Part One: Chapter 2 SELECTED RECENT SOCIAL TRENDS: POPULATION GROWTH, HUMAN DEVELOPMENT GOALS,

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1 Contents UNCTAD/LDC/2004 UNITED NATIONS CONFERENCE ON TRADE AND DEVELOPMENT Geneva THE LEAST DEVELOPED COUNTRIES REPORT 2004 Part One: Chapter 2 SELECTED RECENT SOCIAL TRENDS: POPULATION GROWTH, HUMAN DEVELOPMENT GOALS, THE HIV/AIDS EPIDEMIC UNITED NATIONS New York and Geneva, 2004

2 Selected Recent Social Trends: Population Growth, Human Development Goals, the HIV/AIDS Epidemic A. Population growth, age structure and urbanization Chapter 2 In 2003, the total population of the least developed countries was 718 million people, of whom some 428 million lived in African and Caribbean LDCs, million in Asian LDCs and 2.7 million in island LDCs. In comparison with other developing countries, population growth rates are high in the LDCs. They were actually increasing in the 1980s, and although they are now declining, the decrease is slow. It is estimated that the population growth rate has declined from 2.7 per cent per year in to 2.4 per cent per year in Although projections are difficult because of the progress of HIV/AIDS, the total population of the current group of LDCs is expected to reach 1.04 billion by 2020 and to double between 2001 and Chart 3 and chart 4 show the difference between trends in the LDCs and in other developing countries. The high rates of population growth are due to the fact that the LDCs are at a much earlier stage of demographic transition than other developing countries. 1 The crude birth rate in is estimated at 38.9 live births per 1,000 people in the LDCs as compared with 21.3 in other developing countries. The crude death rate in the same period was 15.1 per 1,000 people in the LDCs as compared with 7.8 per 1,000 in other developing countries (table 17). Although projections are difficult because of the progress of HIV/AIDS, the total population of the current group of LDCs is expected to reach 1.04 billion by 2020 and to double between 2001 and CHART 3. ESTIMATED AND PROJECTED POPULATION GROWTH RATES IN THE LDCS AND IN OTHER DEVELOPING COUNTRIES, Population growth rate (%) LDCs Other developing countries Source: United Nations (2003a).

3 28 The Least Developed Countries Report 2004 CHART 4. INDICES OF THE POPULATION SIZE OF THE LDCS AND OF OTHER DEVELOPING COUNTRIES, (Index, 2001 = 100) Index of population size (2001 = 100) LDCs Other developing countries Source: UNCTAD secretariat estimates based on United Nations (2003a). TABLE 17. CRUDE BIRTH RATE, CRUDE DEATH RATE AND TOTAL FERTILITY IN THE LDCS AND IN OTHER DEVELOPING COUNTRIES, AND AVERAGES Crude birth rate Crude death rate Total fertility (per 1,000 population) (per 1,000 population) (children per woman) Least developed countries Other developing countries Source: United Nations (2003a). The LDCs are at a much earlier stage of demographic transition than other developing countries. Underlying the high birth rates in LDCs are very high fertility rates. During the period , it is estimated that every woman in the LDCs will give birth to 5.1 children. This is much higher than in other developing countries, where the fertility rate is 2.6. Within the LDC group, the fertility rate is higher in African LDCs (6.0 children per woman in ) than in Asian LDCs (4.9). There are 16 LDCs where the fertility rate is over 6 children per woman Afghanistan, Angola, Burkina Faso, Burundi, Chad, the Democratic Republic of the Congo, Ethiopia, Guinea-Bissau, Liberia, Malawi, Mali, Niger, Sierra Leone, Somalia, Uganda and Yemen. Most of these countries have very high population growth rates, as shown in table 18. It is worth noting that amongst the LDCs, island LDCs and landlocked LDCs are at opposite ends of the spectrum in terms of birth rates and death rates. During the period , the average crude death rate in island LDCs, which stood at 5.9 per 1,000 population, was much lower than the rate in landlocked LDCs, which stood at 18.8 per 1,000. Similarly, although the difference was somewhat less, the average crude birth rate, which stood at 32.3 per 1,000 in the island LDCs during , was lower than the rate in the landlocked LDCs, which stood at 43 per 1,000. In general, island LDCs have better social indicators than other LDCs, and landlocked LDCs have worse ones. Life expectancy at birth provides an overall indicator that summarizes the pattern. Within the landlocked LDCs life expectancy is estimated as being only 45.9 years in , whilst in the island LDCs it is estimated at 53.6 years (based on United Nations, 2003a).

4 Selected Recent Social Trends 29 TABLE 18. POPULATION GROWTH RATES AND AGE STRUCTURE IN THE LDCS, Population % of population % of population Dependency Average annual growth rate (%) under 15 under 25 ratio LDCs in which population growth rate is above the LDC average Somalia Liberia Afghanistan Sierra Leone Eritrea Niger Yemen Uganda Angola Burundi Mali Maldives Mauritania Chad Bhutan Burkina Faso Guinea-Bissau Solomon Islands Democratic Republic of the Congo Madagascar Comoros Gambia Equatorial Guinea Benin Sao Tome and Principe Ethiopia Vanuatu LDCs in which population growth rate is below the LDC average Cambodia Senegal Togo Lao People s Democratic Republic Nepal Sudan Rwanda Bangladesh Cape Verde Malawi United Republic of Tanzania Mozambique Guinea Djibouti Haiti Central African Republic Myanmar Zambia Samoa Lesotho LDCs Source: UNCTAD secretariat estimates, based on United Nations (2003a). Note: No data were available for Kiribati and Tuvalu.

