if ART was introduced in 2008 (i.e. the year in which the impact analysis was done). It is noted that the bulk of this saving would have been as a result of a short term deferral in deaths/disabilities.

Not all employees are on PSEMAS making the availability of ART through the scheme not accessible by all employees. Those employees with medical cover (71.8% on PSEMAS) have access to ART when their CD4 count falls below 350. Those employees without medical cover (28.2%) can obtain ART in the public health sector. However, this is not necessarily designed for employed individuals as they would be required to take significant amounts of time off work in order to attend clinic visits. The difficulty of access to treatment and later provision of ART would result in reduced savings to the Public Sector.

For those employees with medical aid cover (PSEMAS), the cost of ART treatment is provided by the medical scheme (with a 5% co-payment). Therefore, the benefit of providing ART over the cost of ART for the Government illustrates a cost-benefit scenario. For those employees with no medical aid cover, the benefit of ART is greater (0.189% versus 0.187% for the 2008 introduction). This is due to higher expected HIV prevalence among the uncovered population. With the current debate around medication pricing it is very difficult to determine the likely cost of providing ART medication. However, based on our observations and assumptions, we expect the benefit of providing ART to the cost of ART, for the uncovered employees, to be 95% of that of the covered employees. In order to cover the costs of ART for the uncovered employees, we estimate that the Public Sector would require a funding rate of 2.20% of annual payroll.

8.2 Recommendations

It is clear that HIV and AIDS is currently having and is expected to have a significant impact on the Public Sector in the future. Based on the study our recommendations are as follows:

Government National HIV and AIDS Expenditure We recommend that the Government allocates a minimum of 15% of its annual budget to the Ministry of Health and Social Services in line with its commitment to the Abuja Declaration to help the ministry strengthen its financial capacity for an effective dispensation of all its mandates including HIV and AIDS management at the national level. Currently about 75% of the funding for HIV and AIDS management comes from donors. This reliance on external sources of funding is a real threat to the future success of combating the effects of HIV and AIDS.

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Public Sector HIV and AIDS Expenditure We have noted that there is a need for the government to establish a system through which HIV and AIDS expenditures within the Public Sector can be accurately collated and verified. Such information will form a sound platform from which future intervention programmes can be formulated. Currently this information is only crudely available making it not very credible. Further, the current HIV and AIDS allocations averaging N$200 000 per O/M/A per year are ridiculously way below the estimates for effective workplace programmes of N$720.00 per employee per year. We recommend that these allocations be seriously revised to significant proportions of the annual requirements. Mission Statements and Definition of Government Objectives The Office of the Prime Minister has not yet undertaken studies to define and measure productivity within the various O/M/As. The study has had therefore to rely on other studies to estimate the costs resulting from productivity losses. We recommend that the Government finalises the introduction of Performance Management Systems and Strategic Plans for all O/M/As to establish clearly defined and measurable objectives for each O/M/A on which their performance can be measured. In line with the above we further recommend that the Government carries out a human resources audit. From this it will be able to to establish, as a baseline, its current human resources requirements for an efficient functioning of the Public Sector focusing on the level of demand for its services as a target with the aspirations of Vision2030 in mind. Automation of Public Sector Workflow Processes Automation enhances visibility of processes, improves productivity, and gives critical results speedily. It imperatively demands methodology and processing architecture in all the areas of O/M/As delivery. Cross-functional solutions are developed. Process owners will think end-to-end on how a value-chain comes together and how their roles, performance, and productivity create value within the greater process. The results of all this will be a lot of value addition to the O/M/As’ key delivery areas. We recommend that the Government increases its pace of automating its operational processes. This is an effective indirect way of harnessing the impact HIV and AIDS on productivity at the workplaces as it reduces the need for human involvement. Redefinition of Goal 14 of NDPIII in Complying with the MDG 6 and Objective 5 of Vision 2030 Goal 14 of NDP III defines the objective as “Reduced spread of HIV and AIDS and its Effects”. The ultimate aim in combating HIV is to reduce or even eradicate the spread of HIV through reducing the number of new infections. The reality is that the HIV epidemic already has had an impact and has spread to significant levels. We therefore recommend, with the crafting of MTPIV, that the goal be redefined and split into two parts: reducing the number of new infections; and managing the impact on those already infected. HIV and AIDS need to be Treated as a Chronic Disease that Requires Specific Provisions HIV and AIDS needs to be treated as a chronic disease that requires specific provisions in most of the Acts and Charters dealing with job relations and employee welfare. As a result of the stigma and fear associated with HIV the issue of confidentiality is very prevalent when dealing with the disease. Employees need to be ensured that their individual rights to privacy will be protected. The legislative environment must be seen to be clear and protective of the rights of employees at the workplaces to disclosure. Safe and Healthy Work Environment There is a duty on the part of every employer to provide a safe and healthy working environment. This includes the protection of employees from contracting HIV via exposures in the working environment. High incidence rates of exposure and high conversion rate to HIV positive status of employees is a failure of any protection and prevention strategies an employer might be having in place. Prevention to exposure is currently not firmly articulated in all the O/M/As across the entire Public Sector. We recommend that these issues of safe and healthy working environments within the Public Sector be a priority and addressed in ministerial meetings and strategic plans. Compensation for Occupational Diseases The Workmen Compensation Act, just like the Public Service Act, is silent on HIV and AIDS and one can only assume that the disease is covered under the many possible diseases to be contracted on the job. Compensation for employees who have converted to HIV positive status through exposure in the workplace or through fulfilling occupational duties is a necessity. Except for the MoHSS, well functioning Post Exposure Prophylaxis Protocols need to be in place for all the other O/M/As in this regard.

