Using agricultural economics to strengthen nongovernmental organizations' food security...

"The impulse to action is strong but does not guarantee success."--Barrett

"In 2002, twenty years into the pandemic, HIV/AIDS initiatives remain stuck at this NGO-style, medicalised, level of activity."--de Waal

For nongovernmental organizations (NGOs) committed to partnering with

people in the developing world to improve the lives of the poor and vulnerable, the HIV/AIDS epidemic poses new and difficult challenges. Many NGOs have long operated programs in nutrition, food security, and agricultural and community development. These are all domains where agricultural economists have contributed. HIV/AIDS has changed the landscape and operating realities for the poor communities that NGOs partner with throughout the world. Therefore, NGOs at present are in the midst of reshaping existing food security and nutrition programs, as well as developing new strategies to assist and promote community development in the context of HIV/AIDS.

This article argues about the implications of economics for the design of effective food security programs for families of people living with HIV/AIDS, as well as the implications of HIV/AIDS for agricultural economics research in the area of nutrition and food security. The article uses the case of CARE--Honduras and their food security program operated in cooperation with the national organization of families of a person living with HIV/AIDS and other partners. This food security effort currently is in a phase of pilot implementation, assessment, and program redesign, with the intention to offer the program to additional communities and derive lessons from it for use in other development contexts.

After describing the food security and general living context of the participating families, this article reviews program impact data collected from the 2003-2004 efforts. The article then describes issues raised in the agricultural economics literature on food security and food assistance programs with relevance for food programs aimed at HIV/AIDS mitigation, care, and prevention. In addition, the article identifies further research questions that, if answered, might assist NGOs in their mission to utilize food security and nutrition programs to assist affected families.

HIV/AIDS in Honduras and the IMANAS Food Supplementation Program

Among countries in Central America, HIV/AIDS has disproportionately affected Honduras. While Honduras has about 17% of the region's people, it is thought that Honduras has about 60% of the region's reported HIV/AIDS cases. In 1999, Honduras reported 10,626 AIDS cases, but by 2002 more than 18,000 cases had been reported. These numbers likely underestimate the number of cases, as UNAIDS estimates the national prevalence rate for people 15-49 years of age with HIV/AIDS in Honduras at 1.8% at the end of 2003 and it is estimated that 6,300 adult and child cases exist (UNAIDS/WHO). The ratio of reported cases between males and females is 1:1 (UNAIDS/WHO), and the most common route of transmission is heterosexual contact (80%). Furthermore, it is estimated that only about 1,400 people with HIV/AIDS have access to antiretroviral treatment (ART) drugs in Honduras (UNAIDS/WHO).

The Interinstitutional Alliance for the Improved Nutrition of People Living with HIV/AIDS (IMANAS) project aims to help people living with HIV/AIDS in Honduras obtain access to needed food and nutritional support. The program was launched in 2003 as a partnership between the Honduran Association of People Living with HIV/AIDS, CARE--Honduras, Foro Nacional de SIDA, Honduras Ministry of Health, UNAIDS, World Food Program, World Initiative for Soy in Human Health (WISHH), and Doctors without Borders. The project provides assistance for people receiving ART pharmaceuticals in the form of a household food basket distributed monthly from a clinic. The primary objective of the project is to improve the care and support of people living with HIV/AIDS through the development of a pilot model of nutritional supplementation.

At the present time, the project involves about 180 participants and their households. The participants come primarily from Tegucigalpa and San Pedro Sula. The food baskets distributed through the project include rice, maize, corn-soy blend, vegetable oil, and beans. The monthly value of the food basket is estimated at Lps. 820 (US$44.32) and the participating households report monthly average expenditures of $233.29 or Lps. 4315.8. In the period 2003-2004 the size of the food basket and its value did not vary by household size or composition (presently the food basket's size does vary depending on the number of household members). The total weight of the monthly food basket was about 130 pounds. The majority of program participants (82%) come from the twenty-one to fifty-year-old age group, and 71% of the participants are women. For the participants living in a household with a permanent home, 74% live in families where the head of the household is a single mother or single father, and 50% of the households had one or two children, with only one household reporting no children.