5 30 The Least Developed Countries Report per cent of total LDCs population were under 25 in For LDCs as a group, it is estimated that in 2000 the dependency ratio was This compares with in other developing countries. The majority of the population in LDCs, some 74 per cent, are located in rural areas. Urbanization is accelerating, however...the total number of cities with over one million people is projected to increase from 22 in 2000 to 27 in 2015 in LDCs. An important consequence of the relatively high rate of population growth within LDCs generally is a relatively youthful age structure of the population. It is estimated that in per cent of the population were children less than 15 years old, and fully 63.2 per cent of the total population were under 25. The median age of the population in the LDCs, namely the age at which 50 per cent of the population is younger than and 50 per cent of the population is older than that age, was 18.1 years in 2000, compared with 17.5 years in The median age is projected to be 20.3 years in Inevitably, there is a high dependency ratio, which is measured as the ratio of the dependent population (persons aged between 0 and 14 years, and 65 and over) to the working-age population (those aged between 15 and 64 years). For LDCs as a group, it is estimated that in 2000 the dependency ratio was This compares with in other developing countries. However, there are significant differences amongst the LDCs between the African and the Asian LDCs. In the African LDCs, the number of dependants is almost the same as the number of people of working age. There has been no change in this situation over the last 20 years, with the dependency ratio in 2000 standing at 0.936, the same level as it was in In Asian LDCs, in contrast, the dependency ratio is lower and has fallen slightly over the same period from to The age structure puts considerable pressure on the provision of social services of all types and also implies that a high rate of employment creation is necessary in order to ensure that the population is fully employed. It is estimated that in 2000, 30.4 per cent of the population was of school age (6 17 years old). This figure is estimated to decrease only slightly to 29.6 in ILO projections for the period suggest that the total population of working age (15 64 years old) in LDCs as a group will increase by 29 per cent between 2000 and The annual increase in the population of working age will exceed 100,000 in 25 out of 44 LDCs for which data are available (table 19). Generating sustainable livelihoods, with remuneration above poverty lines, is a daunting challenge. Finally, it is worth emphasizing that the majority of the population in LDCs, some 74 per cent, are located in rural areas. Urbanization is accelerating, however. The urban population share increased from 19 per cent in 1985 to 20.8 per cent in 1990, but it is estimated that in 2005 it will reach 28.4 per cent. A number of major metropolises are emerging. It is estimated that Dhaka in Bangladesh had a population of 12.5 million in 2000, and Kinshasa in the Democratic Republic of the Congo a population of 5 million. There were 17 other LDCs that had a city with a population of over 1 million in The total number of cities with over one million people is projected to increase from 22 in 2000 to 27 in 2015 in LDCs (based on United Nations, 2002). B. Progress towards selected human development goals 3 The LDCs are identified as the poorest countries not just in terms of per capita income but also in terms of their low level of human assets and human development. The current gap between the LDCs as a group and developing countries as a whole and high-income OECD countries may be gauged from the following statistics: In 2001, life expectancy at birth in the LDCs was 50.4 years as against 64.4 years in developing countries as a whole and 78.1 years in highincome OECD countries.

6 Selected Recent Social Trends 31 TABLE 19. TRENDS IN THE WORKING-AGE POPULATION a OF THE LDCS, Working-age population Average yearly change in working-age population b Change c (Thousands) (Thousands) (%) Afghanistan Angola Bangladesh Benin Bhutan Burkina Faso Burundi Cambodia Cape Verde Central African Republic Chad Comoros Dem. Rep. of the Congo Djibouti Equatorial Guinea Eritrea Ethiopia Gambia Guinea Guinea-Bissau Haiti Kiribati Lao People s Dem. Rep Lesotho Liberia Madagascar Malawi Maldives Mali Mauritania Mozambique Myanmar Nepal Niger Rwanda Samoa Sao Tome and Principe Senegal Sierra Leone Solomon Islands Somalia Sudan Togo Uganda United Rep. of Tanzania Vanuatu Yemen Zambia African LDCs Asian LDCs Island LDCs LDCs Source: UNCTAD secretariat estimates, based on World Bank, World Development Indicators 2003, CD-ROM; and ILO, LABORSTA database. Note: No data were available for Tuvalu. a The working-age population is the number of people between the ages of 15 and 64. b The average yearly increase in working-age population was calculated as the average of the year-to-year changes in the given period. c Percentage increase in working-age population between 2000 and 2010.

