Social Marketing in Health Promotion : Options for Sustainability in HIV / AIDS programmes

The purpose of this review was to assess the effectiveness of social marketing in HIV/AIDS programmes in developing nations and to provide recommendations for improvement which can be applied by Civil Society Organizations. The study was conducted as a desk review of documents on the effectiveness of global HIV programmes, largely accessed through online services. A review was similarly made of behaviour change campaigns in other disease programmes. Generally it was found that behaviour change programmes were most effective during implementation. The effectiveness of programmes tended to decline after programme withdrawal. One of the main reasons for this observed trend was poverty in relation to income access. Because most of the programmes reviewed were based in rural areas where agriculture is the mainstay of the economy, information was provided on how to sustain incomes through agricultural development for rural growth. The approach can also be applied to other industries such as small scale mining and general trade. The recommendations for sustaining programmes beyond the implementation period centered on the development of sustainable market access strategies for small holder farmers, this was mainly through their engagement in formal commercial value chains. Six principles were proffered to guide sustainable engagement, these were: a chain wide collaboration on shared goals; new market linkages; fair and transparent chain management; equitable access to services; inclusive innovations; measurement of outcomes. The author concluded that the improvement of income generation to sustain results of HIV and AIDS social marketing/behaviour change programmes is necessary.


Introduction
The high failure rate of HIV and AIDS programmes in developing nations is of growing concern.Research illustrates that many well funded HIV-prevention programmes that are backed by an impressive array of local and international experts have disappointing results (Campbell, 2003).Main causes of such failure rates include social, economic and cultural obstacles which hinder the project beneficiaries from deriving maximum benefit; other factors include fluctuating levels of commitment by key stakeholders and policy makers.
A study conducted in Botswana regarding the failure of HIV prevention model showed that since the PEPFAR (the U.S. President's Emergency Plan for AIDS Relief) program implemented the ABC model in 2003, there was no significant decline in HIV prevalence rates among adults (SU, 2010).In 2003, UNAIDS reported adult HIV prevalence for Botswana at 25.9%.Five years after the ABC model was widely implemented, the adult HIV prevalence rate remained at approximately 25%.These statistics and many others demonstrate that the ABC model did not dramatically reduce HIV prevalence rates in Botswana as was initially planned.Similarly in 2007 the World Bank funded a $ USD 1 billion Multi Country AIDS Programme in sub-Saharan Africa which was acknowledged to have failed (Harman, 2007).Campbell (2003) also recognizes that many HIV and AIDS programmes have failed because they have not taken into cognizance the social and economic framework of the communities in which projects are implemented.For programme implementers this situation underscores the need to understand why programmes have failed in-order to increase the sustainability of future programmes.

Problem Statement
In 2011 The SADC Secretariat availed a 7 million dollar grant for programmes that address the HIV issues in the region.There is need to review studies that have failed and provide information to be imputed into the design of programmes under the grant and in the wider development community.This information is important to curb the trend of high failure rates that have been documented.This review looks at social marketing programmes that have failed.Common trends are documented and recommendations for programme improvement are given.

Methodology
A literature review was conducted on global and local HIV and AIDS social marketing interventions, their successes and constraints.The reviewed documents were retrieved through online search engines and the following key words were used (HIV + AIDS + Programmes+ developing countries + sustainability).Practical recommendations are put forward for consideration by the targeted CSOs.The rest of this document is structured as follows: Section 3 provides information on the background of HIV and AIDS and its impact with a main focus on Southern Africa.Section 4 reviews the impact of HIV programmes that have been conducted in Southern Africa and provides information for their upgrading.Conclusions and recommendations are provided in Section 5.

HIV/ADIS and Its Impact
Two-thirds of all people infected with HIV live in sub-Saharan Africa, although this region contains little more than 12% of the world's population.During 2010 alone, an estimated 1.2 million adults and children died as a result of AIDS-related illnesses in sub-Saharan Africa (SSA).Since the beginning of the epidemic, more than 15 million Africans have died solely from AIDSrelated illnesses (UNAIDS, 2008).Infection rates among adults in Botswana, South Africa and Swaziland have been reported to be over 20%.The main drivers of the HIV epidemic have been identified as the following: high levels of multiple concurrent sexual partnerships by men and women, inconsistent and incorrect use of condoms, low levels of male circumcision, gender and sexual violence, stigma and lack of openness, and income poverty (UNAIDS, 2008).HIV/AIDS has caused immense human suffering in the continent.The most obvious effect of this crisis has been illness and death, but the impact of the epidemic has undoubtedly not been confined to the health sector; households, educational institutions, workplaces and economies have similarly been severely affected (Avert, 2012).