IMANAS selects participants for the program jointly with the local Self-Support Group (SSG) coordinators and the volunteers working as a link between CARE and the SSG. The criteria to become a participant for the project include: person living with AIDS receiving antiretroviral therapy at a pilot center; person living with AIDS with a low income; number of family members; orphans being raised by their grandparents or others; households in which one or both of the parents are HIV positive; and, families showing evidence of malnutrition.

In the baseline survey, a slight majority of the participants (51%) reported no experience of food shortages in the prior year, while 49% of the respondents reported one or more months with a shortage of food in their household in the previous year. Food shortages were directly associated with the absence of income sources in the households, with 57% of households with no reported source of income having one or more months of food shortages, while 43% of households with one or more sources of income reported one or more months of food shortages. To obtain food when resources were short, households reported a number of strategies, with the most common strategies listed as looking for work, obtaining support from family members and relatives, seeking donations from charities, reducing expenditures and going without.

The project participants were surveyed by the IMANAS Project (CARE-Honduras) to assess the socioeconomic situation of the participants as well as to measure physical and nutritional impacts. A baseline survey was fielded in 2003 and a final survey after one year of project participation in 2004. Prior to the project, 16.9% reported taking antiretroviral drugs, and 99.2% of the participants reported receiving ARTs at the time of the final survey. In terms of associated illnesses, as table 1 shows, participants were asked how many times they were sick during the past three months. While the "Once" category held steady at 19.6% for the baseline and 20.7% after one year of the project, the other categories show a shift of about 10 percentage points (roughly 18 participants) from "Twice or more" to "None." Furthermore, after one year of the project, fewer of the participants (18.4%) reported selling assets in the past three months to help pay for illness-related expenses compared to the baseline level of 23.6%.

The IMANAS project, though a pilot effort involving a small number of households and participants, demonstrates the feasibility of a food supplementation program aimed at improving the quality of life for PLWHA. While not a clinical trial, the baseline and final survey data provides some support for the claim of health improvements due to the combined benefits of access to antiretroviral drugs, food supplementation, and counseling and other advocacy and case management services. However, from the project surveys it is not possible to assess the distinct contribution of food supplementation and improved accessed to food through the food basket on the health and food security of participants. Furthermore, the IMANAS project focuses on the well-being of the person with HIV/AIDS and no attention was paid to collecting measures of other household members' health status, food security, or food intakes.

Insights from Agricultural Economics

Agricultural economists interested in the economics of health and nutrition have long pursued a research agenda with the potential to help inform the response to HIV/AIDS. For example, economic research surrounding the topics of food assistance and supplementation programs, the role of food and nutrition in the production of health, the measurement of unequal access to food and health care treatments, and numerous other food research topics might contain insights that could help inform NGO-delivered HIV/AIDS nutrition programs.

Barrett extends the basic dynamic model of health production and demand for health-producing inputs to focus on food security and its role in producing physical well-being. This microeconomic modeling framework lends itself to the discussion of the economics of programs using food assistance and supplementation to improve the well-being of people living with HIV/AIDS (PLWHA) and to prevent further spread of the disease and to mitigate the affects of HIV/AIDS on households and communities. The health demand model highlights a number of means and structural mechanisms that affect the food insecurity of individuals and households, namely: low labor productivity, poor terms of trade, limited market access, asset poverty, credit market imperfections and the inability to borrow, and the lack of informal mechanisms and institutions to provide a safety net (Barrett). While all of these factors appear to play a role in either encouraging the behaviors that can lead to HIV/AIDS (such as migration and transactional sex), the factors of low labor productivity, asset poverty, and weak safety net institutions are linked in the literature as being most central to the HIV/AIDS and food insecurity nexus.