7 32 The Least Developed Countries Report 2004 During , 38 per cent of the population was undernourished as against 18 per cent in developing countries as a whole. In 2001, 33.7 per cent of the year-old population was illiterate as against 15.2 per cent in developing countries as a whole. In 2001 the infant mortality rate was 101 per 1,000 live births in the LDCs as against 62 in developing countries as a whole and 5 in highincome OECD countries. The lack of data is making it difficult to formulate any generalizations about progress by the LDCs as a group towards achievement of either the Millennium Development Goals or the POA targets. In 2001 the infant mortality rate was 101 per 1,000 live births in the LDCs as against 62 in developing countries as a whole and 5 in highincome OECD countries. In 2001, 16 out of every 100 children born alive in the LDCs died before their fifth birthday as against 9 out of every 100 in developing countries as a whole and less than 1 in every 100 in high-income OECD countries. In only 31 per cent of births were attended by skilled health personnel in the LDCs as against 56 per cent in developing countries as a whole and 99 per cent in high-income OECD countries. In 1995, the maternal mortality rate was 1,000 per 100,000 live births in the LDCs as against 463 per 100,000 in developing countries as a whole and 12 per 100,000 in high-income OECD countries. In 2000, only 55 per cent of the rural population had sustainable access to an improved water source in rural areas of LDCs as against 69 per cent in developing countries as a whole (UNDP, 2003). Progress is, nevertheless, being made in a number of LDCs. Table 20, based on the more detailed information in annex 1 to this chapter, sets out the trends since 1990 regarding a number of human development indicators which are used to measure progress towards achievement of the Millennium Development Goals (MDGs). Those targets are as follows: (i) Halve, between 1990 and 2015, the proportion of people who suffer from hunger; (ii) Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling; (iii) Eliminate gender disparity in primary and secondary education, preferably by 2005 and at all levels of education no later than 2015; (iv) Reduce by two thirds, between 1990 and 2015, the under-5 mortality rate; (v) Halve, by 2015, the proportion of people without sustainable access to safe drinking water. These targets are also contained in the Programme of Action for the Least Developed Countries for the Decade (POA), although there are differences between the goals of the POA and the MDGs (see box 1). For example, in the POA, as it was negotiated, the first target is actually more stringent, namely to halve the number of people suffering from hunger rather than the proportion of such people. From the table and annex a number of points stand out. First, there is a serious lack of data to monitor progress. Data coverage exceeds two thirds of the LDCs for only two of the five indicators. This problem was emphasized by UNCTAD soon after the POA was agreed (UNCTAD, 2001). There is an urgent need to improve national statistical capacity in the LDCs to monitor progress and provide data for informed policy-making on all fronts, including human development (see also UNDP, 2003: box 2.1). The lack of data is making it difficult to formulate any generalizations about progress by the LDCs

8 Selected Recent Social Trends 33 TABLE 20. PROGRESS TOWARDS ACHIEVEMENT OF SELECTED HUMAN DEVELOPMENT TARGETS a IN THE LDCS, Data availability Achieved Achievable by 2015 Low progress Reversal/stagnation b Hunger 34 LDCs Chad Lao People s Dem. Rep. Afghanistan Myanmar Cambodia Burundi Malawi Mauritania Dem. Rep. of the Congo Sudan Niger Liberia Benin Central African Republic Madagascar Haiti Uganda Rwanda Mozambique Yemen Senegal Guinea Lesotho Sierra Leone Mali Somalia Angola Togo United. Rep. of Tanzania Zambia Bangladesh Burkina Faso Gambia Nepal Primary 25 LDCs education Cambodia Rwanda Gambia Dem. Rep. of the Congo Cape Verde Togo Mali United. Rep. of Tanzania Malawi Bangladesh Senegal Djibouti Maldives Lao People s Dem. Rep. Eritrea Samoa Benin Lesotho Uganda Vanuatu Mozambique Burkina Faso Niger Burundi Central African Republic Gender 29 LDCs equality Bangladesh Mauritania Guinea Burundi in Lesotho Malawi Lao People s Dem. Rep. Eritrea education Madagascar United. Rep. of Tanzania Niger Ethiopia Maldives Nepal Sierra Leone Rwanda Djibouti Togo Samoa Myanmar Mali Sudan Gambia Burkina Faso Vanuatu Senegal Mozambique Zambia Dem. Rep. of the Congo Child 48 LDCs mortality Bangladesh Eritrea Cambodia Bhutan Equatorial Guinea Rwanda Samoa Uganda United. Rep. of Tanzania Vanuatu Yemen Zambia Lao People s Dem. Rep. Malawi Afghanistan Nepal Kiribati Angola Cape Verde Madagascar Burundi Comoros Djibouti Central African Republic Solomon Islands Gambia Chad Maldives Haiti Dem. Rep. of the Congo Guinea Sao Tome and Principe Liberia Niger Mauritania Guinea-Bissau Sierra Leone Mozambique Somalia Myanmar Benin Sudan Ethiopia Lesotho Mali Togo Senegal Burkina Faso Access 22 LDCs to safe Bangladesh Central African Republic Malawi Ethiopia water Comoros Burundi Niger Haiti Djibouti Zambia Uganda Mauritania Maldives Sudan Togo Nepal Mali Guinea Samoa Senegal Madagascar United. Rep. of Tanzania Source: UNCTAD secretariat estimates, based on UNDP Human Development Report Office: direct communication. For details, see annex 1, table 1 of this chapter. a The quantitative variables used to monitor the targets on hunger, primary education, gender equality in education, child mortality and access to safe water are under-nourished people as percentage of total population, net primary school enrolment ratio, ratio of girls-toboys in primary and secondary school, under-five child mortality rate (per 1,000 live births) and percentage of people with sustainable access to improved water sources, respectively. b Reversal or stagnation concerns cases in which the selected human development indicator either worsened or stagnated between 1990 and 2000.

