38551
Africa Region
Working Paper Series No. 100
The Impact of Morbidity and Mortality on Municipal Human Resources and Service Delivery
An Analysis of 3 African Cities
Zara Sarzin
Water and Urban, East and Southern Africa (AFTU1)
September 2006
The Impact of Morbidity and Mortality on Municipal Human Resources and Service Delivery: An Analysis of 3 African Cities
Africa Region
Working Paper Series No. 100
September 2006
Abstract
The Africa Region Working Paper Series expedites dissemination of applied research and policy studies with potential for improving economic performance and social conditions in Sub-Saharan Africa. The series publishes papers at preliminary stages to stimulate timely discussions within the Region and among client countries, donors, and the policy research community. The editorial board for the series consists of representatives from professional families appointed by the Region’s Sector Directors. For additional information, please contact Momar Gueye, (82220), Email: or visit the Web Site: http://www.worldbank.org/afr/wps/index.htm.
The findings, interpretations, and conclusions in this paper are those of the authors. They do not necessarily represent the views of the World Bank, its Executive Directors, or the countries that they represent and should not be attributed to them.
1 Table of Contents
1 Table of Contents 3
2 Acknowledgements 4
3 Abbreviations and Acronyms 5
4 Executive Summary 6
5 Introduction 8
5.1 Purpose and Rationale for the Study 8
5.2 Scope 11
6 Municipal Profiles 12
6.1 High Level Comparison of the Three Municipalities 13
6.2 Kampala City Council (KCC) 14
6.3 Ilala Municipal Council (IMC) 16
6.4 City Council of Nairobi (CCN) 18
7 Burden of Disease and Staff Deaths 21
7.1 Leading Causes of Morbidity and Mortality 21
7.2 Mortality of Municipal Workers 26
8 Data and Methodology 30
8.1 Data Collection 30
8.2 Incidence versus Prevalence Approach 31
8.3 Analysis of the Municipal Workforce 32
8.4 Estimating the Cost of a New HIV Infection 32
8.5 Modelling the Demographic Impact of HIV/AIDS in the Workplace 36
8.6 Estimating Aggregate Costs dues to HIV/AIDS 37
8.7 Illustrating the Impact of HIV/AIDS Prevention and Treatment Programmes 37
8.8 Estimating the Cost of Morbidity 38
8.9 Illustrating the Impact of Malaria Prevention Programmes 39
8.10 Full Assumption Set 39
8.11 Questioning the Theoretical Framework 39
9 Results 41
9.1 Cost of a New HIV Infection 41
9.2 Aggregate Impact of HIV/AIDS in the Workplace 43
9.3 Cost of Morbidity 44
9.4 Impact of Workplace Interventions 45
10 Conclusions and Recommendations 52
10.1 Accessing National Level Funds for Workplace Health Interventions 57
10.2 Dissemination of Findings and Areas for Further Research 58
11 References 59
12 Annex A: Acknowledgements 62
13 Annex B: Human Resource Data 65
14 Annex C: Interview Questions 75
15 Annex D: Literature Review 78
16 Annex E: Full Assumptions Set 83
17 Annex F: Sensitivity Analysis 89
Authors’Affiliation and Sponsorship
Zara Sarzin, Senior Consultant at The World Bank
2 Acknowledgements
This study would not have been possible without the valuable assistance and generous contribution of the following people:· Jaime Biderman, Sector Manger, Water and Urban, East and Southern Africa, World Bank;
· Geoffrey Katsoleh, Assistant Town Clerk (Legal), City Council of Nairobi;
· David Kiggundu Tamale, Programme Coordinator, Kampala City Council;
· Jane Njuguna, Principal Administrative Officer, City Council of Nairobi;
· Agnes Nyoni, AMICAALL Tanzanian Programme;
· Kate Kuper, Senior Urban Specialist, AFTU1, World Bank; and
· Nina Schuler, Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ).
There were many other people who generously contributed their time and expertise and to whom the author is extremely grateful. Their names are listed in Annex A.
