HIV/AIDS has serious implications for social security. AIDS is a mass killer and affects the most economically active age group (15 - 49) who are potentially members of social security schemes. It effectively reduces the number of people in employment and therefore may reduce the number of contributors. Plus, HIV/AIDS affects the poor disproportionately and exacerbates income inequality and absolute poverty. Besides, already fragile health systems are being robbed of skilled staff.

On the expenditure side of social security schemes, AIDS reduces the number of old age pensions in the long-term while increasing the number of invalidity claims/pensions in the short-term. AIDS also increases the number of survivors’ claims/pensions in the short-term, as well as the funeral grants they have to pay for.

AIDS overtaxes the social systems and affects disproportionately those who are mostly in need of social assistance. Indeed, affected households have often lost their bread winner and now have to cope with more financial difficulties. 

To counter these problems, social security schemes can intervene on two main fronts: Prevention and access to ARVs. 

Information is key to the fight against HIV/AIDS. Schemes can set aside budgets to participate in HIV/AIDS awareness to improve HIV/AIDS competence among their target population through information and communication campaigns. It can be very effective in preventing the spread of the epidemic. 

Besides, ILO sets priorities in extending coverage of social protection schemes to people with HIV/AIDS and the poor and in investing in social health protection in order to strive for universal access. Schemes should facilitate the access to ARVs and treatments. The cost of frequent treatment of sick members to the health insurance schemes is huge but with declining costs of ARVs and availability of cheaper generic versions, the cost is reducing gradually. Moreover, it is known that with adequate and quick care people living with HIV/AIDS can live a normal and productive life, and then become contributors for health systems. Consequently, the duration of both invalidity and survivors’ pensions should reduce while the use and the availability of antiretroviral drugs improve. Health systems could be thus more sustainable. 

The cost of such measures would be far lower than what is spent today to care for ill people who are not economically productive anymore.  

Following a Resolution on HIV/AIDS and the World of Work, adopted at the International Labour Conference in June 2000, ILO-AIDS, a programme on HIV/AIDS within the International Labour Office, was created. HIV/AIDS was thus considered as a workplace issue. The Conference Resolution also requested that international guidelines be developed to tackle HIV/AIDS in the workplace.

The ILO Code of Practice on HIV/AIDS and the World of Work is the product of an intensive process of consultation between the ILO and its tripartite constituents. It was adopted by the ILO Governing Body in June 2001. Formally launched at the United Nations General Assembly Special Session on HIV/AIDS (New York, 25-27 June 2001), it received the support of the UN Secretary General and UN system, as well as of national leaders, corporations, labour organizations, and NGOs.

The Declaration of Commitment approved at the Special Session makes reference to the need for national laws and policies to take account "of established international guidelines on HIV/AIDS in the workplace". 

• Prevention of HIV/AIDS
• Management and mitigation of the impact of HIV/AIDS on the world of work
• Care and support of workers infected and affected by HIV/AIDS
• Elimination of stigma and discrimination on the basis of real or perceived HIV status.

To read more about the detailed guidelines of the ILO Code of Practice concerning social security, please visit this page.  

In many low income countries affected by HIV/AIDS, three factors are placing an undue burden on the elderly. First, the burden on the elderly has enormously increased with the increase in mortality of prime age adults due to HIV/AIDS pandemic. Second, the traditional safety net of the extended family has become ineffective and unreliable for the elderly. Third, in a few countries, the elderly are called upon to shoulder the responsibility of the family as they became the principal breadwinners and caregivers for young children. 

A household type “elderly and children” or what is known as “skipped generation household” has emerged as an important structure in some countries. In addition, “households headed by the elderly” has also emerged as a significant household type in several countries.

While a number of studies have examined the welfare consequences of these developments on children, few studies have systematically analyzed the poverty situation among the elderly relatively to other groups in low income countries.

Current global figures estimate that 16 million children under 15 have already lost either one or both parents to HIV/AIDS and that another 40 million children will lose their parents within the next 10 years. Recent World Bank studies found that in 20 out of 28 countries in Africa and Latin America, more than one-fifth of orphaned children were living with their grandparents. In South Africa and Uganda it was 40%, and in Zimbabwe, over half. In Zambia, Uganda and Tanzania, grandparents made up the single largest category of carers of orphans.

