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Over the last three decades, 35 million people have died of AIDS. As a result, HIV/AIDS has brought about a significant reduction in human capital, especially in sub‐Saharan Africa. Several studies have examined the effects of HIV/AIDS on human capital, in particular educational attainment. These studies have examined different countries, datasets, and educational outcomes. This systematic literature review provides a comprehensive up‐to‐date overview of peer‐reviewed papers published in English by focusing on the main mechanisms that influence the effects of HIV/AIDS on educational outcomes. These are sickness of the child, orphanhood, and sickness of parents. The results show that educational outcomes of HIV‐infected children, AIDS orphans, and children with HIV‐infected parents are affected differently. HIV‐infected children mainly miss school days due to illness and medical appointments, and orphans mainly face financial problems and lack motivation in their education, while children with HIV‐infected parents may have to take care of their sick parents or face financial problems that affect their education. Distinguishing these groups of children could help to formulate policies that adequately improve schooling outcomes of these vulnerable children. [ABSTRACT FROM AUTHOR]

Summary: The risk of AIDS‐related mortality increased dramatically throughout the 1990s. This paper updates previous work by Fortson (2011) to examine the impact of mortality risk on human capital investment during the deadliest period of the pandemic. We combine Demographic Health Survey data from 30 countries, across 60 survey waves, to generate a sample of over 1,300,000 observations. Cohort‐specific analysis using the updated sample yields new evidence that the negative relationship between HIV prevalence and schooling steepened as mortality risk increased. The reduction in schooling is largest for women, and along the extensive margin of the schooling decision. The findings indicate that the decline in human capital investment associated with the HIV/AIDS pandemic prior to the availability of treatment was larger in magnitude than previously understood, but may be reversing rapidly as access to treatment is expanded. [ABSTRACT FROM AUTHOR]

HIV-positive individuals often face community-wide discrimination or public shame and humiliation as a result of their HIV-status. In Sub-Saharan Africa, high HIV incidence coupled with unique cultural contexts make HIV-positive individuals particularly likely to experience this kind of HIV/AIDS-related (HAR) stigma. To date, there is a relatively small amount of high-quality empirical literature specific to HAR stigma in this context, supporting the notion that a better understanding of this phenomenon is needed to inform potential interventions. This paper provides a thorough review of the literature specific to HAR stigma in Sub-Saharan Africa, finding (a) qualitative support for the existence of important relationships between HAR stigma and health service utilization and barriers; (b) a need for more quantitative study of stigma and its relationships both to health service utilization and to HIV outcomes directly; and (c) a disconnect between methodological techniques used in this context-specific literature and well-known theories about stigma as a general phenomenon. This paper then draws from its empirical literature review, as well as from well-known theoretical frameworks from multiple disciplines, to propose a theoretical framework for the ecological and multilevel relationships among HAR stigma, health service utilization, and HIV outcomes in this context. [ABSTRACT FROM AUTHOR]

The Joint Learning Initiative on Children and AIDS recently recommended that programmes for children affected by HIV and AIDS in sub-Saharan Africa direct more support to families. Interest has grown in including men in such family-orientated interventions by researchers, policy makers, and community and non-governmental organizations. However, there is a lack of good quality data on men's involvement with children in the diverse settings in sub-Saharan Africa. In addition, limited research has examined their role in providing emotional, material support and protection for HIV- and AIDS-affected children and families. In this paper, we describe the availability of data about men and families, in particular fathers, in ongoing sub-Saharan African surveys and longitudinal population cohorts. We discuss the conceptual and measurement issues associated with data collection on men's involvement in these types of studies. We consider the opportunities for improving the collection of data about men and families in household surveys and population cohorts in order to inform the design and evaluation of family-centred interventions for children affected by HIV and AIDS. [ABSTRACT FROM AUTHOR]