9 34 The Least Developed Countries Report 2004 BOX 1. THE NEED TO RECONCILE THE MDGS AND QUANTIFIABLE TARGETS OF THE PROGRAMME OF ACTION FOR THE LEAST DEVELOPED COUNTRIES FOR THE DECADE An important feature of the Programme of Action for the Least Developed Countries for the Decade , which was agreed at the Third United Nations Conference on the Least Developed Countries held in Brussels in May 2001 (United Nations, 2001), was the inclusion of quantifiable development targets. These are similar to the targets associated with the MDGs, but they are not identical. There are differences regarding the level of improvement that is expected, the indicators that are used and the time frame that is applied. One MDG target, for example, is a 75 per cent reduction of the maternal mortality rate between the base year 1990 and the target year 2015, while the corresponding POA target is a 75 per cent reduction of the maternal mortality rate between the base year 2001 and the target year Inconsistencies can be observed with respect to development targets on poverty, nutrition, health, education, gender equality and infrastructure. There are not only overlaps between MDG targets and POA targets, but also several overlaps between different types of POA targets themselves. Furthermore, a good number of development targets in the Programme of Action are formulated in a manner that does not allow for measurement and monitoring of progress. This is because many of the targets have no base years (where necessary), no target years or no indicators associated with them. In order to promote progress towards the monitoring of international development goals for the least developed countries it is necessary that the different targets be made measurable and the data situation improved, but it is also highly desirable that inconsistencies between different sets of international development goals be resolved. The failure to harmonize the two sets of targets until now has effectively led to a focus on the MDG targets and a widespread neglect of POA targets. This does not matter for those POA targets that are similar to those of the MDGs, but it does for those that are different. In sum, it is essential that the POA and MDG targets be harmonized and that the inconsistencies amongst the POA targets themselves be resolved. Source: Herrmann (2003). as a group towards achievement of either the Millennium Development Goals or the POA targets. Secondly, with regard to the only indicator for which data coverage is more or less complete (under-5 mortality), only 11 out of the 48 LDCs for which data are available are likely to achieve the target. Six of these are island LDCs which start with relatively low levels of under-5 mortality. For each individual target there are some countries where significant progress has been made. Thirdly, for each individual target there are some countries where significant progress has been made. Notable cases include the following: The proportion of the population that is undernourished has fallen sharply from very high levels during the 1990s in Chad, Haiti, Malawi and Mozambique. In these four countries, the proportion undernourished during was 58 per cent, 64 per cent, 49 per cent and 69 per cent respectively. During , the proportion had fallen to 32 per cent, 50 per cent, 33 per cent and 55 per cent respectively. Net primary school enrolment rates increased substantially from 1990 to 2000 in Bangladesh (from 64 per cent to 89 per cent), Benin (from 49 per cent to 70 per cent), Eritrea (from 24 per cent to 41 per cent), Gambia (from 51 per cent to 69 per cent), the Lao People s Democratic Republic (from 61 per cent to 81 per cent), Malawi (from 50 per cent to 100 per cent), Mali (from 21 per cent to 43 per cent), Rwanda (from 66 per cent to 97 per cent), Senegal (from 48 per cent to 63 per cent) and Togo (from 75 per cent to 92 per cent). The ratio of girls to boys in primary and secondary school rose impressively from 1990 to 2000 in Bangladesh (from 72 per cent to 103 per cent), Gambia (from 64 per cent to 85 per cent), Mauritania (from 67 per cent to 93 per cent), Nepal (from 53 per cent to 82 per cent) and Sudan (from 75 per cent to 102 per cent).