3 Abbreviations and Acronyms
AAA / Analytical and Advisory ActivitiesAIDS / Acquired Immune-Deficiency Syndrome
AMMP / Adult Morbidity and Mortality Project
CAO / Chief Administrative Officer
CCN / City Council of Nairobi
CPG / Commuted Pension Gratuity
HIV / Human Immunodeficiency Virus
IEC / Information, Education and Communication
IMC / Ilala Municipal Council
ITN / Insecticide Treated Net
KCC / Kampala City Council
KSH / Kenyan Shillings
LAPF / Local Authorities Provident Fund
MAP / Multi-Country HIV/AIDS Program, Multi-sectoral Aids Program
MDGs / Millennium Development Goals
NHIF / National Health Insurance Fund (Tanzania), National Hospital Insurance Fund (Kenya)
NSSF / National Social Security Fund
OVC / Orphans and Vulnerable Children
TB / Tuberculosis
TSH / Tanzanian Shillings
UGSH / Ugandan Shillings
VCT / Voluntary Counselling and Testing
4 Executive Summary
Municipalities are affected by morbidity and mortality (particularly as a result of the HIV/AIDS epidemic) in three ways. Firstly, morbidity and mortality raise the direct and indirect costs of labour to the municipality, which consequently undermines the quality and efficiency of municipal service provision. It also significantly lowers the returns on any investments in capacity building. Secondly, the HIV/AIDS epidemic expands the demand for municipal services, particularly health and social welfare services. And thirdly, disease impacts on the affordability of services and local revenue collection. These problems are compounded by the fact that municipalities often lack the capacity to adequately assess the impact of morbidity and mortality on municipal functioning, and then design and implement effective interventions.
This study focuses on the financial impact of morbidity and mortality in the municipal workplace. The central purpose of the study is to develop a simple methodology and modelling tool that municipalities can use to evaluate the impact of morbidity and mortality on municipal human resources and to estimate the costs and benefits of workplace prevention and treatment programmes. Research was conducted in three East African municipalities: Kampala City Council, Ilala Municipal Council (Dar es Salaam) and the City Council of Nairobi.
While this paper focuses on three large municipalities, the work is relevant for any local government authority and the methodology can equally be applied to any local service delivery organization or public sector entity.
There were significant challenges in collecting data for the purposes of the study, and so many of the assumptions and parameters in the model have been estimated based on the limited data that were available. The emphasis is on establishing a methodology that will allow results to be refined iteratively over time as data collection and collation improves. The preliminary results from the model will help to reinforce the commitment of municipal managers to address the impact of disease in the workplace and will also be a useful tool to advocate for local and national resources. The study also highlights the serious need to improve human resource information systems for overall municipal management purposes.
In Kenya, Uganda and Tanzania the national disease burden is mostly due to communicable and potentially preventable disease, particularly HIV/AIDS, malaria and TB. This pattern of disease is repeated at the city and municipal levels, where HIV/AIDS, TB and malaria account for a significant share of morbidity and mortality in all three site cities.
Mortality rates among municipal staff are extremely troubling. In the City Council of Nairobi, there are around 190 to 200 employee deaths reported every year (approximately four deaths every week), equivalent to a crude death rate of 1 to 1.5 percent. In Ilala Municipal Council there are 40 to 50 reported deaths every year (equivalent to a crude death rate of 1 to 1.5 percent). And, in Kampala City Council, there are 35 to 40 reported deaths every year. It is likely that the true number of employee deaths is higher due to underreporting.
The analysis shows that the cost of HIV/AIDS in the workplace is considerable, even using the conservative base case assumptions of the model:
· the present value cost of a new HIV/AIDS infection is roughly twice the annual salary of an employee; and
· the annual cost of HIV/AIDS in the workplace is between one and two percent of the municipal wage bill.
Disease also undermines the capacity of the municipality to deliver services through increased absenteeism, lower productivity, and the loss of experienced and knowledgeable staff. As a result, the quality, quantity and timeliness of municipal services are compromised. This becomes even more serious as cities undertake institutional reform programs to improve the productivity of workers who might then fall ill.
There are three main strategies that the municipality can employ to manage the impact of morbidity and mortality on municipal human resources and service delivery: (1) investing in prevention activities including Information, Education and Communication (IEC), and the promotion and distribution of condoms in the workplace; (2) investing in the treatment and care of sick employees; and (3) investing in broadening the skills of employees to facilitate re-allocation of responsibilities and establishing career development and succession plans.
The preliminary results demonstrate that beyond ethical and moral imperatives to plan and implement programmes to mitigate the impact of disease in the workplace, there is a strong financial imperative to act now.