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We recommend that the Workmen’s Compensation Act and the other Acts be updated and amended to bring them in line with recent developments. Conflicting clauses amongst these pieces of legislation need to be cleared. Acts, Bills and Charters need to be consistent with and communicating to each other. We advise that an exercise be carried out to harmonise the legislative environment on employee welfare. Institutional Policies on HIV Need to be Aligned with Occupational Environments The National Policy on HIV and AIDS, which serves as the overall reference framework, requires O/M/As to develop and align their institutional policies to it. As the occupational environments of the different O/M/As vary each one has its own unique challenges requiring specific provisions in terms of policy. HIV and AIDS is a more critical occupational risk element for certain O/M/As than others. However the principles of responsibility and liability still rests with every O/M/A. Therefore the processes and guidelines that are followed should be similar across the entire Public Sector to ensure that O/M/As provide safe working environments and that fair procedures are followed right across the entire sector. Disability Benefits The GIPF definition of disability used to determine a member’s eligibility for disability benefits refers to a member becoming totally and permanently disabled as a result of disease or illness to an extent that such a member can no longer pursue his/her own or a similar occupation for which he/she would be qualified by his/her training and experience. It is advised that HIV and AIDS be included in this classification. It is further recommended that all chronic and high risk conditions be treated equally and fairly. The basis of entitlement to certain level of benefits should be the level of disability and not the medical diagnosis. Sick Leave Benefits The Public Sector Staff Rules make provision for the Permanent Secretary (employer) to grant paid sick leave to employees that have a valid medical condition, including an illness as a result of HIV and AIDS. The fact that an employee is or has been diagnosed as HIV positive does not provide an automatic reason to be entitled to sick leave. Only when an employee suffers from medical conditions that cause the employee to be unfit to work can the employee be granted sick leave. It should be noted though that the size of the sick leave benefits requires that they be carefully managed. A process of verification and assessment of the need for the days may need to be done before any one employee is awarded sick leave days in excess of a certain amount in any sick leave cycle. This could be looked at together with the provisions of the HIV and AIDS disease management programme if introduced. Independent Sick Leave Assessor One of the limitations of deciding the “validity” of sick leave applied for by an HIV-positive employee is the non-disclosure requirement of the employee’s HIV status to the employer. The medical information provided as part of the validation process need to be such that it does not compromise the employee’s right to privacy. A possible solution to overcome this could be the involvement of an outside medical expert to assess these special requests. The third party would then be given consent to have access to confidential medical information on behalf of the employer and advise it accordingly. Sick Leave Capturing System

We recommend that the sick leave capturing system be improved so that the collection, maintenance, update and analysis of sick leave taken and the resulting costs can be measured on an ongoing basis.

Employee’s HIV Status and HIV Testing In accordance with international human rights provisions no employee can be discriminated against on the basis of their HIV status. The legal environment thus provides a challenge for implementation of any strategy to mitigate the impact of HIV as it requires the consent and participation of the employee without fear of discrimination and that the individual’s right to privacy is protected. This has the effect of impacting negatively on the effectiveness of any disease management programmes that might be put in place. The only way to overcome this obstacle for the Government as the employer is by way of encouraging voluntary testing and getting employees to open up on their HIV status. A show of commitment by the Government to improve its employees’ wellbeing will assist greatly in building up a culture of openness amongst the Public Sector employees. Access to Medical Care and Support

Access to medical support in terms of medication and clinical management is not currently available to all the employees of the Namibian Government. The principle of equal access to employee benefits for all Public Sector is thus compromised. Membership of PSEMAS entitles members/employees access to

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medical benefits. However, non membership to PSEMAS excludes access to such benefits. Thus those who do not have membership would need to mostly access benefits in the public health sector. We recommend the Government investigates the possibility of a subsidy arrangement that provides a larger subsidy (as a percentage of monthly contribution) to lower income earners compared to higher income earners. This will assist lower income earners in affording medical scheme cover. Alternatively the Government could consider stratifying benefit options to make provisions for cheaper options that provide basic levels of healthcare coverage whilst ensuring that beneficiaries have access to benefits for primary care, chronic conditions and non-elective hospitalization.