10 Selected Recent Social Trends 35 The under-5 mortality rate fell sharply between 1990 and 2001 in Bangladesh (from 144 per 1,000 live births to 77), Bhutan (from 166 to 95), Comoros (from 120 to 79), Guinea (from 240 to 169), the Lao People s Democratic Republic (from 163 to 100), Maldives (from 115 to 77) and Nepal (from 145 to 91). The proportion of the population with sustainable access to improved water sources has risen particularly sharply in the United Republic of Tanzania. It is estimated that in 1990 only 38 per cent had such access, while in 2000 the proportion was 68 per cent. Fourthly, no country is on course to meet all five of these human development targets by However, three countries Bangladesh, Maldives and Samoa are on course to meet four of them. Fifthly, more progress is being made in human development dimensions that are directly affected by the quantity and quality of public services (primary education, gender equity in education and access to water) than with regard to those that are the outcome of both public services and levels of household income (hunger and child mortality). Progress is most promising in the area of gender equity: 9 out of the 29 LDCs for which data are available have already achieved the target, and a further 9 will achieve it by 2015 if current rates of progress continue. More progress is being made in human development dimensions that are directly affected by the quantity and quality of public services than with regard to those that are the outcome of both public services and levels of household income. C. The HIV/AIDS epidemic 4 1. THE GRAVITY OF THE PROBLEM IN LDCS The HIV/AIDS epidemic is an important problem for LDCs and in some, particularly in Africa, it is turning into a development crisis which is threatening growth prospects and the achievement of human development goals. The advance of the epidemic in LDCs is a matter of acute concern because of their limited domestic resources to limit the spread of the virus and cope with its effects. There are major data difficulties in tracking the progress of the epidemic. But according to data in UNAIDS (2002), in 2001, when the LDCs comprised 11 per cent of the global population: 25.5 per cent of all men living with HIV in the world lived in LDCs (4.7 million out of 18.6 million); 35 per cent of all women living with HIV in the world lived in LDCs (6.5 million out of 18.5 million); 46 per cent of all children living with HIV in the world lived in LDCs (1.4 million out of 3 million); 37 per cent of all deaths from HIV/AIDS in the world occurred in LDCs (1.1 million out of 3 million); almost 50 per cent of all child deaths from HIV/AIDS in the world occurred in LDCs (about 280,000 out of 580,000); 48.5 per cent of children orphaned by HIV/AIDS live in LDCs (6.8 million out of 14 million) (UNAIDS, 2002). The HIV/AIDS epidemic is an important problem for LDCs and in some, particularly in Africa, it is turning into a development crisis which is threatening growth prospects and the achievement of human development goals. Out of the 54 countries in which infection rates were above 1 per cent of the adult population in 2001, 28 were LDCs (see table 21). Most of these are located in Africa. For LDCs as a whole the adult HIV prevalence rate in 2001 was 4.1 per cent. But it was much higher (6.6 per cent) in African LDCs than in

11 36 The Least Developed Countries Report 2004 TABLE 21. HIV PREVALENCE RATES IN ADULTS (AGED BETWEEN 15 AND 49) IN THE LDCS, 2001 Less than 3 per cent Between 3 and 6 per cent Between 6 and 13 per cent Above 13 per cent Bangladesh <0.1 Equatorial Guinea 3.4 Haiti 6.1 Malawi 15.0 Bhutan <0.1 Benin 3.6 Ethiopia 6.4 Zambia 21.5 Lao People s Dem. Rep <0.1 Chad 3.6 Burkina Faso 6.5 Lesotho 31.0 Maldives 0.1 Dem. Republic of the Congo 4.9 Sierra Leone 7.0 Yemen 0.1 Uganda 5.0 United Rep. of Tanzania 7.8 Madagascar 0.3 Angola 5.5 Burundi 8.3 Senegal 0.5 Togo 6.0 Rwanda 8.9 Nepal 0.5 Djibouti a 11.8 Somalia 1.0 Central African Republic 12.9 Gambia 1.6 Mozambique 13.0 Mali 1.7 Myanmar a 2.0 Sudan 2.6 Cambodia 2.7 Eritrea 2.8 Guinea-Bissau 2.8 Liberia a 2.8 Source: UNCTAD secretariat classification based on UNAIDS (2002). Note: Data on HIV/AIDS prevalence rate were not available for the following LDCs: Afghanistan, Cape Verde, Comoros, Guinea, Kiribati, Mauritania, Niger, Samoa, Sao Tome and Principe, Solomon Islands, Tuvalu and Vanuatu. a 1999 data. The intensity of HIV/AIDS within LDCs as a group at the present time reflects the current epicentre of the global epidemic in Africa and the weight of African countries within the LDC group. There is some evidence that the epidemic has declined in Uganda and Zambia. Asian LDCs (0.2 per cent). There are 15 LDCs in Africa where the adult HIV prevalence rate exceeds 5 per cent. Infection rates are also high in Haiti and, within Asia, it exceeds 2 per cent in Cambodia and Myanmar. Overall deaths due to AIDS in 2001 were 2 per 1,000 persons in LDCs, as compared with 0.5 in the world as a whole. A very disturbing feature of the epidemic is that the infection rates are high amongst young women. For LDCs as a group, 4.9 per cent of women aged between 15 and 24 live with HIV, as compared with 1.4 per cent for the world as a whole. Within African LDCs, 7.2 per cent of young women live with HIV, and there are at least 5 African LDCs in which one in ten of women aged between 15 and 24 live with HIV. The intensity of HIV/AIDS within LDCs as a group at the present time reflects the current epicentre of the global epidemic in Africa and the weight of African countries within the LDC group. Within Sub-Saharan Africa, there does not appear to be an overconcentration of people living with and dying from HIV/AIDS in LDCs. Within Sub-Saharan Africa, LDCs constituted over 50 per cent of the population in 2001, and accounted for 39 per cent of the men, 40 per cent of the women and 51 per cent of the children living with HIV/AIDS in the region. Similarly, 47 per cent of the adult and child deaths from HIV/AIDS in Sub-Saharan Africa occurred in LDCs. Perhaps the only positive feature of the current situation is that there is some evidence that the epidemic has declined in Uganda and Zambia. In Uganda, HIV prevalence rates among pregnant women in Kampala fell, according to UNAIDS (2002: 24), for eight consecutive years from 29.5 per cent in 1992 to 11.3 per cent in 2001, a fact which suggests that the HIV/AIDS epidemic is being brought under control. More Ugandans are receiving antiretroviral drugs, but the rate of new infections remains high. It is hoped that Zambia is now

