Proactive, Reactive, Sustainable? Analyzing South Africa’s Policy and Strategic Framework on HIV and AIDS for Higher Education

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1. Does this policy offer guidance on the HIV epidemic that is proactive and reactive so that higher education can help drive economic development for South Africa? 2. Is the guidance sustainable to help drive economic development for South Africa?
Proactive, reactive, and/or sustainable guidance, by definition, directly ties to success.
Proactive guidance serves to mitigate and stop the spread and effects of HIV. This could include disease research and programmes targeting risky behaviors, for example. Reactive guidance responds to disease infection. Examples could include policies for support groups and HIV-infected higher education employees, among others. Sustainable guidance is that which can be maintained long-term. As detailed later, to consider sustainability, this analysis examines the Policy according to the two categories, "Infrastructure Capacity-Building" and "Sustainable Innovation Confirmation," drawn from work by Johnson, Hays, Center, and Daley (2004). Together, these three criteria have implications for economic development as they relate to response and mitigation of HIV, which affects millions of South Africans, their families, and communities directly and indirectly. Areas impacting HIV and impacted by it are described in the next section.

Literature Review
Examining the way HIV impacts and is impacted by society, healthcare, and workforce development offers context that helps inform what is needed to effectively combat the disease for this sector and for South Africa's economic development broadly-speaking.
Considering issues related to HIV infection as they intersect with the higher education sector offers more specific insights. In addition to detailing this context and these specifics, connections made in these three areas in the Policy and Strategic Framework on HIV and AIDS for Higher Education itself are outlined.
Society. The HIV epidemic has unfolded against the unique backdrop of South African history. Though democracy and broader support for human rights were adopted in 1994, a legacy of inequality remains across South African society (Coovadia, Jewkes, Barron, Sanders, & McIntyre, 2009). For the higher education setting, inequalities arising from race, financial situations, educational access, health, and opportunity emerge (Department of Higher Education and Training, 2013).

Bruce Current Issues in Comparative Education 22
HIV brings additional issues to light. Stigma related to HIV remains an issue (Human Sciences Research Council, 2015), leading to discrimination within families and by community members, job loss, loss of land holdings, school expulsion, health treatment denial, and violence (Joint United Nations Programme on HIV/AIDS, 2007). Despite recent gains, SANAC notes, particularly, the extreme challenge to progress because violence towards women and sexual minorities has been so prevalent (Human Sciences Research Council, 2015). This violence towards women, as well as risk-taking behaviors by men related to sex, stems from patriarchal norms and views of masculinity leading men to exercise power over women (Coovadia et al., 2009). In the midst of such violence, women face difficulties taking control during sexual encounters, putting them at risk for HIV (Maman, Campbell, Sweat, & Gielen, 2000).
The higher education environment itself tends to place students at further risk for HIV infection. Students are often apart from their families for the first time (UNESCO, 2014). This independence is often accompanied by increased exposure to alcohol and drugs, fuelling risk-taking (UNESCO, 2014). Academic pressures in some cases lead students to exchange sex with higher education staff for grades, and financial stress can lead students to pursue work in the sex trade (UNESCO, 2014). On the positive side, higher education is well-positioned to influence students who will lead in the public and private sector for the future (HEAIDS, 2010).

Healthcare.
Healthcare is critical to reacting to the effects of HIV, and higher education serves as a provider of such services for both students and employees (HEAIDS, 2010). These services focus on physical treatment, as well as psychological and social ones (HEAIDS, 2010). Besides reacting to the disease, universities also serve proactively, conducting research contributing to patient treatment and disease eradication and linking individuals with HIV research interests so as to strengthen collaboration across institutions.
Workforce development. Just as HIV is detrimental to economic development overall, workforce knowledge and development achieved through higher education can be devastated by HIV. Deaths of employees and students decrease the present and future workforce, knowledge base, experience pool, and returns on investment (United Nations Department of Economic and Social Affairs, 2004;UNESCO, 2014). Productivity and quality of work also suffer with compromised health of employees or their family members (United Nations Department of Economic and Social Affairs, 2004).

