AIDS gehört zu den heimtückischsten bekannten Krankheiten. Besonders in afrikanischen Ländern prägt sie stark das Gesellschaftsbild. In Ländern wie Südafrika, die AIDS-Erkrankten finanzielle Unterstützung gewähren, ist immer wieder zu beobachten, dass besonders arme Menschen sich über eine AIDS-Erkrankung in der Familie freuen. AIDS wird dann zu einem Argument für die Einführung eines bedingungslosen Grundeinkommens, um bewusst herbei geführte Erkrankungen zu verhindern.
Nicoli Natrass untersuchte die Bedingungen für die Einführung eines bedingungslosen Grundeinkommens in Südafrika.

Introduction

AIDS is a very serious problem in South Africa. According to the demographic model of the Actuarial Society of South Africa (ASSA2002) for the year 2004, 19% of the adults between the ages of 20 and 64 (and 11% of all South Africans) were HIV-positive. This situation amounts to the deep socio-economic crisis experienced nowadays in the country. The AIDS-emergency in South Africa weakens the economic safeguard of households by reducing the productivity of – and eventually killing – mainly prime-age adults while simul­taneously deflecting scarce domestic resources towards the health-care of AIDS-affected family members. Especially vulnerable to these shocks are in fact the poorest households in South Africa.

It is particularly appalling that the engrossment of the AIDS epidemic in South Africa coincides with the fact that over a third of the nation’s labour force remains unemployed and lacks thereby of social security^[1]. South Africa’s welfare system beholds a full employ­ment programme: means-tested grants exist for over-aged (old age pension) and under-aged (child grant), as well as for disabled citizens (disability grant). Not the less, jobless labour forces do not dispose of such contributions. This ‚gap‘ amidst the social security network of the country may be a good reason for explaining the frequent correlation between unemployment and poverty^[2].

In fact, only the disability grant is available for people of working age. This reality leads not only to social problems within the nation, but – as explained below – to complications with the recently begun Highly Active Antiretroviral Therapy (HAART), South Africa’s ‚rollout‘ on HIV prevention^[3].

Welfare, AIDS and Disability in South Africa

Disability grants are accessible for all those ‚physically and mentally severely disabled‘, whose ages lie between 18 and 65. The whole system works according to a ‚medical model‘. The latter instructs medical officers recommending patients for disability grants to judge the patient’s capacity to labour independently of whether work is available or not^[4]. People who have fallen into the fourth stage of AIDS, i.e. AIDS-sick, as long as they have passed a fairly generous means-test, become eligible for the disability grant. Yet these grants are to be renewed by officers periodically – every six months or up to every five years depending on the kind of contribution the patient is receiving. A dramatic consequence of this is that a patient on antiretroviral treatment who, during the treatment, turns up well enough to work should expect to lose his or her disability grant^[5].

Disability grants (which pay up to R740 [approx. US$115] per month) seem to be an important source of income for AIDS-affected households in South Africa^[6]. Survey evi­dence from Khayelitsha, Cape Town, reveals that for households receiving the disability grant, the contribution comprises between 41 and 49% of the total household income^[7]. The profit obtained from the disability grants can be illustrated by the answer of a woman queried in another study, where she said: „I love this HIV“, a statement she explained as follows:

„Yes, I like this HIV/AIDS because we have grants to support us… Before I was living with my mother, my father and my sister; they didn’t work. Maybe I was passing three to four days without eating. People discriminated me and no one came in the house. The only thing helping was my grandmother’s pension. We survived through that money.  But after the illness, our lives have changed completely.“^[8]

The notion of someone loving HIV seems at first shocking. But it is understandable – albeit in a terrible way – when considering the desperate circumstances to which households can be driven to when they lack of an income-earner. The advent of a disability grant, as was clearly the case for the respondent quoted above, can ensure a longer life-line for an entire family. Thus, the threat of its elimination, resulting of antiretroviral treatment, is utterly serious. If the data from Khayelitsha does constitute a reliable source, it may then suggest that average household income could fall by a third if a disability grant is lost through restored health.

This is evidently bad news for the prospects of the HAART-rollout. Firstly, there will be a great number of HAART-patients to which the access to certain food-products will be bounded once their disability grants are cancelled. People undergoing the treatment need to eat regular, nutritious meals in order to enjoy optimal health benefits. The loss of the disability grant could consequently threat a patient’s health status – thereby shortening his or her life – and could additionally increase viral loads in the patient, increasing by this means his or her infectiousness. Such consequences could undermine the benefits of the HAART-rollout both in terms of preventing from new HIV infections and of extending the lifetime of those infected^[9]. Furthermore, a small, but significant percentage of the AIDS-affected may opt for discontinuing HAART so as to become AIDS-sick again and thus once more qualify to the disability grant; once it is reinstated, the patients take up again the treatment. In cases where the disability grant is cancelled as a result of restored health, some patients go for repeating the cycle. Besides the negative impact on the indivi­dual’s health, such behaviour can dramatically increase the development of drug resistant strains of the HIV virus, thereby diminishing the effectiveness of the entire HAART-rollout. These reasons reinforce the necessity of carrying out a strong case in favour of the introduction of a basic income grant in South Africa’s social security system.