Economic Impact
Through its impacts on government budgets (direct spending in the health sector), the labour force, households and enterprises, AIDS has played a significant role in the reversal of human development in Africa (UNDP, 2005).The general impact on national economies has made it more difficult for countries to respond to the crisis (Stover and Bollinger, 1999; Avert, 2012).One way in which HIV and AIDS affects an economy is by reducing the labour supply through increased mortality and illness.Amongst those who are able to work, productivity declines as a result of HIV-related illness.Government income also declines, as tax revenues fall.The abilities of African countries to diversify their industrial base, expand exports and attract foreign investment are integral to economic progress in the region.By contributing to labour shortages and making it more expensive thus reducing profits, AIDS limits the ability of African countries to attract industries that depend on low-cost labour.This in turn makes investments in African businesses less desirable (Rosen et al., 2004).For organizations that provide health care as a staff benefit, labour costs can increase because of HIV.In Zimbabwe it was found that the cost of providing health care to staff who worked for a large transport firm (employing over 10 000 workers) was equal to 20% of its profits.Half of the health care expenses were accounted for by treatment of AIDS related illnesses (Ainsworth and Over, 1998).The HIV epidemic diverts government funds at the expense of development in other sectors.It is estimated that treating an AIDS patient for one year is about as expensive as educating ten primary school students over the same time period.AIDS affects the health sector for two reasons: (1) it increases the number of people seeking subsidized services and (2) health care for AIDS patients is more expensive than for most other conditions.The number of AIDS patients seeking care is already overwhelming health care systems.Estimates for budgeted expenditures on AIDS as a proportion of public health budget for Kenya and Zimbabwe are between 50-60% (Stover and Bollinger, 1999).

Households
The toll of HIV and AIDS on households can be very severe.Although no part of the population is unaffected by HIV, it is often the poorest sectors of society that are most vulnerable to the epidemic and for whom the consequences are most severe.In many cases, the presence of AIDS causes the household to dissolve, as parents die and children are sent to relatives for care and upbringing.A study in rural South Africa suggested that households in which an adult had died from AIDS were four times more likely to dissolve than those in which no deaths had occurred.Much happens before this dissolution takes place: AIDS strips families of their assets and income earners, further impoverishing households (Avert, 2012).
In Botswana it is estimated that, on average, every income earner is likely to acquire at least one additional dependent due to the AIDS epidemic.Other countries in the region are experiencing similar problems, as individuals who would otherwise provide a household with income are prevented from working, either because they are ill with AIDS themselves or because they are caring for another sick family member.Such a situation is likely to have repercussions for every member of the family.Children may be forced to abandon their education.In some cases women and young girls may be forced to exchange sexual favours for money or gifts in order to meet their basic needs, support their families and pay for school fees.Sex is therefore used as a commodity and a survival strategy, and such 'transactional sex' most often takes place with older men (who are more likely to be HIV positive).This can lead to a higher risk of HIV transmission, which further exacerbates the situation (ICAD, 2006).Data obtained in South Africa illustrates that poor households coping with members who are sick from HIV or AIDS reduced spending on basic necessities in the following manner: clothing expenditures were reduced by (21%), electricity by (16%) and other services (9%).It was also reported that a decline in incomes forced about 6% of households to reduce the amount they spent on food (HJKFF, 2012).
Concerning gender issues women who traditionally have the main responsibility of providing food for the household and attending to agricultural activities, have the additional burden of looking after the sick.When a family member becomes ill, essential activities that determine household security suffer at a time when the chronically ill member requires nutritious food.In cases where children have to drop out of school to assist with household tasks it is usually the girl-child whose education is compromised further exacerbating gender disparities (ICAD, 2006).
Older people are also heavily affected by the epidemic; many have to care for their sick children and are often left to look after orphaned grandchildren.Older people left caring for the sick face the burden of providing financial, emotional and psychological support at a time when they would usually be expecting to receive more support as their energy levels drop.Due to the amount of time spent caring for dependents, older people may become isolated from their peers as they no longer have the time to dedicate to their social networks that need to be fostered to prevent isolation and loneliness (Matshalaga, 2004).

