the impact of morbidity and mortality on municipal human resources and service delivery: an analysis...

The Impact of Morbidity and Mortality on Municipal Human Resources and Service Delivery: An Analysis of Three African Cities

Zara Sarzin, AFTU1

World AIDS Day

29 November 2005

Agenda

1. Preliminary Results from “The Impact of Morbidity and Mortality on Municipal Human Resources and Service Delivery: An Analysis of Three African Cities”

2. Mainstreaming HIV/AIDS into Urban Projects: Rationale, Strategies and Tools

The Impact of HIV/AIDS on Municipal Service Delivery

Expands the demand for municipal services, particularly health and social welfare services

Raises the direct and indirect costs of

labour, undermining the efficiency and

quality of municipal service provision

Impacts local revenue collection and the

affordability of services

Local authorities often lack the capacity to assess the impact, and develop and implement effective HIV/AIDS interventions

Purpose and Rationale of the Study

Identify gaps in human resource management,

and strategies for improving data

collection, collation and analysis

Identify gaps in human resource management,

and strategies for improving data

collection, collation and analysis

Reinforce leadership commitment to

addressing HIV/AIDS workplace issues and help municipalities to

advocate for resources

Reinforce leadership commitment to

addressing HIV/AIDS workplace issues and help municipalities to

advocate for resources

Establish a methodology—results

can be refined iteratively over time as

data collection and collation improves

Establish a methodology—results

can be refined iteratively over time as

data collection and collation improves

Assist municipalities to allocate resources

across different workplace

interventions

Assist municipalities to allocate resources

across different workplace

interventions

Assist municipalities with forward planning

and budgeting

Assist municipalities with forward planning

and budgeting

Facilitate comparisons to be made and

experiences to be shared across participating

municipalities

Facilitate comparisons to be made and

experiences to be shared across participating

municipalitiesDevelop a simple modelling tool to

evaluate the impact of morbidity and

mortality on municipal human

resources

Develop a simple modelling tool to

evaluate the impact of morbidity and

mortality on municipal human

resources

Contribute to the effectiveness of Urban, Health and HIV/AIDS

operations

Adapt the methodology and model for use by other local authorities

Consistent with the Urban Sector’s broader strategic contribution to the

MDGs

A Typical Council Clinic?

18 employees 2 deaths in the last 3

years: a midwife and a member of the support staff

The midwife was absent 9 months in the year she died and 6 months in each of the 2 previous years—she was only able to fulfill 30-50% of her duties when at work

Replacement midwife can only fulfill 70% of job requirements

6 members of staff are known to be HIV positive

1. Increased workload for other staff members

2. Reduction in the comprehensiveness and quality of care

3. Cutback in outreach services

4. Reduced time for one-on-one counselling

Consequences for Service

Delivery

Workplace Profile

• 1,252 employees: one third are support staff earning around $100 pm; 45% are semi skilled earning around $150 pm

• 1,538 teachers

• 1,298 employees: 30% support staff earning around $75 pm; 50% semi-skilled workers earning around $120 pm

• 2,437 teachers

• 13,345 employees: 77% support staff earning around $160 pm

• 60% live in informal settlements

• Understaffed in senior and technical cadres

Municipal Profiles

City Profile • 1.2m residents (40% of urban population)

• Day-time population over 2m

• Contributes over 50% of national GDP

Kampala City Council

• 0.64m residents

• One of 3 municipalities established in 2000 after the dissolution of the Dar es Salaam City Commission

Ilala Municipal Council

• 2.14m residents (third of urban population)

• Day-time population of 3.5m

• 50% below poverty line, 60% live in informal settlements

• Contributes 50% of national GDP

City Council of Nairobi

Leading Causes of Morbidity and Mortality: Dar es Salaam, Tanzania

Leading Causes of Mortality in Adult Men

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

2002 50.3% 18.5% 9.2% 6.9% 2.3%

HIV/AIDS/TBAcute Febrile

IllnessUnintentional

InjuriesCardiovascular

Disorders

Acute Abdominal Disorders

• HIV/AIDS/TB is the leading cause of death for adults aged 15-59 years (50.3 percent for men and 61.9 percent for women) and accounts for 31 percent of Years Life Lost.

• Acute Febrile Illness (mostly malaria) is the second leading cause of death (18.5 percent for men and 14.8 percent for women) and accounts for 9.8 percent of Years Life Lost.