Towards a Basic Income Grant

One way out of the potential trade-off between disability grants and the antiretroviral treatment may consist in removing the grant altogether for HIV-positive people. Such measure would at least facilitate the disappearance of appalling incidents as described above. The result of this, however, could be socially distorting, since its discriminative core is liable of being censured: people disabled by AIDS can’t be categorically disentitled from government support. Moreover, the elimination of the disability grant for all citizens who are HIV-positive would certainly cut down an essential source of income in poor AIDS-affected households. Likewise, the resolution may have unfavourable effects on the nutritional state of people using antiretrovirals. By this means the efficacy of the treatment rollout would be reduced, allowing the following two conclusions: firstly, that in South Africa the decline of a private household income can in fact lead directly to lower food-expenditure. And secondly – taken the fact that AIDS is most common within poor social spheres -: that the ensuing growth of poverty could exacerbate the development of the AIDS epidemic.

An alternative response is to allow HIV-positive people to maintain their disability grants even after their health has been restored. There are, however, two problems with this strategy. The first is that perverse incentives, as described above, can’t be eliminated in this way. Allowing access to the disability grant for patients whose health has been restored may result in some people desiring to become HIV-positive. Although this may sound far-fetched, there is anecdotal evidence from the Western Cape, the Eastern Cape and KwaZulu-Natal indicating that various persons become annoyed when having negative re­sults on their tests – arguing that they were hoping consequently to get the grant. In the Eastern Cape there is the saying that someone has ‚won the lotto‘ if the HIV-test draws positive. Such news is actually seen as a ticket to the disability grant. If antiretroviral treat­ment is regarded – indeed incorrectly – as a ‚cure‘ for HIV, then it is possible that some people may desire to become HIV-positive under the mistaken notion that they will be able to get access to the disability grant, and then be healed through antiretroviral treatment.

The second problem with allowing HIV-positive people to keep their disability grants, even when their health has been restored through antiretroviral treatment, is one of moral character. Why should HIV-positive individuals be privileged over others possibly equally needy, but HIV-negative? Put in this way, the question after the introduction of a Basic Income Grant (BIG) for all disabled nationals immediately arises. Nonetheless the esta­blishment of a BIG would need to be effected at a much lower level (probably in the range of R100 to R200 instead of the current maximum grant of R750). Households having lost the disability grant as a consequence of antiretroviral treatment would obtain in some degree a financial cushioning resultant of the fact that they, and each household member, would have received a BIG. This measure could help prevent people on anti­retroviral treatment from the temptation of quitting their obligations to the treatment’s regimens in order to restore a disability grant.

Suppose that a BIG is introduced for all people, say at R100 per month: what would then be the appropriate level of payment for the disability grant? If the payment to disabled people is to remain at its current level, then a disability grant on the top of the BIG could fall by R100 to R650. This means, for example, that if a person loses a disability grant for entering to antiretroviral treatment, his or her loss in income will consequently sum up R550 rather than R740 – and yet the patient will have a BIG aiding his or her subsistence needs. It is however possible that for some very poor individuals on antiretroviral treat­ment the gap between the disability grant and the BIG may still be large enough to encourage them to stop taking antiretroviral treatment in order to restore the grant. If so, then there is actually a case for reducing the value of the disability grant and/or raising the value of the BIG.

There is a range of arguments, both moral and economic, in favour of a generalized BIG^[10], particularly in the case of South Africa^[11]. This is not the place to review these arguments, nor the arguments against the introduction of a BIG. The point at present is simply to show that given the factual circumstances of the widespread of AIDS in South Africa and, as mentioned above, the perverse incentives associated with the removal of the disability grant, arguments have amounted in favour of the introduction of a BIG.

Previous research and financial simulations have shown that even a modest BIG of R100 per month for all South Africans could indeed contribute to reduce poverty and in­equality in South Africa^[12]. This is the reason why the latest report of the Taylor Committee on „a comprehensive welfare policy reform“ argued in favour of a BIG^[13]. According to Le Roux^[14], financial means for a BIG could be gained through a 7.3% point increase in value-added tax (VAT) and a 50% boost on excise and fuel taxes. This scheme is broad-based and redistributive: those who spend more than R1,000 a month would end up paying more in consumption taxes than they benefit from the R100 BIG.