12 Selected Recent Social Trends 37 becoming the second African country to reverse the epidemiological crisis. HIV prevalence, though still high in Zambia, has significantly decreased among year-old urban women from 28.3 per cent in 1996 to 24.1 per cent in For rural women aged between 15 and 24, HIV prevalence rates fell from 16.1 per cent to 12.2 per cent over the same period (UNAIDS, 2002: 26). 2. THE ECONOMIC AND SOCIAL IMPACT OF THE EPIDEMIC The HIV/AIDS epidemic is having, and will have, major detrimental consequences for economic activity as well as for the achievement of human development goals. This negative impact lags behind the spread of the HIV infection because it takes approximately seven to eight years before HIVinfected people become seriously ill and die. There are various estimates of the macroeconomic impact (see McPherson, 2003). UNDP (2001) estimates that in the 1990s AIDS reduced Africa s per capita annual growth by 0.8 per cent. Other calculations suggest that the rate of economic growth has declined by 2 4 per cent in sub-saharan Africa as result of AIDS (UNAIDS, 2002). It is also suggested that in the worst affected countries one to two percentage points will be pared off per capita growth in the coming years. If this happens, a number of economies will, after two decades, be about per cent smaller than they would have been in the absence of AIDS (UNDP, 2001). According to UNAIDS (2002), for those countries with national HIV/AIDS prevalence rates of 20 per cent, annual GDP growth may fall by an average of 2.6 percentage points. Moreover, there is an adverse fiscal impact. Public revenues could drop by an expected 20 per cent by 2010 as in Botswana in AIDS-affected LDCs as a result of the economic impact of the HIV/AIDS epidemic (UNDP, 2002: 3). Increasing evidence suggests that the effects of the HIV/AIDS epidemic are particularly severe in the agricultural sector. This is going to have important negative consequences in countries such as the LDCs, in which the majority of the population live in rural areas and earn their living from agriculture. The reason for the severity of the impact is that the human resource losses associated with the epidemic are much less easily absorbed given the structure of agriculture, especially smallholder agriculture. The illness of productive members of the household leads to a double loss the productive individual works less and there is a major demand for care for the sick person. About 20 per cent of rural families in Burkina Faso, for example, have reduced the amount of agricultural work done or abandoned their farms because of HIV/AIDS. In Ethiopia AIDS-affected households spent 11.6 to 16.4 hours per week performing agricultural work as compared with an average of 33.6 hours for non-aids-affected households (UNAIDS, 2002: 49). In Malawi, Mozambique and Zambia, there has been a progressive increase in cassava production (less labour-intensive) as a shift from staple-food maize production to compensate for lost labour (De Waal and Tumushabe, 2003). As labour bottlenecks tighten, malnutrition increases and traditional community-level support mechanisms are subjected to strain. The problems of rural women, and especially female-headed households, can be particularly severe. Food security worsens owing to reduced food availability caused by falling production with disruptions of the farming cycle, as well as owing to reduced food access due to declining income for food purchases. Increasing evidence suggests that the effects of the HIV/AIDs epidemic are particularly severe in the agricultural sector. Owing to labour bottlenecks, the problems of rural women, and especially female-headed households, can be particularly severe. Food security worsens owing to reduced food availability caused by falling production with disruptions of the farming cycle, as well as to reduced food access due to declining income for food purchases. The HIV/AIDS epidemic is also affecting non-agricultural enterprises. In Zambia, for example, it is estimated that nearly two thirds of deaths among