Leading Causes of Mortality in Adult Women

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

2002 61.9% 14.8% 3.7% 3.2% 2.6%

HIV/AIDS/TBAcute Febrile

IllnessCardiovascular

DisordersUnintentional

InjuriesNeoplasms

Source: AMMP, Dar es Salaam Sentinel Surveillance Site

Leading Causes of Morbidity and Mortality: Kampala, Uganda

• HIV/AIDS, TB and malaria are the most significant causes of morbidity and mortality in Uganda.

• Nationally, malaria is the leading cause of death, killing 400 Ugandans daily, mostly pregnant women and children under five.

• The 1995 Burden of Disease study attributes over 60 percent of life years lost from premature death to five groups of preventable conditions, including malaria (15.4 percent), acute lower respiratory tract infections (10.5 percent) and AIDS (9.1 percent).

Source: MOH, Reported Cases at Health Clinics in Kampala

Leading Causes of Morbidity (Kampala Clinics)

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

2002 43,084 13,779 12,948 3,047 8,071 4,474 3,584 3,843 1,906 2,893

2003 94,278 39,639 36,754 12,984 34,555 10,224 7,740 8,214 8,743 8,239

2004 92,766 36,073 23,769 16,377 13,636 11,605 10,600 7,309 7,242 6,283

MalariaCough or

ColdDental

ConditionsAIDS

Eye Infections

Intestinal Worms

Genital Infections

Skin Diseases

Pneumonia Urinary Tract

Infections

Leading Causes of Morbidity (CCN Clinics)

-

20,000

40,000

60,000

80,000

100,000

120,000

2004 119,913 40,196 33,198 20,870 20,806 9,750 5,489 4,988 4,580 4,534

Respiratory Diseases

MalariaSkin

DiseasesTyphoid

Diarrhoeal Diseases

Intestinal Worms

Eye Infections

Rheumatism, Joint Pain, etc

AccidentsUrinary Tract

Infections

Leading Causes of Mortality (CCN Clinics)

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

2004 4,014 2,878 2,184 1,471 1,272 1,261 1,173 1,092 589 529

Pneumonia TBOther

CausesCancer Malaria Meningitis AIDS

Respiratory Diseases

Gastro Anaemia

Leading Causes of Morbidity and Mortality: Nairobi, Kenya

• Respiratory diseases and malaria are the leading causes of morbidity, while HIV/AIDS and related opportunistic infections (including TB, pneumonia and meningitis) are the most significant causes of death.

Source: Medical Officer of health, City Council of Nairobi

HIV/AIDS Profile

• Higher incidence and prevalence rates in women.

• Significant differences in prevalence rates between urban and rural areas, strong regional variations.

• Most prevalent in adults during the most productive years of their lives.

• Closely associated with the HIV epidemic, is the rising incidence of TB in all three countries.

Kenya Uganda Tanzania

Adult Prevalence (15–49 years) 7.5% 4.1% 8.8%

Urban Prevalence 10% 10.7% 10.9%

Rural Prevalence 5.6% 6.4% 5.3%

Estimated number of people living with HIV/AIDS (0-49 years)

1.6 million

0.35 to 0.88 million

1.2 to 2.3 million

Reported number of people needing antiretroviral therapy in 2004

233,831 114, 000 263,000

Reported number of people receiving antiretroviral therapy (15-49 years)

38, 000 63,896 8,300

Employee Deaths: City Council of Nairobi

City Council of Nairobi: Number of Employee Deaths

189 190 197 198

0

50

100

150

200

2001 2002 2003 2004

Crude Death Rate:

1% 1% 1.1% 1.4%

Employee Deaths: Kampala City Council

Year Teachers All Other Staff

1998 Not recorded 28

1999 Not recorded 36

2000 1 Not recorded

2001 10 25

2002 24 19

2003 16 11

2004 14 20

Jun-05 4 Not recorded

• Approximately 75 percent of teacher deaths are attributed to “long illness”.