PSEMAS HIV and AIDS Disease Management Programme The cost of providing access to reasonable treatment and care could be compared with the opportunity cost of potential saving by employees not taking sick leave if they have been compliant. The aforementioned clearly make emphasis on the need for PSEMAS to introduce an HIV and AIDS disease management programme to ensure the following: Registration and enrolment of infected beneficiaries on the disease management programme means that the scheme can collect data and statistics about those infected; Managed provision of treatment and care can occur with regular follow-ups and compliance monitoring being conducted to ensure that optimal outcomes are achieved; Provision of treatment according to the most up to date clinical protocols and guidelines; Improved management of the healthcare spend by HIV-positive beneficiaries; Participation in employer-driven HIV and AIDS initiatives such as education campaigns, and voluntary counseling and testing; Facilitation of enrolment of HIV-positive beneficiaries on the disease management programme after VCT initiatives; and Alignment of employer driven HIV and AIDS responses and medical care provided. Once this is done, and recommending in support of the government’s intentions, all members on the programme could be made eligible for a waiver of the 5% levy as a way to encourage employees to register with the programme. Employee Wellness Programmes

In conjunction with the above recommendations for the medical scheme, we recommend that a more co-ordinated workplace programme for HIV and AIDS be implemented as part of an employee wellness programme. This will allow the Government to ensure that its employees are fit to deliver its services effectively and efficiently, while developing innovative approaches to future challenges, and maintaining an institutional memory that sustains the employees and the services rendered to the population of Namibia. Also, the reduction in costs to the Public Sector, from higher productivity, reduced economic costs and reduced absenteeism that come with the introduction of these programmes cannot be ignored.

Incapacity and Ill-Health Programme The implementation of a formal Incapacity and ill-health policy and programme should be considered. Advocacy for equal employment opportunities for all including people with disabilities need to also keep emphasizing the need to continue making provisions of HIV and AIDS workplace programmes particularly earmarked for those with disabilities at the workplaces. Provision of ART

Workplace programmes should place emphasis on the availability of ART in an attempt to increase the number of employees on the medical aid scheme (PSEMAS) or by providing ART to those uncovered employees. If the additional cost of providing PSEMAS membership to those uncovered employees is greater than the 2.20% (of the uncovered employees annual payroll) required to provide ART directly, then we recommend that the Government provide ART through workplace programmes outside of the medical scheme. However, if the additional cost of providing PSEMAS membership to those uncovered employees is less than 2.20%, then it would be more cost effective to the Government to provide membership to PSEMAS, which would then allow those uncovered employees to access ART treatment through PSEMAS.

Technical Guidance The Public Service Sector Management Plan (2006-2009) of the OPM HIV and AIDS Unit aims to ensure that O/M/As have workplace programmes and that they mainstream HIV and AIDS into their core functions. The Plan however assumes that “mainstreaming HIV and AIDS” will be interpreted in the same context across all O/M/As. There might be a need to engage specialists to help O/M/As mainstream HIV and AIDS in their policies, practices, processes and strategic plans. Judging by the observed lack of skill

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on this matter in the entire sector we urge the Government to move with speed in identifying HIV and AIDS consultants to help it implement its policies and programmes successfully. Lessons from MTPIII for MTPIV The implementation of MTPIII depends largely on the availability of human and financial resources of O/M/As. This might not clearly be stipulated and well understood by some stakeholders. The sectoral obligations and commitments outlined in chapter 6 of the plan depend on a number of issues, and these are:

The universal understanding of the O/M/As on what they are expected to do;

The extent to which the OPM as the lead-agency is equipped in terms of human skills to successfully discharge its co-ordinating roles; and

The authority with which the OPM will be able to enforce cooperation from O/M/As in the management of HIV and AIDS needs to be clearly spelt out.

Although there is heterogeneity amongst O/M/As in terms of structure, core functions and level of exposure, it is important for the OPM as the lead-agency to have a standardised implementation framework through which to manage the disease effectively. Although the above issues are critical, they are not clearly outlined in the current National Strategic Plan, MTPIII. We therefore recommend that proper attention be paid to them in the drafting of MTPIV. Monitoring and Review

Going into the future the results of any HIV and AIDS impact assessment are as good as the credibility of the underlying data available and the frequency with which they are reviewed. We have provided indicators to be used for the monitoring and evaluation of the impact assessment. We recommend that the HIV prevalence modeling be re-calibrated by qualified professional experts (actuaries) every two years in order to reflect the results of the MoHSS ante-natal sentinel surveys that are conducted every two years. This will ensure that the modeling reflects the progression of the epidemic over time in Namibia.