The impact on children
The epidemic not only causes children to lose their parents or guardians, but sometimes their childhood as well.As parents and family members become ill, children take on more responsibility to earn an income, produce food, and care for family members.It is harder for these children to access adequate nutrition, basic health care, housing and clothing.Because AIDS claims the lives of people at an age when most of them already have young children, more children have been orphaned by AIDS in Africa than anywhere else.Many children are now raised by their extended families where they are vulnerable to abuse and some are even left on their own in child-headed households.Studies conducted in Southern Africa on the associations between HIV/AIDS and food security show that households without active adults earned 31 percent less income than households with active adults it was also reported that households with two chronically ill adults had 66 percent less income than households without chronically ill adults (SADC/FANR, 2003).

The Impact on Education Sector
HIV/AIDS is affecting providers of education, including teachers as well as pupils and students.In Southern and Eastern Africa, many countries are losing teachers to AIDS or facing HIVassociated teacher absenteeism on a scale that has a severe impact on the ability to supply education and to reach education for all target groups.At the same time, demand for education is affected, since many children are facing HIV-related illness or death of parents or siblings.This can compromise their ability to attend school and their performance, as they remain home to care for sick family members or to find work to compensate for lost family incomes.In Uganda, it was found that among children in the 15-19 year age group whose parents had died, only 29 percent had continued school undisrupted; 25 percent had lost school time, and 45 percent had dropped out of school.The school-age children with the greatest chance of continuing their education were those who lived with a surviving parent.It is unfortunate that HIV is affecting the very sector that can respond directly and effectively to the pandemic, by providing both education to promote sexual behaviour change and the long-term perspectives and plans that are needed to motivate this behaviour change.(Sengendo and Nambi, 1997: Grassly et al, 2003)

Impact on Agriculture
Agriculture is the mainstay of most SSA economies with an estimated 60-70% of the population surviving directly or indirectly off Agriculture.In addition to harsh climatic conditions and poor investments by governments in Agriculture, HIV presents a major social constraint to the development of the sector.Most farmers in the region are small holders and their farm operations rely on manual labour.HIV/AIDS has caused a decline in the supply of labour for food and livestock production.The decline is caused by the illness and deaths of people living with AIDS and by the time spent by household members in caring for sick relatives.In Tanzania, a study found that women who cared for the chronically ill spent 45 per cent less time on agricultural tasks than women in whose households had no chronically ill members.Decline in food production for reasons that include labour shortages have also been documented in Burkina Faso and Swaziland.In two villages in Burkina Faso, for example, revenues from agricultural production declined by 25-50 per cent as a result of AIDS.The Government of Swaziland reported a 54 per cent drop in agricultural production in AIDS affected households.(UNDEPSA, undated).HIV/AIDS has also caused shifts of production from cash crops to food crops in AIDS-affected households.This is because in some households input credit for cash crop production is accessible by the male head or by parents.Child and women headed households cannot in some cases access credit required for engagement in cash crop production.The change has resulted in lower household incomes and a lack of funds to buy non-food essentials or non labour inputs necessary to maintain agricultural yields (UNDPESA,undated).Studies in Nigeria showed that women were not seen as being able to make any meaningful economic achievements and as such they were denied loan facilities (Pitamber, 2003).Similarly Eze and Ugochukwu (2004) showed that there is still some level of gender bias against rural women in the area of credit supply from financial institutions.In light of the devastating impact of AIDS governments have responded through the development of national strategies and policies that guide the implementation of HIV and AIDS programming.Most of the strategies and policies are articulated in the SADC HIV and AIDS Strategic Framework for 2010-2015 and have guided interventions by governments and NGOs.There is a need to understand what has affected uptake and sustainability of recommended practices among communities and proffer suggestions of approaches that organizations in HIV and AIDS programming can mainstream to ensure that interventions are sustainable.