Employee Deaths: Ilala Municipal Council

0

5

10

15

20

25

30

35

40

45

50

Administration 3 2 3 9 7 7

Finance 1 1 0 0 1 0

Health 4 10 14 15 5 1

Planning and Coordination 3 6 5 2 5 2

Rural Development 1 0 1 0 0 2

Education 11 18 26 8

Trade and Informal Sector 1 1 0 3 0 1

Waste Management 0 0 1 1 1 0

Works 0 1 4 2 1 1

Total 13 21 39 50 46 22

2000 2001 2002 2003 2004 2005

Notes: 1. No data on teacher deaths for 2000 and 20012. Half a year of data for 2005

Crude Death Rate 1% 1.2% 1%

Employee Deaths: Ilala Municipal Council

IMC Teacher Deaths by Cause

0

5

10

15

20

25

30

35

Accident AIDS Diabetes Malaria TB Unknown

2002

2003

2004

2005 until June

Total

Data Limitations

Little robust data on the health status of municipal employees

Not possible to disaggregate prevalence rates for different categories of municipal employees

Finding credible data on incidence is problematic.

Difficult to accurately determine the causes of illness or death in the workplace.

Municipal information and human resource management systems are very weak.

Little information available on the cost and impact of different workplace interventions

Little impact on employer costs

Symptoms Appear

Absenteeism increases, productivity falls, and health care

costs rise.

AIDS

The municipality meets funeral expenses, and

a terminal benefit is paid out of the pension

scheme.

Death

Recruitment and training costs, several

months before the replacement worker is fully productive.

Following Death InfectionYears from Infection

(Illustrative)

(5 years) (9 years) (10 years)

Stream of costs arising from a new infection

PV of a New HIV Infection: City Council of Nairobi

Cost per New HIV Infection(3% Discount Rate)

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

Present Value at 3% 1,460,965 756,757 547,221 358,326 -

Average Salary 760,698 375,048 260,299 156,853 -

1. Managers (Grades 1-5)

2. Supervisors and

Professionals

3. Semi-Skilled

(Grades 10-

4. Support Staff (Grades

14-19)

Category not defined

Approximately 2x salary at a

discount rate of 3%

PV of a New HIV Infection: Kampala City Council


-

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

40,000,000

45,000,000

Present Value at 3% 38,567,512 11,946,523 6,231,818 4,601,339 4,260,876

Average Salary 27,226,855 7,262,101 3,313,595 2,313,933 2,002,104

1. Managers (U1,U2)

2. Supervisors and

Professionals

3. Semi-Skilled (U5,

U6, U7)

4. Support Staff (U8)

5. Teachers (All Grades)

Approximately 1.5x salary at a discount rate of

3%

PV of a New HIV Infection: Ilala Municipal Council


-

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

Present Value at 3% 5,188,632 3,139,803 1,935,724 1,349,190 2,200,741

Average Salary 4,965,023 2,794,733 1,519,272 976,787 1,800,000

1. Managers2. Supervisors

and Professionals

3. Semi-Skilled

4. Support Staff

5. Teachers (All Grades)

Approximately 1x salary at a

discount rate of 3%

Projected Aggregate Cost of HIV/AIDS in the Municipal Workplace

2006 2007 2008 2009 2010

City Council of Nairobi

HIV/AIDS Related Costs 52,682,397 57,393,941 59,918,437 62,569,158 65,352,415

Wage Bill 2,517,012,961 2,499,733,461 2,481,947,811 2463629809 2444751946

Cost % Wage Bill 2.1% 2.3% 2.4% 2.5% 2.7%

Kampala City Council


Wage Bill 8,142,188,649 8,549,298,082 8,976,762,986 9,425,601,135 9,896,881,192

Cost % Wage Bill 1.3% 1.5% 1.5% 1.5% 1.5%

Ilala Municipal Council


Wage Bill 6,662,048,433 6,861,909,885 7,067,767,182 7,279,800,198 7,498,194,203

Cost % Wage Bill 1.1% 1.2% 1.2% 1.2% 1.1%

Impact of Prevention and Treatment Programmes

Prevention Programme Treatment Programme

Description Information, Education and Communication (IEC), provision of condoms etc.

Antiretroviral treatment for HIV positive employees.

Costs Modelled simply as a fixed amount per employee in the workplace.

The cost of a first-line drug regimen for all HIV-positive employees.

Benefits New HIV incidence rate falls (new infections are avoided).

Life expectancy of HIV-positive employees is extended (productive time in the workplace is extended and the costs associated with death are deferred).Absenteeism is reduced and productivity improves.Medical expenses as a result of the treatment of opportunistic infections falls.

Net benefit The present value of the avoided costs less the cost of the prevention programme.