The health demand approach to food security also emphasizes the microeconomics of the individual and household decisions related to the production of physical well-being. For PLWHA access to a balanced diet has been demonstrated to produce better outcomes. Gillespie and Kadiyala survey evidence that demonstrates a strong link between malnutrition and poor health outcomes for PLWHA. They report evidence at both the level of general malnutrition and at the level of some micronutrients, notably vitamins E, B6, B12, and selenium, that nutritional deficiencies relate directly disease progression and poorer health states. In addition, evidence exists that people with poorer nutritional status and in environments with heightened income inequality are more at risk for HIV than others (Stillwagon). Nevertheless, the quantitative evidence of the relationship between food insecurity and risk of HIV/AIDS remains unclear and the ability to translate some nutritional research findings to effective food assistance and supplementation programs is not well demonstrated.

At its core, food insecurity involves risk and uncertainty. Looking at risk of HIV/AIDS raises entirely different questions in the area of food security and food assistance than the questions raised in clinical and medical settings. Here agricultural economists have developed quantitative approaches to measuring food insecurity and such measures can be developed in the case of HIV/AIDS to help identify the households, communities, regions, and countries most at risk. For example, Christiaensen, Boisvert, and Hoddinott develop a dynamic measure of household food security based upon longitudinal data on agricultural production, food security and food intakes, and household labor, income and assets collected from villages in northern Mali. Their dynamic food security profile demonstrates how a static view of food insecurity understates the extent of food insecurity by failing to consider the possibility of future food shortfalls. Insights such as these might be extended into the HIV/AIDS arena by incorporating an understanding of the epidemic's social and biological dynamics. Such measures would quantitatively measure the extent to which all people are at risk of HIV/AIDS, where the risk is understood to be an impact from HIV/AIDS (in terms of health status, and economic, psychological, social, and emotional well-being). Thus, as Loevinsohn and Gillespie have suggested, AIDS mitigation efforts that involve food assistance have a preventive role, in that others in the household who are not yet infected, may have their risk of contracting HIV lessened. Developing a better quantitative understanding of the magnitude of these risks is necessary to assess the likely preventive impact of such food assistance programs. We do not at present understand well how HIV/AIDS serves to change food security for noninfected household members over time, particularly after the death of an adult child or a parent from AIDS.

In the health demand and health production framework, the demand for health inputs and health-related behaviors is conditioned upon the information and knowledge held by the decision maker. Key dimensions of the information relevant to preventing and treating HIV/AIDS and ensuring food security include an understanding of disease transmission and disease management, knowledge of safe sex, an understanding of healthy eating, and knowledge of sources of treatment and assistance. In Honduras, despite the education and awareness work of NGOs and the Government of Honduras, many people do not understand the nature of HIV transmission and the risk factors for the disease. Among the children participating in the IMANAS program, most (94%) of the caregivers knew the source of the infection. Other indicators such as the adult female literacy rate, 80.2% in 2001 (World Bank), and the 90% of males and 81% of females that reported the knowledge that a healthy-looking person can have HIV (based upon fifteen to twenty-four-year-olds surveyed), show that Honduras lags behind a number of its Central American and Caribbean neighbors (UNAIDS). A promising development in HIV/AIDS education and knowledge in Honduras is the lead of two major agribusinesses (Cargill and Chiquita Brands) in providing employee education and prevention knowledge regarding HIV/AIDS (Reuters). Little or no research exists on the role of agricultural businesses in the distribution of information and in treatment and mitigation efforts, with little known about the incentives for action in this sector and the prospects for successful company-provided education programs.

A significant topic of research in the food security literature regards the targeting of food assistance program resources. Targeting is concerned with ensuring that food assistance gets to its intended beneficiary and that "leakages" of food assistance to others are minimized. Targeting often raises program costs and often lessens the political support of food programs (Barrett). The IMANAS program uses the local SSGs to identify program participants and target the program resources. Presumably, significant volunteer and staff time resources are involved in the process of allocating program participant slots and it is not known whether this model could be replicated at a larger scale. Also relevant to the discussion of targeting is how long the food assistance ought to be provided in order to maximally benefit the entire population of program participants and potential participants. Kraak et al. raise the question of whether the program assistance should remain in place to the household for a period of time if the participant with HIV/AIDS dies so that the household can ensure access to food while recovering from the financial impact of the lost worker and the expenses of caring for the person and the funeral expenses. Should the focus of HIV/AIDS food assistance efforts, such as the IMANAS project, have as an objective solely the welfare of the PLWHA or should weight be placed upon the welfare of others in the household or in the community? Clearly, answers to these questions about intended beneficiaries will vary by NGO and by community.