Against a background of rising adult mortality and morbidity in the context of the HIV/AIDS pandemic in sub-Saharan Africa, this paper provides both quantitative and qualitative evidence for the existence of a largely neglected group of young people with increased responsibility for caregiving. Using questionnaire surveys, focus groups, storyboards and in-depth interviews in three studies across Southern and Eastern Africa some young people in Lesotho, Tanzania and Zimbabwe are found to devote considerable time and energy to caring for sick members of their households. Examination of the tasks carried out by these youngsters finds them to be burdened beyond usual familial and societal expectations of children's 'normal' contributions to the reproduction of households via domestic chores and suchlike. It is concluded that these young people can be described as 'young carers'. The three studies are presented to illuminate different socio-spatial aspects of caregiving by young people. First, using qualitative data from Lesotho the range of caring tasks young caregivers perform for care recipients — usually a grandmother, parent, or sibling — is identified. Second, the impact caregiving responsibilities have on children's primary school attendance is examined using survey data from Tanzania. Third, the wider negative and positive impacts of caregiving including loss of friends and gaining of emotional maturity for young carers and their households is explored with in-depth individual interviews from Zimbabwe. Finally, suggestions are made for further research to deepen understanding of the geographies of caring within the context of the population geographies of the HIV/AIDS pandemic in sub-Saharan Africa and beyond. [ABSTRACT FROM AUTHOR]

The paper shows how policies aimed at confronting HIV/AIDS in sub-Saharan Africa have shifted over the past 10 years. Initially, the focus was on prevention. Anti-retroviral treatments (ARVs), which could prolong the lives of people living with HIV and AIDS, were considered too expensive for the African poor. In 2000, following global campaigns to lower the prices of ARVs, and concern about the political instability caused by AIDS in Africa, policies started focusing on access to treatment. Cost-effectiveness arguments played a key role in the formulation and implementation of the prevention policies, while human rights and equity considerations drive the current treatment programmes. Though different in policy content, the prevention and treatment policies have in common that they pay little attention to the socio-cultural realities in sub-Saharan Africa that ultimately determine their success. Based on illustrative case material from Uganda, the paper calls for more research on and understanding of the successes and failures of prevention and treatment programmes. Such understanding can help adapt global policies to local realities. [ABSTRACT FROM AUTHOR]

Copyright of Tropical Medicine & International Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

This paper investigates the effect of HIV/AIDS on output using an overlapping generations model with heterogeneous agents calibrated to sub-Saharan Africa. Output is found to be below a no-AIDS output in a range between 3% (10%), when only unskilled workers are affected, and 10% (28%), when only skilled workers are affected, whenever the overall infection rate is 7% (20%). When investigating the hypothesis that AIDS affects skilled workers more severely than unskilled at the beginning of the epidemic, with the effect switching as the epidemic becomes more mature, the findings are that the economy can be 8% smaller along the transition path. In all scenarios where the epidemic is temporary, it would take four to five generations or about 90 years for sub-Saharan Africa to recover. [ABSTRACT FROM AUTHOR]

Objectives: Universal Test and Treat (UTT) strategies are being adopted across sub‐Saharan Africa based on clinical benefits to morbidity and mortality and to attain targets of the Joint United Nations Programme on HIV/AIDS (UNAIDS). Universal Test and Treat is expected to change the client population at clinics, due to more asymptomatic HIV clients initiating antiretroviral therapy (ART). We assessed the impact of UTT on client appointment adherence at 14 government‐managed health facilities in Eswatini's public sector health system. Methods: We assessed the impact of UTT on client adherence to appointment schedules from 2014 to 2017 in a stepped‐wedge trial. Repeated measures analysis was used to assess adherence to each scheduled appointment (primary definition: presenting for care within 7 days after the scheduled appointment), adjusting for time, age, sex, stage, marital status, ART status and facility. Results: Among 3354 clients (62.1% female; 57.4% < 35 years), a median (interquartile range) of 10 (6–15) appointments were scheduled during follow‐up. In a multivariable‐adjusted model, appointment adherence was significantly greater in clients who were female [odds ratio (OR) = 1.38, 95% confidence interval (CI): 1.25–1.52], older (e.g. 40 to < 50 years vs. < 20 years; OR = 1.45, 95% CI: 1.00–2.09), married (OR = 1.31, 95% CI: 1.19–1.44), had lower WHO stage at study enrolment (1–2 vs. 3–4: OR = 1.26, 95% CI: 1.13–1.41), and were currently on ART (OR = 3.55, 95% CI: 2.62–4.82). However, UTT strategy was not significantly associated with client adherence to scheduled appointments (OR = 1.02, 95% CI: 0.72–1.45). Conclusions: Despite transitioning to UTT, there was no change in visit adherence, a reassuring finding given the large volume of clients currently being initiated at earlier stages of HIV. [ABSTRACT FROM AUTHOR]