Society, healthcare, and workforce development in the Policy. The Policy and Strategic
Framework on HIV and AIDS for Higher Education explicitly presents connections among HIV; society, healthcare, and workforce development as they relate to higher education; and subsequent economic development of South Africa. First, the "strong social and structural underpinnings" of the disease are referenced in connection to development and poverty reduction struggles (HEAIDS, 2012, p. 10). The higher education sector as a pipeline to the labor market is specifically highlighted in overcoming these struggles, with the sector referred to as "one of the fundamental and critical levers for overall development" (HEAIDS, 2012, p. 11). Second, this policy points to the unique positioning of the sector to address HIV impacts as necessary for its involvement. Higher education action is framed as imperative because its environment is uniquely conducive to HIV transmission, with health declines, absenteeism, and high stress encountered by students, educators, and support staff threatening the sector's ability to fulfill its mission of teaching and learning (HEAIDS, 2012).
More optimistically, its unique situation for grooming "agents of change" in society at large and its mandate to "generat[e] new technologies, practices, and understanding through research" are also stressed (HEAIDS, 2012, p. 12). The attitudes, skills and knowledge pertaining to HIV gained during time at universities have protective possibilities for those with access, and these individuals contribute to economic activities. These attributes also have the potential to serve as foundational building blocks for longterm broad economic development. The economic imperative of HIV policy for the higher education sector is ultimately framed as fulfilling its role in developing "cherished" human resources fundamental to economic development (HEAIDS, 2012, p. 12).

