My comment on CSIS Online Africa Policy forum

Amy Patterson has a post on a new CSIS online Africa Policy forum.

Here is my comment on her piece.

Amy Patterson makes a number of important points. I generally agree that greater civil society mobilization would likely foster country ownership of HIV/AIDS programs, but what would that look like? How would that alter what donors are already doing? And, given the opportunity costs of focusing on civil society mobilization compared to other possible priorities, is a greater focus on participation by community organizations the most pressing need in the fight against HIV/AIDS?

Patterson notes that HIV/AIDS is not seen as a top priority in Afrobarometer polling. Does that not suggest that there may be difficulties in mobilizing civil society in Africa for this cause? The basic supposition in this piece is that the failures to date have been in part failures of insufficient engagement at the local level.

That may be true, but it also could be difficult for well-meaning outsiders to engender this kind of mobilization in the absence of top-level support by African leaders. We have witnessed the difference in the aggressive approach by President Museveni of Uganda in contrast to South Africa’s Thabo Mbeki whose support for AIDS denialists is well-known. Can or should external donors empower local groups in the face of state opposition? In the case of South Africa where the Treatment Action Campaign was already active, external support has been important. But, what if civil society is not especially active, the country’s executive is hostile, and the health system is decrepit? Where are resources best spent?

I am sympathetic to Patterson’s argument, but those of us who worry about public health and HIV/AIDS in sub-Saharan Africa need to flesh out what our specific policy recommendations would look like. The closest we gets in terms of specifics come in terms of the need for more simplified and harmonized reporting requirements by donors and finanicial support for civil society groups to hire and train bookkeepers, community organizers, and grant writers. All of that sounds reasonable, but I do not know how transformative efforts like that would be, if they were implemented.

It appears that bilateral programs like PEPFAR have focused on getting anti-retroviral drugs to needy populations in short order, which may have come at the cost of building local capacity in the health sector. Other donors like the Global Fund may have had more success in coordinating with local groups, yet they too have imperatives of getting money out the door and people on treatment. Alex de Waal’s 2006 book presciently warned of this potential outcome of focusing on short-term exigencies over long-term capacity.

In recent months, the debate about whether or not HIV/AIDS funding is coming at the cost of other health care priorities taps into this anxiety that people are getting treated for AIDS, but two problems are not being addressed as they should 1) other health care needs (and implicitly local health care capacity) and 2) prevention programs.

As I understand it, donors are increasingly seeking funds not just for HIV but for broader health systems capacity. Moreover, the ABC agenda seems to have run aground; changing sexual behavior is hard and political disagreements in the West have made it difficult to implement a coherent strategy.

As a consequence, the prevention discussion has turned towards male circumcision as a powerful strategy to reduce new infections. If this is where the discussion at the policy level is headed, how would or could civil society mobilization enhance the success of those programmatic efforts?

In the 1980s and 1990s, donors chose to go around the state because of fears about corruption and lack of capacity, but the argument has turned. Donors now know that long-run success depends on capable governance by recipient countries (as well as efficient markets). The political imperative of getting HIV/AIDS funds spent quickly and effectively has cut against this broader recognition of the importance of state and market capacity in health systems.

I worry that focusing so much effort on civil society mobilization could come at the cost of state capacity and development of markets for health care. There certainly is an important role for community groups in this process, particularly in terms of holding governments and service providers accountable. To the extent Patterson and other scholars can draw out the implications of this line of critique, I think the discussion will be richer for it.

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3 Responses to “My comment on CSIS Online Africa Policy forum”

  1. Everyone seems to pick look at one side of the coin only. In fact a broad public campaign involving local community efforts together with a professional and well maintained healthcare system would be essential. But reality is far away from this idealistic approach in most of the touched countries. And also infrastructure, money, religion, social structeres etc. are very different in the large range of African countries.
    In the African continent we have to face reality and not wishes. It makes no sense to feed hungry government employees, if nothing of the funding arrives where it is really needed. So I think it would be more realistic to see country-by-country to select the best strategy for the people. And if there are attractive people or organisations which could help involving the population, yes that could speed-up the help. Also it is really essential that inhabitants from the country are involved in hte planning process, as the situation in each area is different for many reasons.

  2. I think we need more widespread education programs in order to create a impact that can be relised both in the short and long term. Also I do think there is a reason to feed those government employees and thats so they don’t starve.

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