Older people make up a significant proportion of the poorest, and HIV/AIDS exacerbates the extreme poverty faced by older-headed households. This compromises the ability of older carers to care adequately for children and limits their access to health care and education services. The financial burden of caring for children means older carers are often forced to sell their assets or borrow money. Moreover, in most countries of Africa and Asia, older people have few forms of support outside their families. Contributory pensions are only available to the relatively small numbers who have had jobs in the formal economy, while non-contributory pensions exist in only a handful of countries. Nevertheless, most of them continue to work and support themselves and their families well into old age. Despite the exclusion they face, older people provide a vast pool of social capital as knowledge bearers and educators, as well as taking on the triple roles of caregiver, homemaker and income earner in many households.

Until recently, one of the main responses to the growing numbers of orphans and vulnerable children has been the development of orphanages and childcare institutions. However, experience shows that institutional care does not cater for all the developmental needs of children, and that they develop better in a family environment. In addition, this response fails to recognise that orphans and vulnerable children can provide older people with economic security and psychosocial support. 

Economic support in the form of social assistance to older citizens is a direct and intergenerational poverty reduction mechanism. The issue of social cash transfers to address child poverty has been researched and piloted extensively in the international humanitarian AIDS world. Research has consistently demonstrated the poverty reduction effectiveness of an old age pension in the form of cash transfers, i.e. regular and predictable grants, usually in the form of cash.

Unconditional cash transfers’ are a relatively new instrument in the range of interventions that donors and NGOs have supported in low income countries. But there are some positive experiences with cash transfer programmes to learn from, and early reports from recent, often innovative, cash transfer projects are encouraging. 

Social protection, in the form of a low level of income guarantee, would indeed go a long way to offset the additional financial burdens experienced by older people as carers of orphans and vulnerable children. 

Of the countries most affected by HIV/AIDS, only three in sub-Saharan Africa (Namibia, Botswana and South Africa) have comprehensive social protection measures for older people, in the form of a basic non-contributory pension. In South Africa, where the HIV prevalence is high, non-contributory pension programmes reach a large number of poor older people (1.9 million) at relatively low cost (1.4% of GDP). The programme is financially sustainable, and attracts a large measure of political support. The 640 Rand (about US$75) old-age pension is acknowledged as providing an important complement to income support to older people. It is a vital contribution to the household economy, securing older people’s basic needs and, in households with orphans paying for school fees, clothes or medicines. 
Lesotho has also spontaneously introduced non-contributory social pensions within the last ten years, providing vital assistance to older people who have lost their adult children to AIDS and are increasingly caring for their orphaned grandchildren. 
But most Governments in the region lack the financial resources and management capacities required to implement comprehensive social welfare programmes that would effectively meet all the social protection needs of all their citizens. It is for these reasons that international donors and non-governmental organisations (NGOs) are increasingly stepping in to offer their support to local Governments, communities and households. 

According to ILO estimates, financing a social pension would require less than 1 percent of GDP in low income countries. If well designed, social pensions can reduce poverty and vulnerability among older persons an their households, especially those affected by HIV/Aids and migration, and contribute to production, trade, and growth in poor communities. 

A number of international policy commitments to tackling HIV include older people, but few of these are being met. Key policy commitments include: 

• 2001 UN Declaration of Commitment on HIV/AIDS: This recognises the role played by older people, and pledges to adjust and adopt economic and social development policies to address the specific needs of older carers. The resulting 2006 Political Declaration on HIV/AIDS also recognises the role of older people as carers of orphans and vulnerable children. It commits the international community to scaling up towards universal access to prevention, treatment, care and support by 2010. Despite these commitments and recognition of the role of older people, the indicators used to track progress in implementing the declarations neglect people aged 50 and over. 
   