Conceptual Framework
The attention to health in relation to economic development, including through higher education, is laid out in the literature. Higher education is a site of formation and application of human capital resources, enhancements, and innovations (see, for example, reviews of literature on economic growth summarized in Hanushek and Woessmann [2010]). In his work on human capital, T. W. Schultz (1961Schultz ( , 1980 focused on issues affecting individual abilities to gain and, ultimately, utilize human capital, as through economic participation, with particular attention to influences of health. Building from this, Mushkins (1962) explained how effects of health-related programming are two-fold: increasing the size of the workforce as well as improving quality of labor outputs. Hamoudi and Sachs (1999) presented five means by which health impacts economics: costs of treatment and loss of productivity at work, ongoing effects of illness and disease, demographics, impacts on social behaviors and commerce, and the "vicious cycle" of poor health (pp. 7-8).
The attention to health in relation to human capital accumulation leads to consideration of prevention and the sustainability of "prevention innovations," particularly in the arena of health, to target promotion of helpful practices and reduction of unhelpful ones longterm. Johnson et al.'s (2004) work on sustaining these innovations, approaches which may be proactive and/or reactive, led them to develop a sustainability planning model. Johnson et al. (2004) found a strategy's sustainability to be connected to two factors, "Infrastructure Capacity-Building" and "Sustainable Innovation Confirmation" (p. 138). The former focuses on resources in the context of the innovation, including people's abilities, knowledge, and relationships, as well as physical and institutional features, like financing, technology, and administrative guidance (Johnson et al., 2004). The latter focuses on the innovation itself and its continued usefulness to stakeholder needs and their connections to it and each other before, during, and after implementation (Johnson et al., 2004). Sustainable Innovation Confirmation, according to Johnson et al. (2004), includes communications and evaluation. Influenced by Schultz, Mushkin, and Hamoudi and Sach's work factoring health into human capital formation, these two categories Bruce Current Issues in Comparative Education 24 outlined from the prevention literature provide guidance for examining the Policy and Strategic Framework on HIV and AIDS for Higher Education to determine whether it proactively and reactively responds to the disease in a sustainable way.
Higher education has been working to address HIV impacts for many years. Critiques published just before the Policy's release provided specifics on gaps and ways in which future investment for HIV could be most beneficial. These critiques, shown in Figure 1 alongside issues related to HIV infection and the higher education population, are explicitly cited as reasons for revision in remarks by the chairperson of the HESA-HEAIDS group (HEAIDS, 2012, p. 5). Most are self-explanatory and can be categorized based on their relationship to society, healthcare, or workforce development. One critique, recommending "critical intellectual engagement," was contributed by Mary Crewe, the Director of the Centre for the Study of AIDS at the University of Pretoria with ten years' experience in integrative HIV/AIDS programming (UNESCO, 2014, p. 79). Her recommendation pertained to the need for higher education to extend its approach beyond only treatment and prevention. She advocated extending approaches to raise student awareness of how "poverty, race, globalization, and class" spread HIV and the addition of programming to encourage students to grapple with issues around sexuality and tolerance (UNESCO, 2014, p. 79).
Paralleling recommendations to broaden awareness of the roles played by poverty, race, globalization, and class, literature and media reports on the South African higher education sector overall indicate systemic gaps related to these. These gaps are relevant not only to discussions for what higher education should offer in terms of health and HIV but also to whether these offerings, should they be introduced as a result of the Policy, are even accessible.
For example, university fees are often quite high in South Africa, meaning many individuals are excluded entirely or, if they do attend, they are often burdened with debt (Department of Higher Education and Training, 2013;Falkof, 2016). This burden is obviously felt most greatly by those in poorer households. The highest levels of poverty are found in female-headed households and households headed by black South Africans (The World Bank, 2018). Large families and households that are rural also are likely to face impoverished circumstances long-term (The World Bank, 2018). The country's loan program can add to this burden, covering amounts per student that are too little to cover fees (Council on Higher Education, 2016; Falkof, 2016; "How much students owe," 2015). If students are able to afford attendance, different experiences are frequently offered according to the campus on which they arrive. Some of these differences have been linked to socio-economic contexts of the communities where they are located (Capacity4dev.eu, 2017) and the leadership in place at that particular campus (Tau, 2016;Tshehle, 2016). Once in the classroom, statistics indicate differences in successful completion of coursework. For example, black African students are shown to have an average course success rate of 74% in comparison to an 84% success rate for white students (Universities South Africa, 2015). Also, many black students, faculty, and staff feel alienated and little sense of belonging at their universities (Universities South Africa, 2015). This is connected to South Africa's history of a segregated higher education system (Universities South Africa, 2015); an ongoing "institutional culture" unwilling to embrace diversity, including through hiring more diverse staffs and addressing sexism, racism, and discrimination head-on (Universities South Africa, 2015, p. 14); and pressures to be more financially efficient to the detriment of being fair (Luckett & Mzobe, 2016). Outsourcing staff positions, many of which are filled by blacks and women, as part of efforts to improve efficiency and competitiveness has increased race and class divisions among workers and feelings of marginalization among those employed at universities (Luckett & Mzobe, 2016).
Because these systemic issues impact who will be reached by the Policy, they are listed among the critiques presented in Figure 1. This figure offers a framework for analysis of results presented in the next section.   (2017)