An Agricultural Economics Research Agenda to Inform NGO Efforts

Agricultural economists interested in international development and food security have the opportunity to contribute much to the emerging understanding of how social and economic phenomenon, such as poverty and food insecurity, influence the trajectory of regional HIV/AIDS epidemics. A first challenge to be reckoned with, before outlining some areas where economists can contribute to the programs of NGOs responding to the pandemic, concerns the difficult issues of stigma and the overall lack of resources necessary to address HIV/AIDS. Haddad and Gillespie note the necessary data to conduct detailed econometric analyses is mostly lacking in the area of HIV/AIDS and that efforts to assess interventions are challenged by communities and participants who resist randomization in the experimental designs of interventions. They state (p. 505) "even where intervention resources are insufficient to address the entire needs of the eligible population such randomization is difficult both politically (the leaders of communities that are excluded in a random fashion understandably feel aggrieved) and ethically (if one has a good idea that a mitigation intervention will be effective, what are the grounds for denying the control group the intervention?)." The lack of such data is a significant barrier to learning about effective food and community development responses to HIV/AIDS and NGOs face this issue commonly in the development and implementation of HIV/AIDS care and mitigation efforts. Closely related to this is the ongoing and pervasive problem of stigma. Stigma and fear results in people avoiding HIV/AIDS project surveys and refusing to be associated with public health and nutrition workers.

What are the most significant questions for NGOs involved in food assistance programs aimed at treating, mitigating, and preventing HIV/AIDS that agricultural economists might address? Here are some suggestions:

1. Quantitatively, how does HIV/AIDS impact household structure over time?

2. Are programs and interventions using food assistance cost-effective ways to reduce the burden of disease attributable to HIV/AIDS? Should NGOs and governments target their scarce staff and financial resources elsewhere? What are the health outcome changes due to food assistance? What are the real costs of implementing such a program?

3. How can communities develop and sustain equitable programs of providing food security assistance to households impacted by HIV/AIDS? How can food assistance programs for PLWHA avoid the common difficulties of leakage and benefits accruing to those in political power?

4. What explains agribusinesses offering HIV/AIDS prevention programs? Why do some companies offer these programs yet others avoid them? Is the explanation due to the role of labor in the company's production process or is it attributable to a company philosophy?

5. How can we measure a person's vulnerability to HIV/AIDS in a manner that incorporates the dynamics of disease incidence and burden? Does such a measure add to our knowledge of targeting prevention, treatment, and mitigation efforts?

6. Cost-effective analyses that compare prevention efforts with treatment and care efforts have been criticized as ignoring the "mutually reinforcing synergy of integrating these interventions" (UNAIDS, p. 105). Do examples exist where quantitative evidence demonstrates such mutually reinforcing benefits? Under what conditions do such mutually reinforcing synergies occur? Is there a role for food assistance in such interventions?

NGOs involved in food assistance programs in the HIV/AIDS area can do a number of things to facilitate the economic assessment and evidence regarding program effectiveness and impact. First, the use of survey questions from widely recognized surveys (such as the Living Standards Measurement Survey or the Demographic and Health Surveys) for measuring living standards and household conditions would facilitate comparisons to national and regional survey data from the project baseline and evaluation data. NGOs should consider expanding the unit of analysis from the individual living with HIV/AIDS to the household affected by HIV/AIDS in their assessment surveys in order to capture spillover effects on other household members. Furthermore, NGOs should consider and work with their local communities to assess whether a key project outcome ought to be the welfare of people not yet infected by HIV/AIDS, along with the welfare of PLWHA. If possible, multiple food security related questions should be fielded in baseline surveys and assessment surveys, with anthropometric measures included along with questions about food expenditures, food intakes, income sources and assets.