Introduction: HIV self-testing (HIVST) has the potential to increase uptake of HIV testing among untested populations in sub-Saharan Africa and is on the brink of scale-up. However, it is unclear to what extent HIVST would be supported by stakeholders, what policy frameworks are in place and how variations between contexts might influence country-preparedness for scale-up. This qualitative study assessed the perceptions of HIVST among stakeholders in three sub-Saharan countries. Methods: Fifty-four key informant interviews were conducted in Kenya (n=16), Malawi (n=26) and South Africa (n=12) with government policy makers, academics, activists, donors, procurement specialists, laboratory practitioners and health providers. A thematic analysis was conducted in each country and a common coding framework allowed for inter-country analysis to identify common and divergent themes across contexts. Results: Respondents welcomed the idea of an accurate, easy-to-use, rapid HIV self-test which could increase testing across all populations. High-risk groups, such as men, Men who have sex with men (MSM), couples and young people in particular, could be targeted through a range of health facility and community-based distribution points. HIVST is already endorsed in Kenya, and political support for scale-up exists in South Africa and Malawi. However, several caveats remain. Further research, policy and ensuing guidelines should consider how to regulate, market and distribute HIVST, ensure quality assurance of tests and human rights, and critically, link testing to appropriate support and treatment services. Low literacy levels in some target groups would also need context-specific consideration before scale up. World Health Organization (WHO) policy and regulatory frameworks are needed to guide the process in those areas which are new or specific to self-testing. Conclusions: Stakeholders in three HIV endemic sub-Saharan countries felt that HIVST will be an important complement to existing community and facility-based testing approaches if accompanied by the same essential components of any HIV testing service, including access to accurate information and linkages to care. While there is an increasingly positive global policy environment regarding HIVST, several implementation and social challenges limit scale-up. There is a need for further research to provide contextual and operational evidence that addresses concerns and contributes to normative WHO guidance. [ABSTRACT FROM AUTHOR]

Sub-Saharan Africa is home to millions of HIV-affected children. These children are likely to experience multiple developmental delays. In this chapter, I present data highlighting compromised neurobehavioral, mental health, and scholastic outcomes for children affected by HIV. Furthermore, I discuss biomedical factors (e.g., disease severity and nutritional status) that may exacerbate the adverse effects of HIV on childhood outcomes. I also present evidence on how psychosocial risk factors such as poor maternal mental health, orphanhood, and poverty may aggravate the effects of HIV. The concluding section of the chapter highlights conceptual and methodological refinements in research on the impact of HIV on child development in Sub-Saharan Africa. © 2014 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Introduction: There are limited data on paediatric HIV care and treatment programmes in low-resource settings. Methods: A standardized survey was completed by International epidemiologic Databases to Evaluate AIDS paediatric cohort sites in the regions of Asia-Pacific (AP), Central Africa (CA), East Africa (EA), Southern Africa (SA) and West Africa (WA) to understand operational resource availability and paediatric management practices. Data were collected through January 2010 using a secure, web-based software program (REDCap). Results: A total of 64,552 children were under care at 63 clinics (AP, N=10; CA, N=4; EA, N=29; SA, N=10; WA, N=10). Most were in urban settings (N=41, 65%) and received funding from governments (N=51, 81%), PEPFAR (N=34, 54%), and/or the Global Fund (N=15, 24%). The majority were combined adult-paediatric clinics (N=36, 57%). Prevention of motherto- child transmission was integrated at 35 (56%) sites; 89% (N=56) had access to DNA PCR for infant diagnosis. African (N=40/ 53) but not Asian sites recommended exclusive breastfeeding up until 4-6 months. Regular laboratory monitoring included CD4 (N=60, 95%), and viral load (N=24, 38%). Although 42 (67%) sites had the ability to conduct acid-fast bacilli (AFB) smears, 23 (37%) sites could conduct AFB cultures and 18 (29%) sites could conduct tuberculosis drug susceptibility testing. Loss to follow-up was defined as >3 months of lost contact for 25 (40%) sites, >6 months for 27 sites (43%) and >12 months for 6 sites (10%). Telephone calls (N=52, 83%) and outreach worker home visits to trace children lost to follow-up (N=45, 71%) were common. Conclusions: In general, there was a high level of patient and laboratory monitoring within this multiregional paediatric cohort consortium that will facilitate detailed observational research studies. Practices will continue to be monitored as the WHO/ UNAIDS Treatment 2.0 framework is implemented [ABSTRACT FROM AUTHOR]