13 38 The Least Developed Countries Report 2004 managers are related to AIDS (UNAIDS, 2002: 58). Studies in southern Africa suggest that direct and indirect expenses incurred by firms on account of AIDS could cut profits by 6 to 8 per cent (ibid.: 54). In sub-saharan Africa, the annual direct medical costs of AIDS, excluding antiretroviral therapy, have been estimated at $30 per capita, although overall public health spending is less than $10 per capita for most African countries. The public sector has also been suffering the costs of AIDS as service delivery has faltered, with experienced State employees falling sick and dying. This is affecting school teachers and health workers. In the Central African Republic, 85 per cent of teachers who died between 1996 and 1998 were HIV-positive, and they died on average 10 years before they were due to retire. Malawi has reportedly been losing at least one teacher a day (UNFPA, 2002). According to UNAIDS (2002), in Malawi and Zambia there has been a five- or sixfold increase in illness and death rates among health workers. To compensate for this, expenditure on the training of doctors and nurses to replace dying medical personnel would have to increase by per cent in southern Africa in The epidemic is also adversely affecting school attendance. Children, especially girls, are removed from school, and kept at home to care for parents and family members, or to do housework to free older women for nursing, thus damaging growth prospects for the next generation. Children may become the household s only breadwinners, as working-age adults start falling victim to AIDS, and with other household members too old or too young to work. Carrying the burden of AIDS, the household may become unable to afford school fees and other expenses, and this could have serious intergenerational implications for future income, savings, productivity and growth, creating a vicious downward spiral. Spending on education is often redirected to the AIDS patient if he or she is a household member. Moreover, AIDS-infected children may not survive through the years of schooling. Among the LDCs, in the Central African Republic school enrolment is reported to have fallen by 20 to 36 per cent, with girls being most affected (UNAIDS, 2002: 52). It is also notable that orphan school attendance in African LDCs is estimated to be 79 per cent of non-orphan school attendance. For LDCs as a group child mortality rates in are expected to be 14 per cent higher with the HIV/AIDS epidemic than they would have been without it. Finally, the epidemic is overwhelming the capacity of health budgets and systems. In sub-saharan Africa, the annual direct medical costs of AIDS, excluding antiretroviral therapy, have been estimated at $30 per capita, although overall public health spending is less than $10 per capita for most African countries (UNDP, 2001: 8). It is in this context that access to cheap retroviral drugs is so important. The quality of care is being adversely affected for all diseases owing to the high patient load and the inadequate number of hospital beds in AIDS-affected countries. Some evidence of the expected social impact of the epidemic in LDCs is shown in table 22. For LDCs as a group child mortality rates in are expected to be 14 per cent higher with the HIV/AIDS epidemic than they would have been without it. Life expectancy at birth in LDCs in is expected to be 46.1 years rather than 58.7 years, which would have been attained without the HIV/AIDS epidemic. Life expectancy at birth in the LDCs with the highest rates of adult HIV prevalence now Lesotho, Malawi and Zambia is expected to be as low as 32.2, 39.7 and 35.3 years respectively during Without the HIV/AIDS epidemic they would have been 63, 59.2 and 57.4 years respectively.

14 Selected Recent Social Trends 39 TABLE 22. ESTIMATED AND PROJECTED IMPACT OF AIDS ON UNDER-5 MORTALITY RATE AND LIFE EXPECTANCY AT BIRTH IN THE LDCS, GROUPED BY ADULT HIV PREVALENCE RATE RANGES, a , , AND (Annual average) Under-5 mortality rate (per 1,000 live births) 3. THE NEXUS BETWEEN POVERTY AND HIV/AIDS There is a close, two-way relationship between poverty and HIV/AIDS. As UNFPA (2002: Overview of Chapter 6) has put it, HIV/AIDS accompanies poverty, is spread by poverty and produces poverty in its turn. Poverty is one of the factors that create situations that cause people to engage in high-risk behaviour that makes them more vulnerable to HIV. For survival in conditions of extreme poverty, people, especially women and young girls, trade sex, often Life expectancy at birth (years) With Without % With Without % With Without % With Without % AIDS AIDS diff. AIDS AIDS diff. AIDS AIDS diff. AIDS AIDS diff Adult HIV prevalence rates above 13% Lesotho Malawi Zambia Adult HIV prevalence rates between 6 and 13% Burkina Faso Burundi Central African Republic Djibouti Ethiopia Haiti Mozambique Rwanda Sierra Leone United Rep. of Tanzania Adult HIV prevalence rates between 3 and 6% Angola Benin Chad Dem. Rep. of the Congo Equatorial Guinea Togo Uganda Adult HIV prevalence rates less than 3% Cambodia Eritrea Gambia Guinea Guinea-Bissau Liberia Mali Myanmar Sudan LDCs, average African LDCs, average Memo: Africa, average World average Source: UNCTAD secretariat estimates, based on United Nations (2002). a Refers to the countries 2001 adult HIV prevalence rates, except for Djibouti, Liberia and Myanmar for which 1999 was the latest year available.