Effectiveness of HIV and AIDS Programmes: The role of access to income
The range and mix of interventions needed to address the HIV and AIDS pandemic vary by country depending on local epidemiology and sociocultural context.Generally components of the HIV and AIDS response strategies have included but are not limited to the following: education on the 'ABCs' of prevention (abstinence/delayed sexual initiation, being safer by being faithful to one's partner/reducing the number of sexual partners, and correct and consistent condom use), treatment and care of sexually transmitted infections, voluntary counselling and testing services, prevention of mother-to-child transmission, harm reduction, safe blood supplies and medical injections, and addressing discrimination and stigmatization (UNAIDS, 2008).
The success of most of the interventions outlined is underpinned by behaviour change in target communities which will lead to the sustained uptake of the recommended best practices.In this regard social marketing in HIV and AIDS programming becomes a key element.The sustained uptake of recommended practices also relies on improving access to income among the poor and vulnerable groups (ILO, undated).Evidence illustrates that where poverty and income is not sustainably addressed the effectiveness of HIV and AIDS programmes diminishes soon after implementation.For households that are affected by HIV, the negative impact originates from the loss of earnings versus the need for increased expenditure for medical and health care.The need for income also increases with the demand for healthier food and transportation expenses to health facilities.Where families fail to cope with the increased expenses treatment is not adequately accessed and poor nutrition compromises effectiveness of treatment.In South Africa a HIV and AIDS programme which targeted the treatment of STI's in a mining community was reported to have failed.Not only was there no reduction of STIs observed over 3 years, but STI levels actually rose amongst mineworkers, one of the key target groups.Part of the explanation for the project's results lie in social and economic obstacles which hindered the likelihood that project beneficiaries (in particular mineworkers, commercial sex workers and young people) would derive maximum benefit from state-of-the-art STI control efforts and peer education (Campbell, 2003).
In many African countries poverty also negates the effectiveness of HIV programming among groups who are involved transactional sex.In several regions, significantly higher rates of sexually transmitted infections (STIs) and HIV are found among sex workers and their clients in comparison to other population groups.In many cases clients pay sexual workers more for unprotected sex (UNAIDS 2008).Therefore without economic development programmes that will provide sex workers who seek alternative sources of income with choices the effectiveness of HIV programmes is threatened (CHGE, 1999).These poverty dynamics do not only affect HIV for instance in a malaria prevention campaign in Uganda it was observed that without subsidies on mosquito nets the use drastically fell among poor communities.During community-based distributions (campaigns) use of the treated mosquito net reached 80% coverage among the targeted population.However, following the campaign distributions a drop in coverage was observed in the range of 5-13%-points per year for the first two years mainly because of affordability.The implication of this is that where behavior change for HIV and AIDS prevention/treatment and other health interventions requires financial input, the CSOs implementing the programmes need to also include income generation activities in their project design.Their project design should also include a research component on the dynamics of treatment use among different socio-economic groups.The results would allow for the advocacy for governmental financial support policies to the most vulnerable groups.However because of financial constraints in most developing countries access to affordable or free treatment even where governments provide subsidies will be limited.In addition even where free services are provided in rural areas transport fees can prevent some from accessing needed treatment (ICAD, 2001) In mainstreaming income generation in HIV programming the question then becomes how to position social campaigns for behaviour change within public health programmes and how to link these activities to sustainable income generating activities.

