Barriers to accessing conventional schooling for children and young people affected by HIV and AIDS in sub-Saharan Africa: A cross-national review of the research evidence
Dr. Pat Pridmore,
Institute of Education,
University of London.
Abstract
This paper reviewsexisting evidence access to conventional schooling and learning in high HIV prevalence areas in sub-Saharan Africa in order to develop a holistic picture of the way that barriers at the household/family level and at the school level can reduce educational access.
The findings reveal the complex nature of the educational impact and show that broad adaptive capacities are emerging that may enable households to support a larger number of orphans. However,a key finding from this review is that many impoverished households in high HIV prevalence areas are reaching the limits of their capacity to cope, leading to reduced educational access and attainment for affected children, especially maternal orphans who are a particularly disadvantaged group in terms of schooling, even relative to other poor children. At the same time schoolsare increasingly challenged tomeet the educational andemotional needs of the children who walkin through their door and are unlikely to reachout to the youngpeople who cannot attendregularly.
The findings imply that there is a need for educational reform to move away from the ‘one size fits all’ view of schooling and to think creatively, ‘out of the box’, about alternative, more flexible forms of educational delivery. It is argued that ODFL systems and structures could play auseful role infacilitating such educational reform bysharing the burden facedby schools and helpingto integrate responses tolearners' needs more effectivelyand the need for more case studies and pilot interventions in specific contexts to be conducted in specific cultural context to be able to make effective policy recommendations and inform practice. The review concludes with a call for more case studies and well evaluated interventions in specific social and cultural contexts.
Table of Contents
1. Introduction
1.1 Background
1.2 Method
1.3 Defining key terms
1.4 Organisation
2. Household/family level barriers to education
2.1 Childhood malnutrition and infection
2.2 Changing patterns of household organisation and increased child migration
2.3 Parental ill health and death, increased poverty and demand for child labour
2.4 Family skepticism and intra-household discrimination against orphans
2.5 Trauma, child abuse and pregnancy
2.6 Loss of social cohesion
3. School level barriers to education
3.1 Lack of support for the special educational needs of HIV-affected children
3.2 Gender-based violence, stigma and discrimination
3.3 Reduced supply and quality of education
4. Discussion and conclusion
4.1 Implications for case study design
4.2 Implications for the design of an intervention package
4.3 Concluding comments
References
List of abbreviations
AIDSAcquired Immune Deficiency Syndrome
ACEM Association of Christian Educators in Malawi
ARTAnti-Retroviral Treatment
CBEPComplementary Basic Education Programme
CRCConvention on the Rights of the Child
DFIDDepartment for International Development (UK Government)
DHSDemographic Household Survey
EFAEducation for All
EMISEducation Monitoring Information System
ESRCEconomic and Social Science Research Council
FAOFood and Agriculture Organisation
HIVHuman Immunodeficiency Virus
IFSWInternational Federation of Social Workers
HISIntegrated household survey
IRINUN Office for the Coordination of Humanitarian Affairs
MDGMillennium Development Goals
MOEMinistry of Education
MTCTMother to child transmission
ODFLOpen Distance and Flexible Learning
OVCOrphans and other vulnerable children
SSASub-Saharan Africa
UKUnited Kingdom
UNUnited Nations
1. Introduction
1.1 Background
This review paper is one of five being prepared within the initial work programme of a three-year DFID-ESRC funded research study. The study seeks to develop a more flexible model of schooling for high HIV prevalence areas through strengthening open, distance flexible learning (ODFL) systems to complement conventional schooling. The field work for the study will be carried out in MalawiandLesotho where AIDS is recognised to be a major threat to national development. The study rationale clusters around three main issues.
Firstly, the rapid increase in the number of children orphaned by AIDS in sub-Saharan Africa (SSA) which is projected to continue over the next decade. In SSA alone by 2005 over 12 million children 0-17 years had been orphaned by AIDS and 46 million by all causes. (In Malawi559,000 had been orphaned by AIDS and 950,000 by all causes and in Lesotho97,000 by AIDS and 150,000 by all causes) (2007). It has also been estimated that by 2010, 15.7 million (30%) of the 53 million anticipated orphans from allcauses in sub-Saharan Africa, will have lost at least one parent due to AIDS. Even where HIV prevalence stabilizes or begins to decline, the number of orphans will continue to grow or at least remain high for years,reflecting the time lag between HIV infection and death. (UNICEF, 2006a).