In earlier work, I estimated that the implementation of a full-scale AIDS prevention and of a treatment intervention that could provide HAART to all those in the need of it (i.e. with a rapid rollout and no share in antiretroviral treatment), would require an increase in resources equivalent to raising VAT by between 3 and 7% points according to the level of care provided to those suffering from any AIDS-related illness^[15]. Given the subsequent, remarkable decrease in the price of antiretrovirals (between November 2003 and June 2004 the first line triple therapy treatment regimen dropped by 72%) the revenue expected to be raised would now probably require only an increase of between 1.9 and 5.7% points on VAT. If we take the mid-point estimate and sum it to Le Roux’s valuation of a necessary tax increase, then it seems that South Africa would have to raise tax revenues by an equi­valent of a 12% point increase in VAT so as to finance a BIG and implement a national AIDS prevention and treatment intervention for all who need it.

This, of course, implies a significant increase in taxation. The viability of this can’t be exactly estimated, as different societies tolerate different levels of taxation, and at different times. Welfare expenditure as a proportion of GDP has risen economic development, and in times of crisis, such as war, citizens have accepted large increases in taxation as legitimate^[16]. The notion of what is and is not ‚affordable‘ thus varies according to social and economic circumstances. Given the high degree of unemployment and the progress of the AIDS epidemic, it is possible that a part of South Africa’s population does agree with an increase in taxation, and may be able to deal with it. Whether one appeals to Rawlsian logic to protect the lives and livelihoods of the poor, or to more radical left libertarian ideas of providing each citizen with a social dividend as a basic right, the issue in the end boils down to whether people can tolerate living in a society that forces AIDS-affected individuals to choose between income and health.

Finally, it is important to note that even if a BIG and a suitable AIDS prevention and treatment intervention were to be introduced, there is yet much more to be done regarding the problem of unemployment and poverty in South Africa. A BIG of R100 a month is ac­tually very small: it amounts only to one tenth of the average African per capita income, and to one twentieth of the average per capita income in South Africa. Addressing poverty through other means – most notably by encouraging labour-intensive growth – must therefore have an essential role in any future solution.

References

• Bhorat, H.: „A universal income grant scheme for South Africa: An empirical assessment“, Paper presented at the 9th International Congress of the Basic Income European Network, Geneva 2002.
• Coetzee, C./N. Nattrass: „Living on AIDS Treatment: A Socio-Economic Profile of Africans Receiving Antiretroviral Treatment in Khayelitsha“, Centre for Social Science Research, Working Paper No. 71. Cape Town 2004. Available on www.cssr.uct.ac.za.
• Leibbrandt, M./Woolard, I./Bhorat, H.: „Understanding Contemporary Household Inequality in South Africa“, in: Studies in Economics and Econometrics, vol. 24, no.3: 31-51. 2000.
• Le Roux, P.:  „Financing a Universal Income Grant in South Africa“, in: Social Dynamics, vol.28, no.2: 98-121. 2003.
• Nattrass, N.: „Unemployment and AIDS: The Social-Democratic Challenge for South Africa“, in: Development Southern Africa, vol.21, no.1, March: 87-108. 2004a.
• Nattrass, N.:  The Moral Economy of AIDS in South Africa. Cambridge: Cambridge University Press 2004b.
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• Seekings, J.: „Providing for the Poor:  Welfare and Redistribution in South Africa“, Inaugural Lecture, University of Cape Town, 23 April. 2003.
• Seekings, J./Nattrass, N. From Race to Class: The Changing Nature of Inequality in South Africa. Yale University Press, New Haven (forthcoming).
• Simchowitz, B.: „Social Security and HIV/AIDS: Assessing ‚Disability‘ in the Context of ARV Treatment“, Draft paper presented at the Centre for Social Science Research, University of Cape Town, July 29, 2004.
• Standing, G./Samson, M. (eds): The Basic Income Grant in South Africa. Cape Town: University of Cape Town Press 2003.
• Taylor Committee: „Transforming the Present:  Protecting the Future“, Report of the Committee of Inquiry into a Comprehensive System of Social Security for South Africa, RP/53/2002, Pretoria, Government Printer. 2002.
• Van der Berg, S./ Bredenkamp, C.: „Devising Social Security Interventions for Maximum Poverty Impact“, in: Social Dynamics, vol.28, no.2: 39-68. 2003.
• Van Parijs, P.: What is Wrong with a Free Lunch? Boston: Beacon Press 2001.