Mainstreaming Income Generation into HIV Programmes for Sustainability: New Approaches
Most of the rural poor live off agriculture and boosting agriculture production and marketing will contribute to increasing income for the majority (World Bank, 2007).The development of agriculture in countries where the majority of the poor live off it will provide an engine of growth for other sectors through multiplier effects.This section thus focuses on sustainable ways to increase income generation through agriculture.The approaches proposed can be applied to alternative industries such as small-scale mining, clothes manufacturing and general trade.To be effective in boosting agriculture there is need to not only increase yields but to facilitate commercial production even on a small-scale.To successfully commercialize smallholder production there is need to engage farmers in formal value chains (ILO, undated: Vorely, Ferris, Don Seville, Lundy, 2009).This is very important because lack of access to markets is a key constraint to the improvement of agricultural productivity in smallholder farming systems.By engaging farmers in commodity value chains deliberate effort is made to remove barriers to entry in formal markets by all stake-holders involved in the market chain.The value chains should not only focus on improving farm incomes but making more nutritious food available on the market.By linking smallholder farmers to formal agricultural value chains and increasing income, the burden of providing free treatment to governments in developing countries which already struggle because of limited resources will be lightened (ILO, undated: Vorely, Ferris, Don Seville, Lundy, 2009).
In Mozambique commercial production of the orange fleshed sweet potato (OFSP) has been instrumental in raising farmer incomes and availing nutritious food on the market.OFSP contain high levels of vitamin A, 125g of fresh tuber supply the daily Vitamin A requirements for children who are under 5 years of age (CIP, 2012).The promotion of OFSP value chain in Mozambique involved raising awareness of their nutritional benefits among farmers, traders and consumers.The action resulted in an increased demand of the OFSP.Market assessments illustrated that the proportion of OFSP, compared with white fleshed sweet potato, sold in four urban markets increased from less than 1 percent in 2006 to 18 percent in 2008 and to 50 percent in 2009 (Hawkes and Ruel, 2011).To promote diversification the engagement in of farmers in value chains should also link them to markets in niche products.There is scope for farmers to collect wild fruits and process it into products such as cosmetic oils and health supplements.This has already been successfully explored in marginalised communities and the collection of forest products is significantly contributing to household income (Kalinganire and Koné, 2011).For the engagement of farmers in value chains from which they have been traditionally excluded there are six recommended principles (Varely, Ferris, Don Seville and Lundy, 2009).The details of the six principles that should guide the action are briefly discussed below.
A chain wide collaboration on shared goals: This principle ensures that all chain actors gravitate towards the same direction and this is based on value chain actors developing and setting common goals, action plans and resolving challenges.

New market linkages:
Where farmers have limited access to markets and opportunities for trade exist, this principle promotes the incorporation of small farmers in the new business models.Strategies are to be designed in a manner that doesn't disadvantage small-farmers.In this regard policy support is vital to stimulate inclusion of smallholders in formal business ventures.Policy strategies that have been effective in other countries include (1) mandating private sector to have a specified quota of their supplies provided by small-holders and (2) tax reductions for organizations that support small-holders.The new market linkages should include the design and provision of viable services (financial and technical) for farmers and be effective in uplifting smallholder farmers out of poverty.For buyers, these linkages must provide a consistent supply of safe, quality products at a competitive price and with low transaction costs.

Fair and transparent chain management:
This principle refers to the setting, monitoring and enforcement of formal and informal rules along the chain.The rules cover issues of price setting (including conditions for awarding premium prices) as well as grades and standards and regularity of delivery.Fair and transparent governance also covers clear commitments to buy and sell certain volumes of certain grade products at certain times, and equitable processes of risk management.The processes of chain governance needs to be facilitated through instruments such as the transparent design of user friendly contracts, participatory development, management and consistent application of standards, improved forecasting and planning as well as clear, consistent and known guidelines for pricing.
Equitable access to services: This principle seeks to enhance the access of farmers to extension support, namely, access to weather forecasts, production guidelines and market information.It also seeks to meet the farmers needs for access to credit and/input provision services.Different models can be adopted in different systems depending on the most feasible option.Inclusive innovations: This principle focuses in having all actors in a value chain being afforded the opportunity to contribute to innovations and novel ideas that can drive the business growth.It aims to move away from innovations that involve only part of the actors in the supply chain, which in recent historic times normally means exclusion of small-holder producers from participating in innovation.Measurement of outcomes: This principle inculcates the regular review of the economic (cost benefit), social (including gender aspects and labour issues), household food security and environmental facets related to development of the value chain.It is crucial that cumbersome, complex and costly review processes/methodologies are kept to the minimum and the results from reviews are shared among all stake holders and used for profitable action.As mentioned earlier on these principles should be appropriately used to engage poor households in other value chains outside agriculture and deliberate effort should be made to engage households affected by HIV.

Conclusions and Recommendations
The implementation of social marketing/behavior change programmes is central to HIV and AIDS interventions.However in countries where poverty restricts access to treatment or uptake of behavior change interventions HIV programmes should be complemented by income generation interventions.In rural areas of Southern Africa agriculture is the main source of livelihood and commercializing activities through linking farmers to commodity value chains provides scope to improve the welfare of HIV/AIDS affected households.For programmes that link farmers to value chains efforts should also be made to promote the production and the sale of nutritious food which is beneficial to HIV patients.Engagement in agricultural value chains should also seek to sustainably engage low income households in the export of high value forest products.Value chains should also be developed for other industries.Deliberate policies should engage disadvantaged households in trade through setting up platforms where deliberations and planning for successful business are undertaken.