Secondly, the evidence to show that orphans and other vulnerable children made vulnerable by HIV and AIDS are missing out on education now. Household data from 40 countries in sub-Saharan Africa has shown that orphans are 13% less likely to attend school than non-orphansanddouble orphans are most likely to be disadvantaged (Monasch and Boerma, 2004). In MalawiandLesotho the school attendance school ratio[1] is 93 for Malawiand 95 for Lesotho (UNICEF, 2007). Given the large and rapidly increasing size of the orphan population these figures represent a serious loss of education which reduces the ability of high HIV prevalence countries to reach Education for All (EFA) and the Millennium Development goals (MDGs) for education by 2015 and can have a major impact on economic development by affecting the human capital accumulation of the next generation (Deininger et al., 2003, UNICEF, 2006b, Evans and Miguel, 2007, Pridmore, 2007, Nyabanyaba and Letete, 2007)
Thirdly, the dearth of evidence about how vulnerable children and schools interact in AIDS affected communitiesand evidence that not enough is yet being done by national governments to make adequate educational provision for (Kendall and O'Gara, 2007, Booysen and Tanja, 2002). An analysis of school survey data from Uganda, Botswana and Malawi, found that schools have provided very little support for children affected by HIV and AIDS (Bennell, 2003)and a study in Zambia concluded that the Ministry of Education has not been successful in meeting the educational challenges of orphans and other vulnerable children (OVC) or in supporting community school initiatives (Family Health International, 2003). According to a recent report from the Commonwealth Secretariat, the Global Campaign on Education (GCE) has calculated that around 700,000 annual cases of HIV in young adults could be prevented if all children received a complete primary education and the economic impact of HIV and AIDS could be greatly reduced.The report emphasises that countries face an urgent need to strengthen their education systems as a key strategy for escaping the grip of HIV and AIDS.
Current efforts to accelerate the education sector response to HIV/AIDS in SSA mainly focus on how to shore up the education system and continue ‘business as usual’ in the face of the challenges presented (Carr-Hill et al., 2002). A powerful argument can be made that this approach is unlikely to succeed in high prevalence countries and that new more effective models of schooling need to be developed (Badcock-Walters et al., 2003, Crewe, 2004, Bennell, 2005a, Nyabanyaba and Letete, 2007). Ministries of Education in some countries are now becoming aware of this need:
As deaths from HIVand AIDS cause the number of orphaned children to increase drastically, action must be taken to protect their right to schooling and education. It will, therefore be necessary to create alternative pathways to learning that meet needs and requirements of these children. (Government of Malawi, (undated))
The need to provide flexible, certified educational options including open and distance learning has also been recognised in a report by the UK working group on education and HIV/AIDS in relation to the educational needs of girls, working and street children (Boler and Carroll, 2005).
The purpose of this paper is to review the existing evidence on barriers to conventional schooling in high HIV prevalence areas in SSA in order to capture what is already known and inform the design of the cases studies and educational interventions that will be carried out as part of the DFID-ESRC funded Project in MalawiandLesotho. The paper has two aims. Firstly to develop a holistic picture of the ways that barriers at the household/family level and at the school level can reduce educational access and attainment. Secondly, to reveal the complexities and country specific nature of the barriers.
1.2 Method
A systematic, step-by-step, approach was taken to searching the literature as follows:
Step 1 A search of peer reviewed journal article published from 2005 onwards was conducted of the Education Resources Information Centre (ERIC) database using the using the following string of keywords in stages: (HIV or AIDS) and (developing countries or Africa or Lesotho or Malawi) and (households or orphans or vulnerable children) and (education or schools or school or schooling)
Step 2 Similar searches were conducted of the separate databases PubMed, Popline and the Social Sciences Citations Index (SSCI) using the same string of keywords.
Step 3 Searches were conducted on the web pages of key international development agencies – UNICEF, UNESCO, UNAIDS, WHO, World Bank.
Step 4 Personal communication was made with key people in the line ministries, development agencies and NGOs during a field visit to LesothoandMalawi in April 2007 to collect further literature.
Step 5 Key references cited in the literature collected were followed up.
Step 6 The whole database was then carefully scrutinized and key references published in English were entered into the Endnote bibliography. The following criteria were used for selecting key references:
- Recent summaries and meta-analyses of the evidence base.
- Well-designed, individual studies from DFID priority countries in Africa, including MalawiandLesotho.
- The mostrecent statistical data and consensual views from the international development agencies.
The bibliography includes scientific papers published in peer-reviewed journals, international development agency and NGO reports, government documents, and books.
The selected references were carefully scrutinized again to identify categories and themes that increase the risk of HIV affected young people being excluded from conventional schooling in SSA. Within the category of household/family level factors six overlapping themes were identified: Childhood malnutrition and infection; changing patterns of household organisation andincreased child migration; parental illhealth and death, increased poverty and demand for child labour, family scepticism and intra-household discrimination against orphans; trauma, child abuse and unplanned pregnancy; loss of social cohesion. In relation to schoool-level factors the categories were: lack of support for the special educational needs of HIV-affected children; gender based violence, stigma and discrimination; reduced supply and quality of education.
