摘要：Objectives. Botswana has one of the world’s highest HIV-prevalence rates and the world’s highest percentages of orphaned children among its population. We assessed the ability of income-earning households in Botswana to adequately care for orphans. Methods. We used data from the Botswana Family Health Needs Study (2002), a sample of 1033 working adults with caregiving responsibilities who used public services, to assess whether households with orphan-care responsibilities encountered financial and other difficulties. Thirty-seven percent of respondents provided orphan care, usually to extended family members. We applied logistic regression models to determine the factors associated with experiencing problems related to orphan caregiving. Results. Nearly half of working households with orphan-care responsibilities reported experiencing financial and other difficulties because of orphan care. Issues of concern included caring for multiple orphans, caring for sick adults and orphans simultaneously, receiving no assistance, and low income. Conclusions. The orphan crisis is impoverishing even working households, where caregivers lack sufficient resources to provide basic needs. Neither the public sector nor communities provide adequate safety nets. International assistance is critical to build capacity within the social welfare infrastructure and to fund community-level activities that support households. Lessons from Botswana’s orphan crisis can provide valuable insights to policymakers throughout sub-Saharan Africa. The AIDS pandemic is creating a generation of orphaned children who have lost 1 or both parents to the deadly disease. By 2004, an estimated 15 million children between the ages of 0 and 17 years had been orphaned by HIV/AIDS, 1 and the rate of orphaning is increasing. Worldwide, the number of orphans increased by 23% between 2001 and 2003, although it would have declined in the absence of HIV. 1 Almost 80% of children orphaned by HIV/AIDS, or 12.3 million infants and youth, are living in sub-Saharan Africa. 1 Nearly 1 in 5 children in Zimbabwe and Lesotho, and 15% of children in Zambia, Swaziland, and Mozambique, require fostering and care. 1 In Botswana, the nation with the highest rate of orphanhood (20%), an estimated 120000 children aged 0 to 17 years had lost their mother, father, or both parents to AIDS by the end of 2003. 2 In addition, an estimated 200 000 children in Botswana will be orphaned by 2010. 3 Twenty-five million people in sub-Saharan Africa are infected with HIV, and the orphan population is likely to expand as parents with HIV/AIDS continue to die. Botswana has the second-highest rate of HIV in the world. 4 In 2003, 37% of adults aged 15 to 49 were HIV-positive, 5 placing Botswana in danger of losing one third of its adult population by 2010. 6 Although antiretroviral treatment is becoming more accessible in countries such as Botswana, Zambia, and South Africa, still only a portion of the people requiring treatment receives it. 7 Even with declines in the rate of orphaning because of uptake in access to antiretroviral treatment, the orphan population in sub-Saharan Africa is expected to increase to 18 million children younger than 18 years by 2010. 1 Historically, the fostering of children by extended family members, including aunts, uncles, grandparents, and other relatives, is common throughout sub-Saharan Africa. 8 Extended family members have fostered children for a variety of reasons including the deaths of mothers in childbirth, for youth to gain access to education, and so that the children could be used for domestic labor. 8 The tradition of fostering by extended family continues today and is a vital coping mechanism in nations with high HIV prevalence and growing orphan populations. Throughout sub-Saharan Africa, an estimated 90% of orphaned children in households live with extended family members, 9 and the working or income-earning households are considered to be in the best financial position to meet the costs of care, including providing basic needs such as food and shelter. The advantages of extended-family fostering are that it is culturally acceptable and assumed to be sustainable throughout a child’s development, partially because communities will band together to support these households. 8 , 10 , 11 In most cases, children can find stability, love, and emotional support in relatives’ homes. By contrast, institutional care in orphanages or residential facilities is recommended only in desperate situations, such as when there is abuse, child-headed households without support, or homelessness. 9 , 12 Institutional care generally lacks the capacity to meet emotional needs, 9 , 13 costs more per child than family care, and is potentially unsustainable in the long term because of a reliance upon charitable giving. 9 , 12 Consequently, fostering by extended-family households is the preferred choice guiding policy, 1 , 14 – 18 even when it is unclear whether households are able to provide adequate care. In truth, the African tradition of strong extended-family networks sustaining households in times of need may no longer be viable. 9 , 19 In some nations, urbanization has diminished the strength of extended-family networks and kinship obligations have become less compelling. 20 Moreover, reports of breakdown in family ties have emerged when adults have expressed reluctance to care for orphans, fearing that additional children will be a drain on household finances. 21 Subsequently, there are growing gaps for children to slip through in what were previously thought to be impermeable traditional extended-family networks. 22 Furthermore, community members are commonly believed to provide the resources that sustain AIDS- and orphan-affected households. 13 , 23 In reality, communities are often providing little or no support to individual households. 10 In Botswana, rapid development has eroded the custom of reciprocity among community members. 20 Families in Lesotho and Malawi reported that the burden of care lay with extended family households despite care policies stressing the role of communities. 24 Community-based and nongovernmental organizations are also credited with supporting orphan households. However, one study from Uganda revealed that only 5% of orphans were reached by the combined efforts of nongovernmental organizations, government, and other donors, and community-based organizations reached only 0.4% of orphans. 10 In 2004, 20% of sub-Saharan African households with children were caring for orphans, 23 , 25 even though 2001 data shows that nearly 50% of households in the region were living on less than US $1 per day. 26 Ample evidence confirms that households living in extreme poverty, such as those headed by nonworking and elderly grandparents, lack the resources to adequately care for orphans 10 and that orphan care provided by destitute families can be disastrous for all concerned. 17 , 27 , 28 Therefore, given that large-scale institutional care is impractical, impoverished households provide inadequate care, and communities and organizations lend minimal assistance, it would appear that economically productive, working households represent the greatest hope for providing adequate orphan care. Still, the feasibility of working households providing care and economically surviving over time is unclear. Nonetheless, there is a paucity of scientific research describing the impact of fostering on households. Several existing studies examining orphan households have used snowball sampling and small sample sizes, which frequently capture the poorest of households. 29 , 30 Analyses of national household surveys have provided insight into aspects of orphan care, yet these data sources may underrepresent working households where 1 or more adults are in the workplace during daytime hours when surveys are administered. 23 In addition, much of the existing literature is based on data from the early- to mid-1990s, which may not be relevant given the rapid rate of HIV transmission and orphaning. 30 , 31 In this study, working households are defined as those in which at least 1 adult had both working and caregiving responsibilities in the previous year. Human and social development throughout sub-Saharan Africa is contingent upon the ability of working households to survive economically while caring for orphans. The purpose of this study is to assess whether, in light of current realities and policies, working households can adequately care for orphans without becoming impoverished. We examined whether working households encountered problems and whether they received assistance with orphan care.