Results of the Policy Analysis
Reflecting guidance by the South African Constitution and the National Strategic Plan on HIV, STIs andTB 2012-2016, the Policy and Strategic Framework on HIV and AIDS for Higher Education directs actions of the sector, organizing them according to three strategic objectives, listed as follows: 1. To ensure the comprehensive and appropriate use of the Higher Education mandate of teaching and learning; research, innovation and knowledge generation; and community engagement to effectively respond to the epidemic drivers of the pandemic.
2. To promote the health and well-being of the Higher Education community at individual, group and institutional levels though strengthening capacity, systems and structures responding to the epidemic.
3. To create an enabling environment to ensure a comprehensive and effective response to HIV and AIDS within the Higher Education sector, free of stigma and discrimination. (p. 22) "Critical Components" related to each of these objectives are presented. In the sections that follow, policy related to these components is overviewed, presented in relation to issues surrounding HIV and the higher education population and the critiques just presented (see Figure 1) as appropriate. Measures advocated are categorized as proactive, reactive, and/or both, to move towards answering the first research question. The Policy's sections entitled "Roles and Responsibilities" and "Section 3: Monitoring and Evaluation Framework" are similarly examined. Finally, evidence as to whether the policy is sustainable based on attention to Infrastructure Capacity-Building and Sustainable Innovation Confirmation is presented to begin addressing the second research question.
Proactive, reactive, both? Objective 1. In relation to its Component 1, graduates are framed as future "leaders in society" (p. 24), not just in general but specifically, in facing challenges of HIV personally and professionally. Higher education is framed as uniquely positioned through its role in generating and sharing research and evidence to not only improve progress in this area for the sector but also for communities and the nation as a whole, positioning it to respond both proactively and reactively.
With Component 2 a range of proactive and reactive innovations are presented, and many align with recommendations of earlier critiques, including attention for mother to child transmission, condom availability, counselling and testing, and general health promotion. For Component 3, "peer educators and youth ambassadors," as well as teachers, are designated as valuable to communicating with students, addressing another critique (p. 26). Social and behavioral factors affecting HIV transmission and treatment are among the "combination" (p. 24) of interventions higher education is to offer. Aligning with critiques advocating differentiation among audiences for innovations, there are calls for programming that "customize[s] interventions for different groups" (p. 26), though these are left vague for the most part. Older, working adults, frequently enrolled at open distance learning (ODL) universities, are specifically mentioned. Women regardless of whether they are infected or not are also specifically targeted by Objective 1. "Gender norms and gender-based violence, masculinity issues, transactional sex, [and] issues of sexual consent" (p. 26) are listed as issues for attention by the sector, connecting them to their effects on women. More broadly, unprotected sex, alcohol, and substance abuse are to be addressed, as directed in Components 3 and 4.
Objective 2. Components for this objective are both proactive and reactive in their focus on promoting health and well-being through corporate approaches at institutions. Programs are to be proactive in their protection and maintenance of health as well as reactive to support those already infected by the disease. Staff is given great attention in the components for this objective, addressing criticism they have previously been ignored despite the high HIV prevalence exhibited by this group. Reflecting research found in the HIV literature, Component 1 calls for reactive approaches addressing not just physical but "cognitive, behavioural, spiritual, and psychosocial aspects of wellness" (p. 27) as well. Component 2 focuses on "recommended minimum components" of workplace policy to react to the disease (p. 28), while advocating contextualization. Additionally, institutions are directed to develop specific responses based on particular "impacts of HIV infection and illness" they experience, "programmatic gap areas" that exist, and observed needs for "attitudinal and behaviour changes" (p. 28). Though not directly identifying complacent low-prevalence institutions, this component could certainly speak to this criticism. Needs of individuals living with HIV/AIDS-related illnesses in a "non-discriminatory way" are also put forth for address in Components 1 and 2.
Objective 3. Components of this objective emphasize stigma and discrimination free responses to HIV under a human rights approach. When reacting to the disease, past critiques pointed to the lack of inclusion and involvement by those already HIV-positive, and policy under this objective continues to speak to this group specifically calling for their "greater involvement" (p. 30). Component 2 also calls for training related to HIV that addresses discrimination including for those with disabilities, a group notably ignored according to critics. Communication regarding awareness and activities undertaken are the focus of Component 3. Proactively, Component 4 acknowledges the leadership potential of the higher education sector to actively communicate, engage, and partner with others as well as to obtain appropriate levels of funding (see Component 5). Notably in Objective 3, this leadership position is noted to span from executive to student levels, as well as to trade unions and staff associations. Also proactively, monitoring and evaluation are introduced here to indicate what this might look like and how findings might be used.

Roles and Responsibilities.
This section is less about outlining proactive or reactive approaches and more about who carries out the approaches connected to the objectives and monitoring and evaluation, which is described in the next section. The Department of Higher Education and Training (DHET) and Higher Education South Africa (HESA) are designated as the primary drivers of this policy, positioned to offer resource identification, mobilization, and support in line with policy prescriptions. Support is also to be provided through the National Department of Health, supplemented by provincial, district, and municipal health departments. Roles for institutions themselves, including contextualization, implementation, evaluation, and responsiveness to stakeholders, are delineated.