• Madrid International Plan of Action on Ageing (2002): This global agreement promotes the full realisation of all human rights and fundamental freedoms of older people in all countries. It calls for: improvement in the assessment of the impact of HIV and AIDS on the health of older people infected and affected; provision of adequate information, training in caregiving skills, treatment, medical care and social support; and recognition of the contribution of older people in their role as caregivers. However, these calls are not supported by other UN targets and commitments on HIV, or through the monitoring and data-collection systems. 
   
• European Programme for Action to Confront HIV/AIDS, Malaria and Tuberculosis through External Action (2007-11): The programme calls for country strategies to reflect the fact that family-based and community-based care often plays a crucial role in alleviating the burden of HIV and AIDS, including as an alternative to institutional care for orphaned and vulnerable children, and to take into account the age dimension, with reference to orphaned children and older people who often care for them and may need support to this end in terms of social protection.     

ILO is currently promoting a research on “Old age non-contributory pensions, HIV-AIDS and the World of Work”. The study intends to explore work related effects of old-age non-contributory pensions in recipient households affected by HIV/AIDS in Sub-Saharan Africa and define key policy recommendations in this domain. Besides carrying a worldwide literature review on this issue it is previewed to have case studies in 3 countries: Mozambique, South Africa and Lesotho. The consolidated results of this research should be available in the first trimester of 2010. 

What is the diagonal approach? Between the “vertical financing” and “horizontal financing” of health services in developing countries, there exists a third way, labelled “diagonal financing”. This diagonal approach seems to be an essential concept for the positive evolution of the global structure of health assistance, as explained in Gorik Ooms et al.: “The 'diagonal' approach to Global Fund financing: a cure for the broader malaise of health systems?”, March 2008.

The vertical approach: extra resources are channelled into disease-specific programmes, meaning that the treatment of certain diseases is adequately provided for (the ‘island of sufficiency’). However, in general health systems remain vastly inadequate and understaffed, and in the long run these fragile ‘islands of sufficiency’ come up against major difficulties because of dysfunctional health systems and the problem of staff shortages. 

The horizontal approach: an additional layer is supplied to the vastly insufficient current health expenditure targeting the improvement of health systems in general. Yet total health expenditure remains well below the minimum and across the board health systems remain largely inadequate. 

The “diagonal approach” is based on the idea that programmes targeting specific diseases (e.g. AIDS) must be accompanied by a broader range of activities for the reinforcement of shared health systems (e.g. training and expansion of the health workforce, integration and coordination with other disease programmes, strengthening laboratories, health management, health insurance schemes) if they are to be successful in the long term. Thus the diagonal approach would allow the building of ‘islands’ with a broad and solid base, which could gradually be connected. 

The example of Rwanda: the diagonal approach of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria.

It was in this vein that the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria began a five year project to strengthen health systems in Rwanda in January 2006. Faced with the knowledge that the three diseases were collectively contributing to the highest disease burden in the country, and in view of the very low utilization rate of healthcare services in Rwanda, the Global Fund set out to improve access to quality care. Since evidence indicated that those people within the low-income population who were members of mutual health organisations had a higher level of contact with health services than those who were not members, the Global Fund centred its project on strengthening the development of mutual health organisations in line with the Government policy. The objective of improving access was facilitated by the decision of the Rwandan Government to introduce obligatory family health insurance in 2006. The national obligatory health insurance contribution rate for a basic universal healthcare package was set at FRW 1000 per person per year as from January 2007, with a 10% co-payment due upon treatment at a health centre or hospital. As this seemingly minimal contribution was still out of reach for the poorest Rwandans, the Global Fund set the objective of financing health insurance premiums for the poor, orphans and people living with HIV/AIDS. In 2007 the Global Fund paid premiums for around 800,000 of the poorest Rwandans.

The report, “Mid-term evaluation of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM) 5^th Round Project on Health Systems Strengthening” (2007) describes the progress made and identifies future challenges relating to the implementation of this project in Rwanda.  For more information about the diagonal approach, please read the 4th issue of the G-News, page 25 (compilation prepared by Tess Abbott and Valérie Schmitt-Diabaté, ILO/STEP).