The data from the secondary analysis of literature has been supplemented by a small amount of empirical data from meetings and discussions with key stakeholders in MalawiandLesotho.
1.3Defining key terms
Terms such as ‘child’, ‘orphan’, ‘youth’, ‘vulnerable children’, are subject to a variety of different meanings and vary across communities and contexts. For the purpose of this paper the following working definitions will be used.
A child is defined as a boy or girl under the age of 18 years, following the definition given in the UN Convention on the Rights of the Child (CRC) (UN, 1989). An orphan is defined as a child who has lost one or both parents under the age of 18 years and this includes both single (maternal or paternal orphans) who have lost one parent and double orphans who have lost both of their parents. This is a widely used definition and is the definition set out in the Malawi National Task Force on orphans (1996). The term ‘youth’ and ‘young people’ are used interchangeably to refer to young men and women between the ages of 15 and 25 years.
A vulnerable child is defined as a boy or girl considered by their teacher or other community members to be most at risk of social, emotional, economic and health problems because of the circumstances in which they are living. Children may be deemed vulnerable if they are orphans or they live with disabled or chronically or terminally ill parents or in households that have already expanded as a result of taking in other children, or have been abandoned by their parents or abused. Whilst adopting this definition, there is a need to acknowledge that not all of these children will be living in especially difficult circumstances and to recognize the agency of those who are but who challenge the notion of vulnerability in different ways.
The term fostering is used to refer to situations where a child has been taken in by a household that is not part of their extended family. Fostering may be arranged officially through an agency or take place spontaneously without outside intervention.
The term social cohesion, in the present context, refers to the solidarity and willingness of communities to work cooperatively to address OVC andHIV/AIDS issues. Building social cohesion is an ongoing process towards developing a community of shared values, shared challenges and equal opportunities based on a sense of trust, hope and reciprocity among all community members.
1.4 Organisation
This review paper is organized into three further sections. The first section will review literature on the following household/family level factors that can reduce demand for education in high HIV prevalence areas in SSA:
- Childhood malnutrition and infection.
- Changing patterns of household organisation andincreased child migration.
- Parental illhealth and death, increased poverty and demand for child labour.
- Famikly scepticism and intra-household discrimination against orphans.
- Trauma, child abuse and unplanned pregnancy.
- Loss of social cohesion.
The second section will address the following school-level factors that can affect the supply of education:
- Lack of support for the special educational needs of HIV-affected children.
- Gender based violence, stigma and discrimination.
- Reduced supply and quality of education.
In the third and final section, the implications from the literature review for the future Project empirical work in MalawiandLesotho will be discussed. This will include the design of case studies to further explore the complex nature of the educational barriers faced by HIV affected young people and an intervention package that seeks to address some of the barriers identified and help strengthen ODFL systems and structures to increase educational access and attainment.
2. Household/family level barriers to education
Under conditions of poverty children and young people in high HIV prevalence areas are frequently subjected to adverse conditions that can be cumulative and endure over time leading to educational exclusion. Exclusion may take the form of late or no enrolment, poor attendance and inability to concentrate due to psychosocial social impact of HIV and AIDS. These adverse conditions include shocks from malnutrition and infection, constantly changing household organisation and child migration, increased poverty and demand for child labour,family skepticism andintra-household discrimination against orphans, trauma, stress,child abuse and unplanned pregnancy and loss of social cohesion.
2.1Childhood malnutrition and infection
A recent review of the evidence to link health, nutrition and education access and attainment by Pridmore (2007) pointed out that without access to inexpensive anti-retroviral drugs to prevent mother-to-child transmission about 30% of infants born to HIV positive mothers become infected with HIV in utero or through breastfeeding. In the absence of anti-retroviral therapy (ART) the vast majority (about 90%) of these children fail to thrive and die before they reach school-ageand those who do survive have reduced attendance and increased drop out as they become progressively ill with AIDS-related health problems. However, as Boler and Caroll (2005) point out, the wider availability of ART has resulted in more paediatric HIV cases reaching adulthood and the educational needs of children born with HIV, which have previously been ignored, now need to be urgently addressed.
Although lack of adequate child protection leading to sexual abuse, especially of OVC, is of growing concern, relatively few children are infected in the lower primary school grades. During the upper primary andsecondary school-age years, however, young people are becoming sexually active andin high HIV prevalence countries prevalence rates rise sharply, especially amongst women and girls. For example, UNICEF reports that in 2005, HIV prevalence figures for 15-25 year olds were 9.6% for women and 3.4% for men in Malawiand 14.1% for women and 5.9% for men in Lesotho (UNICEF, 2007).