Despite significant progress in theory and empirical methods, the analysis of food consumption patterns in developing countries, particularly those in Sub-Saharan Africa (SSA), has received very limited attention. An attempt is made in this article to estimate an Error Corrected Almost Ideal Demand System for four major cereals consumed in Kenya employing annual data from 1963 to 2005. This demand system performs well on both theoretical and empirical grounds. The symmetry and homogeneity conditions are supported by the data and the Le Chatelier principle holds. Empirically, all own-price elasticities are negative and significant at 5% level and irrespective of the time horizon, maize, wheat, rice, and sorghum may be considered as necessities in Kenya. While the expenditure elasticities of all four cereals are positive, they are inelastic both in the short run and in the long run. Finally, wheat and rice complement maize consumption in Kenya while sorghum acts as a substitute. Since cereal consumers have price and income inelastic responses, a combination of income and price-oriented policies could improve cereal consumption in Kenya. [ABSTRACT FROM AUTHOR]

Objectives. Given that HIV/AIDS in sub-Saharan Africa is largely spread through heterosexual contact, there is marked variation in levels of gender equity across sub-Saharan African countries, and levels of gender equity are likely to influence both exposure to sexual practices that increase the likelihood of exposure to HIV and the efficacy of prevention programs, we hypothesize that levels of gender equity account for the levels of and changes in the prevalence of HIV/AIDS across sub-Saharan African countries. Methods. We explore this hypothesis by first discussing the role of gender and several other contextual variables in the spread of HIV/AIDS. The resulting model is tested with regression analyses of both the level and change of HIV/AIDS in sub-Saharan African. Result. We find strong support for our hypothesis. Conclusion. This suggests that further policy attention be given to gender equity in combating HIV/AIDS. [ABSTRACT FROM AUTHOR]

Cross-sectional and repeated surveys from household components of Demographic and Health Surveys in sub-Saharan Africa were examined to determine whether household composition indicators for older adults (N = 52,573 ), involving offspring and grandchildren, correlated with national levels of AIDS mortality. One in 4 was living with a grandchild whose own parents were absent. Absence was a result of residence elsewhere and parents being deceased. Older adults in countries with a high accumulation of AIDS mortality were more likely to live in a skip-generation household and with a double-orphaned grandchild and less likely to live in a 3-generation household. Change in living arrangements toward skip generation and a double orphaned household was experienced in countries with high accumulation of AIDS mortality. [ABSTRACT FROM AUTHOR]

This article consolidates and expands on evidence on how National AIDS Commissions (NACs) in sub-Saharan Africa are measuring up to expectations that drove their rapid adoption across the continent. While their overall performance seems reasonably good, most NACs still lack adequate power and incentive structures to hold line ministries accountable, a key requirement for co-ordinating activities and mainstreaming HIV-AIDS across the public sector. Second-generation African NACs urgently need the authority and institutional stature to effectively co-ordinate the channelling of the larger funds now available through government bureaucracy. The evolution of the epidemic also imposes requirements different from those when the current NAC architecture was crafted. [ABSTRACT FROM AUTHOR]