Section 3: Monitoring and Evaluation Framework.
Building from Objective 3, this section and the logic model included indicate the Policy's heavy emphasis on monitoring and evaluation to react to what happens and have information to (potentially) shape future responses. The monitoring and evaluation process employed is expected to supply indicators, drive evidence-based decision-making, and promote information exchange. Such monitoring and evaluation build in opportunities to continually reflect on and discern whether proactive and/or reactive approaches are working.
The logic model is constructed according to the three objectives guiding the policy. For example, Objective 1 begins with two goals: "Reduced HIV infections" and "Reduced vulnerability of higher education students and staff to HIV and AIDS" (p. 34). For the most part, each is broken down into one or more results statements with sector and institution-level indicators specified.
Analyzing alignment between the policy text and logic model reveals close matches between objectives and evidence gathering in some areas, with gaps in others. For example, entries for Objective 1 address two of the four components outlined in the policy text. Noticeably absent are indicators related to combatting alcohol and substance abuse (Component 3) and the communication of such strategies (Component 4). Overall, the logic model for this objective does not include indicators disaggregating data by key groups like women and first-year students. As a result, more detailed information, like data on gender-based violence, is not called to be collected. In contrast, Objective 2 is more comprehensively addressed by indicators in the logic model. For addressing Objective 3, while aligning with all components, the logic model lacks details to reflect the specificity of the policy text itself in terms of particular stakeholders. Instead they are often referred to broadly as "strategic leadership" or "all participants" (p. 38). This is surprising since involvement of trade unions and staff bodies was called for by critics, is easily measurable, and simultaneously addresses greater involvement of staff historically struggling with high disease prevalence, another concern raised by critics. Stigma and discrimination for Objective 3 is set to be quantified using measurement tools provided by The People Living with HIV Stigma Index.

Sustainable?
As explained in the Conceptual Framework, in order to consider sustainability, Johnson et al. (2004) have found attention needs to be paid to "Infrastructure Capacity-Building" and "Sustainable Innovation Confirmation." To review, Infrastructure Capacity-Building is related to contextual factors, including human, physical, and institutional resources. Turning to Sustainable Innovation Confirmation, the focus is on stakeholders and their relationships to each other and the policy itself. Consequently, to answer research question 2, the Policy must be revisited with these in mind.
Infrastructure Capacity-Building. For Objective 1, peer educators and youth ambassadors are advocated to augment HIV education. To build up administrative safeguards, minimal workplace guidelines are a part of Objective 2. Two of the objectives also direct that needs of individuals already HIV-infected be addressed, important for improving life expectancy and the quality of their life and work. Training on HIV as it relates to discrimination, including for those with disabilities, and leadership which spans from the executive level to the student level is highlighted in accordance with Objective 3. Throughout the document, contextualization by institutions themselves is stressed which could enable them to develop additional capacity-building and institutional resources to target HIV according to university and even their individual campus needs.

Sustainable Innovation Confirmation.
Multiple stakeholder needs are addressed and monitored within Objective 1 of this document: mother to child transmission, condom availability, counselling, testing, peer education and promotion of health as is communication "to encourage positive behaviours and to promote and sustain change" (p. 26). Communication across communities and stakeholders is to be undertaken according to Objective 3. Several student and staff stakeholder groups (older, working adults and women in Objective 1; those already infected in Objective 3) are directly addressed with disabled individuals addressed more indirectly. Presumably support from the National Department of Health and health departments locally will ensure ongoing match to health needs of those in the higher education sector. Evaluation, part of the Sustainable Innovation Confirmation category ascertained by Johnson et al. (2014), is a large part of this policy's recommendations, found in Objective 3 and in a section entirely dedicated to monitoring and evaluation.