15 40 The Least Developed Countries Report 2004 unprotected under the threat of competition, for food, money, school fees or other essentials for themselves or their families, thus exposing themselves to HIV infections. This is contributing to the high incidence of HIV amongst young women noted earlier. Migration, some of which is associated with economic stress and the search for work, is also associated with the spread of the disease. HIV/AIDS accompanies poverty, is spread by poverty and produces poverty in its turn. In Southern Africa, the negative effects of the combination of food insecurity and AIDS have been further reinforced owing to a weakened capacity for governance following the death from AIDS of key personnel in government institutions. Extreme income poverty is associated with a lower nutritional status and a poorer general state of health. This can result in a less robust immune system, which lowers resistance to HIV exposure, and makes those already infected more susceptible to related infections. The poor may also have less access to sexual health and HIV education programmes, and less access to public health facilities, including treatment for sexually transmitted infections. HIV/AIDS also exacerbates poverty. The very limited resources of households are drained as sick wage earners lose their jobs, and household assets are used for medicines and health care for sick family members. Savings and capital, which are so important for recovery and rebuilding, are drawn upon, and available resources are utilized for survival consumption instead of investment. According to one case study on the United Republic of Tanzania cited by UNAIDS (2002: 48), in households where one person was ill because of AIDS, as much as 29 per cent of savings was redirected in order to cope with the illness, with families thus being driven to the brink of economic ruin. The financial burden of funerals is high, for example in the United Republic of Tanzania, where households are reported to spend up to 50 per cent more on funerals than on medical care (UNDP, 2001). The vicious spiral is even more evident when AIDS strikes one family member and the family disposes of its assets, and other family members with bleak prospects for decent work are forced into high-risk activities to help cope with the costs of the disease. The great danger is that this process will reach such a scale that communities break down and economic regress occurs at the national level. It has been argued that parts of Africa, including a number of LDCs, are now facing, or will soon face, a new variant famine (De Waal and Tumushabe, 2003). This is a type of famine that is closely associated with the undermining of productive capacities in agriculture and the breakdown of community support systems as an increasing proportion of the local population succumbs to AIDS. The situation in parts of southern Africa in 2002 is said to exemplify this phenomenon. There too the negative effects of the combination of food insecurity and AIDS have been further reinforced owing to a weakened capacity for governance following the death from AIDS of key personnel in government institutions. To sum up, the nexus between poverty and HIV/AIDS is a particularly vicious link in the various domestic vicious circles that make it so difficult for poor countries and poor people to escape from poverty. It may also lead to economic regress which will intensify poverty and threaten human development achievements. Dealing with this will be a key challenge in the coming years not only for the LDCs where the epidemic is already raging, but also in the Asian LDCs. D. Conclusions A defining characteristic of the LDCs is that they have low levels of life expectancy, widespread hunger, disease and illiteracy, and high rates of infant, child and maternal mortality. The data in this chapter show that a few of them made significant progress in the 1990s towards the achievement of some of the human development targets set following the Millennium Declaration and

16 Selected Recent Social Trends 41 contained in the Programme of Action for the Least Developed Countries for the Decade These successes suggest what may be possible. But overall the picture is one in which urgent action will be needed in most LDCs to achieve agreed goals. With regard to under-5 mortality, the only indicator where data coverage is almost complete, only 11 out of 48 LDCs can be expected to meet the goal of reducing child mortality by two thirds between 1990 and 2015 if the trends of the 1990s continue. The task that the LDCs face is difficult because of the very low starting level in relation to most social indicators. But in addition, population growth rates in the LDCs are higher than in other countries and the age structure is much younger. It is estimated that in per cent of the population of LDCs was of school age (6 17 years old) and 43 per cent were under 15 years old. The dependency ratio was in that year. Thus, each person aged between 15 and 64 had to support almost one dependant (under 15 or 65 years and over). By 2020 the median age of the LDC population, the age at which half the population is younger than and half the population is older than that age, is projected to be 20.3 years, up from 18.1 years in The pressure on education and health services from the very youthful population is thus going to continue for the next 20 years. It is expected that the population of the LDCs, some 718 million in 2003, will increase to over 1 billion in The working-age population will increase by 29 per cent between 2000 and Reducing poverty will depend on creating remunerative employment for these new entrants to the workforce, as well as on improving the incomes of the existing workforce. The latter task is a major challenge, given that in per cent of the population aged between 15 and 24 in LDCs was illiterate. The social and human challenges facing LDCs are all the more difficult because in some, particularly in Africa, the HIV/AIDS epidemic has reached a level where it is threatening growth prospects and further reducing the likelihood of achieving human development targets. At the present time the LDCs are disproportionately affected by the epidemic. This is perhaps best exemplified by the fact that whilst the LDCs constituted 11 per cent of the world population in 2001, they were the location for 46 per cent of the children recorded as living with HIV, 50 per cent of recorded child deaths from AIDS and 48.5 per cent of children orphaned by HIV/AIDS. The HIV/AIDS epidemic threatens to become a particularly vicious link in a cycle of pervasive poverty, economic stagnation and low levels of human development. The seriously affected LDCs have very limited resources to cope with the problem, and urgently need external assistance to reverse current trends. Unless trends improve, as they have done in Uganda, not simply the achievement of the MDG and POA targets for reducing HIV infection rates, but also the achievement of all other poverty and human development targets will be put in jeopardy. Those LDCs that currently have low rates of infection need to ensure that the epidemic does not spread further among the population. The LDC working-age population will increase by 29 per cent between 2000 and Reducing poverty will depend on creating remunerative employment for these new entrants to the workforce, as well as on improving the incomes of the existing workforce. The HIV/AIDS epidemic threatens to become a particularly vicious link in a cycle of pervasive poverty, economic stagnation and low levels of human development. The seriously affected LDCs have very limited resources to cope with the problem, and urgently need external assistance to reverse current trends. Finally, the need for better, more and more timely information on economic and social trends in the LDCs needs to be reiterated. As noted in the 2002 LDC Report, the data that are internationally available for measuring progress towards achievement of the MDGs and also the POA targets are woefully inadequate in terms of their coverage of LDCs, their quality and their timeliness (UNCTAD, 2002: 32). There is an urgent need for increased investment in national statistical systems. Better policies, at the national and international levels, ultimately depend on better information.