The present value of the avoided costs less the cost of the treatment programme.

• Non-financial benefits of workplace interventions: additional benefits might accrue as drug prices fall, new treatments are developed and public infrastructure to treat HIV/AIDS expands; municipality buys time to expand and implement responses; impact on employee morale, institutional memory; labour relations

Impact of Workplace Interventions: Treatment Programme

City Council of Nairobi Kampala City Council Ilala Municipal Council

Discount Rate of 3%

Positive return to providing treatment for all employees

Cost of treatment outweighs benefits for support staff and teachers. Positive return to providing treatment for all employees if municipality meets 50% of treatment costs.

Positive return to providing treatment for managers and supervisors. Positive return to providing treatment for almost all employees if municipality meets 50% of treatment costs.

Discount Rate of 10%



Positive return to providing treatment for managers and supervisors. Positive return to providing treatment for all employees if municipality meets 50% of treatment costs.

• Assumes that treatment begins on average in the sixth year following infection, and results in a four-year extension to life expectancy. Absenteeism and productivity losses are reduced.

Impact of a HIV/AIDS Prevention Programme: KCC

Table 9.3: Kampala City Council (UGSH)

Number of Employees

Cost of Prevention Programme (US$ 10 per

person)Infections Averted

Benefit of Prevention Programme (PV Cost of

Infections Averted)

"Break Even" Infections to

Avert

2006 UGSH 50% @ 3% @ 10% @ 3% @ 10%

1. Managers (U1,U2) 34 596,207 0 5,966,394 3,219,798 0 0

2. Supervisors and Professionals (U3-U4) 127 2,227,008 1 6,903,298 3,724,479 0 0

3. Semi-Skilled (U5, U6, U7) 693 12,152,098 9 58,949,574 31,885,887 2 4

4. Support Staff (U8) 397 6,961,591 2 8,311,628 4,510,856 2 3

5. Teachers (All Grades) 1538 26,969,591 7 29,817,187 16,178,048 6 12

Total 2789 48,906,494 19 109,948,082 59,519,069

• Assuming the programme costs US$ 10 per person and that the impact of the programme is a 50 percent reduction in HIV incidence rates, then the financial benefits of the programme outweigh the financial costs of the programme.

Impact of a HIV/AIDS Prevention Programme: CCN

Table 9.2: City Council of Nairobi (KSH)

Number of Employees


person)Infections Averted


Infections Averted)


Avert

2006 KSH 50% @ 3% @ 10%@ 3% @ 10%

1. Managers (Grades 1-5) 65 52,647 0 633,876 348,103 0 0

2. Supervisors and Professionals 621 502,985 4 3,136,891 1,721,120 1 1

3. Semi-Skilled (Grades 10-13) 2394 1,939,044 48 26,233,686 14,383,334 4 6

4. Support Staff (Grades 14-19) 10274 8,321,529 69 24,573,638 13,454,754 23 42

Total 13354 10,816,206 121 54,578,091 29,907,312

• Assuming the programme costs US$ 10 per person and that the impact of the programme is a 50 percent reduction in HIV incidence rates, then the financial benefits of the programme far outweigh the financial costs of the programme.

Impact of a HIV/AIDS Prevention Programme: IMC

• Assuming the programme costs US$ 10 per person and that the impact of the programme is a 50 percent reduction in HIV incidence rates, then the financial benefits of the programme outweigh the financial costs of the programme at a discount rate of 3% (approximately break-even at a discount rate of 10%).

Table 9.4: Ilala Municipal Council (TSH)

Number of Employees


person)

Infections

Averted


Infections Averted)


Avert

2006 SH 50% @ 3% @ 10% @ 3% @ 10%

1. Managers 41 442,800 0 1,451,909 788,262 0 0

2. Supervisors and Professionals 171 1,846,800 1 3,664,386 1,986,802 1 1

3. Semi-Skilled 765 8,262,000 16 30,319,965 16,404,771 4 8

4. Support Staff 442 4,773,600 3 4,070,034 2,202,675 4 7

5. Teachers (All Grades) 2437 26,319,600 17 36,603,872 19,817,783 12 22

Total 3856 41,644,800 37 76,110,166 41,200,293

Conclusions

Morbidity and mortality contributes both directly and indirectly to the municipal wage bill. There is an opportunity cost to this additional spending, which could otherwise be directed to more productive municipal activities.