Conclusion

To sum up, NGO food assistance programs offer an arena where agricultural economists might make a contribution to the design and implementation of more effective programs involving food assistance to address the challenge posed by HIV/AIDS. Food assistance programs such as the IMANAS project in Honduras work at the front lines of the HIV/ AIDS pandemic in developing countries. Whether it is at the level of international policy in institutions such as IFPRI and the World Bank or in a corner of the world like Tela, Honduras in an HIV/AIDS nutrition program, agricultural economists have a view of human behavior and incentives, along with skills in economic measurement and modeling, that can provide useful insights to help craft more effective responses to HIV/AIDS.

The author gratefully acknowledges the support of the Illinois Future Foods project as well as the CARE-Honduras staff, especially Dacia Ramirez and Xiomara Cruz, for conversations regarding food assistance programs for people living with HIV/AIDS.

This article was presented in a principal paper session at the AAEA annual meeting (Providence, Rhode Island, July 2005). The articles in these sessions are not subjected to the journal's standard refereeing process.

References

Barrett, C.B. "Food Security and Food Assistance Programs." In B. Gardner and G. Rausser, eds. Handbook of Agricultural Economics, vol. 2A. New York: Elsevier Science, North-Holland, 2002, pp. 2103-90.

CARE-Honduras. Report on IMANAS Project Baseline and Final Survey, 2003-2004. San Pedro Sula, Honduras, February 2005.

Christiaensen, L.J., R.N. Boisvert, and J. Hoddinott. "Validating Operational Food Insecurity Indicators against a Dynamic Benchmark." Policy Research Working Paper 2471, November 2000, The World Bank.

de Waal, A. "A Disaster with No Name: The HIV/AIDS Pandemic and the Limits of Governance." In G. Ellison, M. Parker, and C. Campell, eds. Learning from HIV and AIDS. New York: Cambridge University Press, 2003, pp. 238-67.

Gillespie, S., and S. Kadiyala. "HIV/AIDS and Food and Nutrition Security: From Evidence to Action." Food Policy Review 7, International Food Policy Research Institute, Washington DC, 2005.

Haddad, L., and S.R. Gillespie. "Effective Food and Nutrition Policy Responses to HIV/AIDS: What We Know and What We Need to Know." Journal of International Development 13(2001):487-511.

Kraak, V.I., D.L. Pelletier, E.A. Frongillo, and S. Rajabiun. "The Potential Role of Food Aid for AIDS Mitigation in East Africa: Stakeholder Views." Food and Nutrition Technical Assistance Project Report, November 1999. Available at www.fantaproject.org.

Loevinsohn, M., and S. Gillespie. "HIV/AIDS, Food Security and Rural Livelihoods: Understanding and Responding." RENEWAL Working Paper No. 2 (International Food Policy

Research Institute and the International Service for National Agricultural Research), accessed at www.isnar.cgiar.org/renewal/pdf/ RENEWALWP2.pdf, 2003.

Reuters Foundation. "AIDS in Honduras: Invest Now or Pay More Later." Accessed at www. alertnet.org/thefacts/reliefresources/227775. htm, 2005.

Stillwagon, E. "HIV/AIDS in Africa: Fertile Terrain." Journal of Development Studies 38(6) (2002):1-22.

UNAIDS/World Health Organization. "Honduras: Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections." Accessed at hivinsite.ucsf.edu/pdf/UNAIDS/ Honduras_en.pdf, 2004.

UNAIDS. 2004 Report on the Global AIDS Epidemic: 4th Global Report. Joint United Nations Program on HIV/AIDS. Geneva, Switzerland, 2004.

Paul E. McNamara is assistant professor in the Department of Agricultural and Consumer Economics at the University of Illinois at Urbana--Champaign.

Table 1. Illness and Asset Disposition Indicators for IMANAS
Participants

Item                      Baseline (%)   Final (%)

Number of times the participant was sick
  during the last three months
  None                        18.9         28.3
  Once                        19.6         20.7
  Twice or more               61.5         51.0

Have sold assets during       23.6         18.4
  the last three months
  to pay for treatment

Source: CARE-Honduras, IMANAS Project Baseline and Final
Survey, 2003-2004.