Background: The pandemic of HIV/AIDS is actually a composite of many regional and national-level epidemics. The progress made in many parts of the developed and developing world is tempered by the continued devastating consequences of HIV infection in sub-Saharan Africa (SSA). This review focuses on the ways in which children and adolescents are impacted by the epidemic, giving particular attention to their mental health. Methods: A health promotion framework is adopted to guide analysis. Three issues are covered: prevention of HIV infection, care and treatment of children infected with HIV, and care of children whose caregivers are ill or have died of AIDS. Existing reviews and literature search engines were used to review the scientific literature, focusing on the past five years. Results: Preventive interventions continue to manifest limited benefits in behavioral changes. More complex causal models and improved behavioral measures are needed. In the African context, the time has come to view pediatric AIDS as a chronic disease in which the mental health of caregivers and children influences important aspects of disease prevention and management. Increasingly sophisticated studies support earlier findings that social and psychological functioning, educational achievement and economic well-being of children who lose parents to AIDS are worse than that of other children. Conclusions: Important changes are taking place in SSA in increased access to HIV testing and antiretroviral therapies. To be effective in promoting mental health of children and adolescents, interventions require a more fundamental understanding of how to build HIV competence at personal and community levels. A key recommendation calls for the design and execution of population-based studies that include both multilevel and longitudinal features. Such rigorous conceptual and empirical investigations that assess the capacities of children are required to mobilize children, families and communities in comprehensive actions plans for prevention, treatment and care in response to the enduring HIV/AIDS pandemic. [ABSTRACT FROM AUTHOR]

The dual campaigns of Education for All (EFA) and the Millennium Development Goals (MDG) have made universal primary school enrolment for boys and girls a priority for developing countries. The HIV/AIDS epidemic has affected millions of people in sub-Saharan Africa and has depleted the teaching corps. As a result, the HIV/AIDS pandemic has pushed the targets of EFA and MDG further out of reach for many medium and high HIV-prevalence countries. The provision of highly active antiretroviral therapy (HAART) in developing countries, however, has given hope to thousands who have not had access to treatment. The Commission on Human Rights in 2001 and again in 2002 confirmed that access to AIDS medication is a key component of the right to the highest attainable standard of health, enshrined in the Universal Declaration of Human Rights, the International Covenant on Economic, Social and Cultural Rights and the Convention on the Rights of the Child. This article explores how scaling up of HAART for teachers can make the EFA and MDG targets attainable. A HAART programme for teachers can produce substantial fiscal savings in sick leave pay, the cost of training new teachers, and funeral expenses, even under high HIV prevalence situations. [ABSTRACT FROM AUTHOR]

Sub-Saharan Africa carries the overwhelming share of the global burden of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and of HIV-associated tuberculosis (TB). The impact of HIV on TB patients and programmes has implications for TB control policies. The impact on patients includes the effect of HIV on diagnosis and on the patterns of HIV-related TB, the response of HIV-infected TB patients to TB treatment, the benefits of antiretroviral therapy (ART), and the quality and continuity of care for TB patients. The impact on national TB programmes (NTPs) includes increased case load, impaired NTP performance, increased need for access to ART and difficulties in reaching TB control targets. Implications for policies include the need to promote TB and HIV/AIDS programme collaboration, aimed at improving NTP performance (TB case-finding and treatment outcomes), quality and continuity of care, and monitoring and interpretation of progress towards TB control targets. In order to provide the recommended international standard of care for TB patients, clinicians need to be aware of the impact of HIV on TB patients and programmes and the implications for the policies that provide the framework for this standard. Conversely, policy-makers need to understand the impact of HIV on TB patients and programmes. This can help to ensure a firm evidence base for TB control policies aiming at the high standard of patient care that is at the heart of TB and HIV programmes. [ABSTRACT FROM AUTHOR]