The present value cost of a new HIV/AIDS infection is roughly twice the annual salary of the employee;

The annual cost of HIV/AIDS in the workplace is 1-2% of the wage bill.

Disease undermines the capacity of the municipality to deliver services through increased absenteeism, lower productivity, and the loss of experienced and knowledgeable staff.

Conclusions

There are three main strategies that the municipality can employ to manage the impact of morbidity and mortality on municipal human resources and service delivery:

1. Investing in prevention activities including Information, Education and Communication (IEC), and the promotion and distribution of condoms in the workplace

2. Investing in the treatment and care of sick employees

3. Investing in broadening the skills of employees to facilitate re-allocation of responsibilities and establish career development and succession plans.

Conclusions

Prevention and treatment are in most cases profitable investments.

These investments may have other non-financial benefits including skills retention, improving morale in the workplace, improving labour relations, buying time for advances in medical research and falling costs of drugs, and demonstrating local government leadership.

The ethical and moral imperatives to act are also very high.

Next Steps

Validation of assumptions, methodology and results with each of the municipalities who participated in the study, possibly through a series of small workshops;

Refinement of the model based on the outputs of these workshops;

Development of a manual to accompany the modelling tool; and

Production and dissemination of appropriate learning tools such as a CDROM.

Agenda

1. Preliminary Results from “The Impact of Morbidity and Mortality on Municipal Human Resources and Service Delivery: An Analysis of Three African Cities”

2. Mainstreaming HIV/AIDS into Urban Projects: Rationale, Strategies and Tools

Rationale for Mainstreaming HIV/AIDS into Urban Projects

Urban bias of the HIV/AIDS epidemic

Local authorities and the urban projects that support them are strategically placed to respond

Local authorities are themselves directly affected by HIV/AIDS

Internally: impact on municipal human resources and supply of services

Externally: impact on local revenues and demand for services

Local authorities are often overwhelmed and ill equipped to deal with these challenges

Mitigates project risks

Opportunities to leverage funds for HIV/AIDS interventions

Strategies for Mainstreaming HIV/AIDS into Urban Projects (1)

Workplace HIV/AIDS Interventions

Provide information, education and communication (IEC) and condoms within the counterpart organisation (including public utility companies, asset holding companies, municipalities, and project management units).

Support counterpart organisation to develop HIV/AIDS workplace policies and programmes.

Support counterpart authorities to establish focal points for HIV/AIDS and/or AIDS committees to coordinate interventions.


Sensitisation of beneficiary communities

Provide IEC and condoms to communities affected by the project, including construction sites

Municipal capacity building

Integrate capacity building on HIV/AIDS into curriculum for municipal planners.

Support LAs in designing and implementing HIV/AIDS activities (workplace programmes, community outreach, mainstreaming of HIV/AIDS into municipal activities).

Support LAs to coordinate HIV/AIDS service providers, and build a coordinated referral system in the city.

Support local authorities to monitor and evaluate community interventions.


Mainstreaming within infrastructure investments

Support HIV/AIDS related infrastructure within the context of infrastructure investments. For example, the project might include VCT centres, youth centres and AIDS orphanages in investment menus or plans. Ensure linkages with existing Health and HIV/AIDS projects.

Municipal and public work contracts

Integrate performance based agreements with measurable HIV/AIDS activities into municipal and public works contracts.

Safeguards

Include an assessment of the impact of the project on HIV/AIDS mitigation.


Internal and external partnerships

MAP and Health projects

Related operations (including PSD, transport and other sectors) within the region

Other Bank partners (including Global AIDS Unit, WBI and others)

IFC and private sector initiatives (especially when working with large municipal providers and private contractors)

Global partners (e.g. Global Fund, Gates Foundation, UNAIDS, PEPFAR)

Relevant NGOs and associations


Monitoring and Evaluation

Design project M&E to include HIV/AIDS related indicators.

Analytical and Sector Work

Integrate HIV/AIDS into sector analysis work or into larger pieces of urban analysis in order to identify the impact of HIV/AIDS on the sector and those HIV/AIDS issues that could be addressed through Bank or donor funded projects or programmes.

Resources and Tools

1. Local Government Handbook and CD-ROM

2. Urban Website: Local Government Responses to HIV/AIDS

3. Lessons and Experiences from Mainstreaming HIV/AIDS into Urban/Water (AFTU1 & 2) Projects

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