Analysis shows that workplace prevention and treatment programmes are in most cases profitable investments. Making some simple assumptions about illness and death in the workplace, the analysis demonstrates that in most cases, the municipalities will achieve positive returns on investments in prevention and treatment of HIV/AIDS in the workplace. In cities where malaria accounts for a large proportion of regular absenteeism, it may also make sense for municipalities to build prevention activities (in particular the provision of Insecticide Treated Bed Nets) into their workplace health programme. These workplace interventions can also have other non-financial benefits including strengthened staff morale, improved labour relations and skills retention, while buying time for drug prices to fall and for advances in medical research. The ethical and moral imperatives to act are also high.
There may also be opportunities for municipalities to access funds from national programmes for HIV/AIDS, TB and malaria interventions, particularly in view of the high returns on investments in workplace programs for the municipalities. The analysis is expected to be a useful tool to strengthen and shape requests for both local and national funding.
5 Introduction
Anecdotal evidence from mayors, city officials and communities suggests that morbidity and mortality (particularly as a result of HIV/AIDS and malaria) are having a significant impact on municipal service delivery and are undermining the development gains that have been made in cities and towns of East and Southern Africa.
Morbidity and Mortality raise the cost of labour to the municipality and consequently undermines service delivery. Morbidity and mortality in general, and the HIV/AIDS epidemic in particular, increase the direct costs borne by the municipality through increased absenteeism, lower productivity, higher health care costs, funeral expenses, pension payments, and recruiting and training of replacement workers. There are also indirect and less measurable costs to the municipality that may include service delivery failures or disruptions, loss of institutional memory, experience and skills, breakdown in morale, disruption of established teams, diversion of management time, and deteriorating labour relations.[1]
HIV/AIDS also expands the demand for municipal services, particularly health and social welfare services. As a result of the epidemic, local authorities face increasing demands for new and expanded services. These might include demands for expanded health and social welfare services, home and community based care, cemetery space, and services targeted at orphans and street families.
In addition, HIV/AIDS has an impact on local revenue collection and the affordability of services. If the spread of the disease is left unchecked, the epidemic has the potential to affect the local economy and the growth rate of cities and towns. Households tend to suffer from multiple infections and productive labour and household income is diverted to the care of sick household members, and the payment of medical expenses and funeral costs. This contraction in household income and shift in household expenditure away from savings and consumption towards medical expenses, affects households’ ability to pay local rates, user fees and taxes. This also impacts negatively on the local business environment, contributing further to lower local revenue collection from market fees, business licenses and taxes.
Local authorities often lack capacity to develop and implement effective HIV/AIDS interventions. In the last few years, there has been increasing attention paid to decentralised responses to HIV/AIDS and the contribution that local governments can make in engaging, mobilising and supporting communities, identifying priorities, and coordinating local responses. National resources, including the World Bank’s Multi-Country AIDS Programme (MAP), are increasingly being allocated to the local level. However, a significant challenge continues to be the absorptive capacity of local governments and the quality and effectiveness of local interventions. In many cases, local decision makers lack the information, systems and capacity to understand the full extent of the problem and then design, implement and monitor effective interventions.
5.1 Purpose and Rationale for the Study
The purpose of the study is to develop a simple methodology and modelling tool to evaluate the impact of morbidity and mortality on the human resources of three municipalities in East Africa. It is intended that the model will be adapted for use by other local governments and local decision makers to plan cost effective and high impact interventions within their workplaces. The study draws on the methodology of similar studies conducted in the private sector (particularly in South Africa).[2]
The rationale for this study is consistent with the Urban Sector’s broader strategic contribution to the Millennium Development Goals[3]. There are several important areas where core urban activities have the potential to contribute significantly to public health outcomes. Some of these linkages include: (1) the contribution of adequate water and sanitation services to urban health outcomes; (2) the impact of drainage on the incidence of malaria in cities and towns; (3) the urban character of the HIV/AIDS epidemic and the concentration of high risk and vulnerable groups in urban areas, including street families and orphans and vulnerable children; (4) the decentralised nature of service delivery in East and Southern African, which means that local authorities are often responsible for providing primary health care services and community outreach at a local level; (5) the contribution of slum upgrading, improvements in housing and transport, and adequate waste management systems to public heath and safety.