Purpose: To increase understanding of the meaning of quality of life for people living with HIV/AIDS in four countries in sub-Saharan Africa: Botswana, Lesotho, South Africa, and Swaziland.Methods: Using a cross-sectional design and convenience sample, we administered a survey and collected data on demographic characteristics, measures of severity of illness, and perceptions of quality of life. The purposefully selected sample (N=743) consisted of community-based people living with HIV/AIDS in 2002. Based on the Wilson and Cleary framework for organizing variables related to quality of life, a hierarchical multiple regression was conducted with quality of life as the dependent variable.Results: The sample of 743 persons was 61.2% female with a mean age of 34 years. Approximately 62% of the sample reported having received an AIDS diagnosis. Ten predictor variables explained 53.2% of the variance in life satisfaction. Those participants with higher life satisfaction scores were less educated, had worries about disclosure and finances, did not have an AIDS diagnosis or other comorbid conditions, had lower symptom intensity, had greater functioning, and had fewer health worries. None of these participants was taking antiretroviral medications at the time of this study.Conclusions: Several dimensions of the Wilson and Cleary model of quality of life were significantly related to life satisfaction for people living with HIV/AIDS in sub-Saharan Africa. Quality of life for this sample was primarily defined as overall functional ability and control over symptom intensity. These findings are similar to studies in developed countries that have shown the significant relationships among functional abilities, symptom control, and perceived quality of life. As antiretroviral medications become more available in these areas, community members and care providers can help clients realize the possibility of living well with HIV/AIDS, and can work with clients to improve functional ability and control symptom intensity to make living well a reality.Journal of Nursing Scholarship, 2005; 37:2, 120-126.© 2005Sigma Theta Tau International. [ABSTRACT FROM AUTHOR]

According to the 2003 report from the Joint United Nations Programme on HIV/AIDS, sub-Saharan Africa is the region of the world worst affected by the epidemic. In 2003, an estimated 26.6 million people in Sub-Saharan Africa were living with HIV. In 2003, an estimated 26.6 million people in Sub-Saharan Africa were living with HIV. On average, 7-8 per cent of the adult population is infected. The international community has slowly begun to recognise the magnitude of the crisis and to respond. More funding than ever before is now being put on the table by the international community as well as by the governments of affected countries, to tackle HIV/AIDS.

Despite significant debate about the efficacy, ideology, and ethics of the method, condom social marketing (CSM) has become the dominant approach to AIDS education in many sub-Saharan African countries. However, critics have charged that social marketing (SM) distracts from the structural determinants of health-related behavior and excludes genuine community participation. This article argues that the diffusion of SM techniques in Africa is not driven by demonstrated efficacy but is attributable to the promotion of privatization and free markets in the structural adjustment era across the region. The CSM experience in a central Mozambican community reveals the dangers of using the method at the expense of community dialogue and participation to confront the AIDS epidemic. The advertising campaign developed to sell condoms has clashed with Pentecostal and Independent Churches, now a majority of the population, that have expanded rapidly across the region spreading a contrasting message about sexuality and risky behavior. [ABSTRACT FROM AUTHOR]

This article surveys the main economic issues associated with the HIV/AIDS epidemic, paying special attention to sub–Saharan Africa. It explores the economic and behavioural determinants of HIV transmission, the microeconomics of market failures associated with high HIV prevalence, the prospects for regional development from a macroeconomic perspective and the efficient design of policies for coping with the epidemic. In line with the recent appeal by the UN Secretary General, the article argues that, without a decisive effort to halt HIV/AIDS, people living in the region are bound to experience a further fall in their standard of living in both relative and absolute terms. However, to be effective, anti–AIDS programmes must be rooted in sound economic principles. [ABSTRACT FROM AUTHOR]

Focuses on the prevention and intervention of acquired immune deficiency syndrome in Sub-Saharan Africa. Relationship between costs and treatment care of HIV; Importance of factors influencing costs of scaling range of HIV infection; implications regarding efficiency; Use of infrastructure on prevention activities.

Copyright of Population & Development Review is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Population & Development Review is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The article reports on the increasing number of children orphaned by AIDS in sub-Saharan, Africa as reported by the U.S. Human Rights Watch (HRW). The HRW reported that there are more than 12 million children having aids and United Nations charity says that 18 million children could be orphaned by AIDS in 2010. The impact of AIDS on children is that children's access to education begins to suffer and they are falling victim to exploitation.

Editorial. Focuses on the factors that affect the effective implementation of AIDS control in sub-Saharan African societies. Management of AIDS control by major government policies; Establishment of functional operational structures and effective parallel nationally directed systems; Use of synergetic interaction to address the issue of changing social norms.