Conclusions
Looking closely at these results and comparing them to the issues and critiques presented in Figure 1, the Policy and Strategic Framework on HIV and AIDS for Higher Education does offer proactive and reactive approaches to combatting HIV. Many of these align with issues specific to individuals served by and serving higher education institutions and critiques directly related to HIV exposure, transmission, and prevention. Advocating that monitoring and evaluation be employed has potential to enhance success where there is close alignment between objectives and evidence gathered; however, this is not consistently the case across the logic model presented.
Consequently, in answer to research question 1, higher education is likely in an improved position to impact economic development. First, this improved positioning stems from investments in students, who can carry what they learn into society at large as they graduate. With this policy, this knowledge is set to include messages related to gender norms and issues of sexual consent, especially important for women, who statistics indicate are especially prone to contracting HIV. Messages are also set to address stigma and discrimination, a crucial issue for HIV-infected individuals. As students carry what they are exposed to during university forth to their own families, communities, and workplaces, others are exposed to their knowledge and these approaches. This multiplies benefits so that many are better informed to prevent and deal with HIV and its effects, thereby enhancing human capital stores that can contribute to economic development. Similarly, benefits can be gleaned by entities outside higher education as they learn from the sector's experiences trying out approaches and seeing what works. This allows others to adopt evidence-based approaches themselves, which can also enhance economic development.
Additionally, attention to staff needs regarding HIV and implementing workplace policies around the disease help maintain and maximize the higher education workforce with its knowledge and wealth of experience. Staff contribute not only to students but to society at large through their research and expertise. Healthier staff are more productive and contribute better quality work, further benefitting the South African economy.
Certainty of the policy's potential to make a difference economically comes into greater question, however, when considering research question 2 regarding sustainability. Drawing from the prevention literature and looking at Infrastructure Capacity-Building and Sustainable Innovation Confirmation, both categories are addressed to an extent; however, the burden is placed primarily on the institutions and individuals there. While DHET and HESA are named in "Roles and Responsibilities" for the national level, a lack of specifics on their involvement includes absence of ways they might address systemic gaps seen across higher education, stemming from race, gender, geography, and socioeconomic situations. While government decisions and market forces impact the higher education sector (Universities South Africa, 2015), the higher education system itself has the capability to lead on issues, especially related to teaching, learning, staffing, and student needs, that can have ripple effects on factors related to HIV exposure, transmission, and prevention. Thus, there is incomplete address of Infrastructure Capacity-Building and Sustainable Innovation Confirmation.
For example, on its website, the National Student Financial Aid Scheme, responsible for providing financial aid to poor and working-class students, lists DHET as among its stakeholders (http://www.nsfas.org.za). This means there is potential for this entity to move to affect change in terms of financing for students. Such actions would take away one obstacle to entering university, thereby increasing the number of students, and particularly the number of less well-off students, exposed to what is laid out in the Policy. Such actions could also prevent students already in attendance from entering the sex trade as a way to pay for their education. Measures to affect resource availability so that all campuses start at the same level, and then can contextualize to enhance what they offer, needs to be prioritized by higher education sectoral leadership. Teaching, learning, and staffing are clear mandates over which the sector has influence to help disadvantaged students to succeed and to decrease outsourcing of workers, so both groups might remain in a position to benefit from the Policy's strategies. Specific steps in these areas for DHET and HESA are not included nor defined in the way that, for example, data gathering is across the logic model.

Implications
The results stemming from this policy then are likely to continue as follows: peer educators, called for in the Policy to supplement other instruction on HIV, will not represent a variety of backgrounds because large numbers of students remain unable to enroll in university education that is out of reach financially or are forced to drop out because they are ill-equipped for success. The time spent serving as a youth ambassador, called for in the Policy, is time that cannot be spent working to pay for school or studying, making such roles luxuries for many and, again, leading to a group lacking in diversity. Contextualization of HIV programming on campuses will remain inadequate because of ongoing, glaring "underfunding in infrastructure, staff and student services" (Universities South Africa, 2015, p. 19) for those universities that were historically black or those campuses, formerly part of historically black universities, made part of a different university in restructuring. Gender issues will continue to be overlooked without more women in place to ensure they remain on the agenda. Many staff members, often the most in need of services for HIV, will remain unreached because of outsourcing, preventing them from benefitting from the Policy. And, finally, an education, itself highly preventive to HIV (Department of Basic Education, 2010; HEAIDS, 2012), will continue to be inaccessible and difficult for many. Economic development cannot be maximized until systemic, not just individual and institutional, issues related to HIV are made a part of higher education policy in South Africa.

Elizabeth R. Bruce holds a Master of Education degree from Lehigh University in Pennsylvania.
Her consulting work draws from her experience in the field of comparative and international education and has included research for various projects. Her personal research centers on HIV/AIDS policies in education and health research partnerships.