The Causes, Contours and Consequences of Multi-Sectoralism
By Sophie Harman
Sophie Harman is a Research Fellow at the Centre for the Study of Globalisation and Regionalisation. She has conducted extensive research into the World Bank-Civil Society engagement under the Multi-Country HIV/AIDS Programme in East Africa. Her primary interests are institutions of global governance, civil society, gender and HIV/AIDS governance.
The multi-sectoral approach to HIV/AIDS has shaped the global response to the epidemic over the last ten years. Initially advocated by the World Bank under its seminal Multi-Country HIV/AIDS Programme(MAP) and promoted by National AIDS Councils (NACs) and United Nations (UN) agencies alike, multi-sectorality refers to the widespread involvement of all members of society – government agencies, communities, the public and private sectors – in the response to HIV/AIDS. Multi-sectorality has precipitated a mushrooming of non-governmental actors in communities, governments, the private and the not-for-profit sector. Its origins, expression and outcomes, however, remain free from academic scrutiny or assessment. These issues are evident in policy documents, but few question where this concept arose from, and the impact it is having on the HIV/AIDS response. This paper argues that the concept and practice of multi-sectorality has its origins within the era of the James Wolfensohn Presidency of the World Bank, and has been expressed and promoted through the widespread absorption of the MAP as the guide for practice and ideology in HIV/AIDS responses.The paper uses extensive research findings from three case study countries: Kenya, Tanzania and Uganda.
The paper proceeds in the following manner. First, it provides a definition of multi-sectorality. Second, it maps the origins of multi-sectorality by demarcating its grounding within the MAP and wider Bank ideology and institutional preferences. Third, the paper outlines the mechanisms of multi-sectorality within the case study countries before highlighting its main drawbacks and limitations. Fourth, the consequences of multi-sectorality in regard to the shifting of civil society, the accountability of international organisations and donors, and how this impacts upon governance of the HIV/AIDS response are discussed. The main issues and content of the paper are then drawn together in conclusion.
What is multi-sectorality?
Multi-sectorality refers to the mass scaling up of participation, through implementation and decision-making, and ownership of the response to HIV/AIDS by all sectors of state and society: the government, the private sector, civil society, the individual and international organisations and donor partnerships. The concept came into existence in the late 1990s, and has since been incorporated into policy and practice at every level of HIV/AIDS governance. Mechanisms of promoting multi-sectorality within the response have grown in tandem to such commitments. The most integrated of which has been the Global Fund to fight AIDS, Tuberculosis, and Malaria’s (Global Fund) Country Co-ordinating Mechanisms (CCMs) that integrate non-state actors at every level of decision-making.
Discourse surrounding multi-sectorality is evident within UN policy prescriptions, speeches and country profile documentation and agendas. At the country level, HIV/AIDS strategic planning stresses the multi-sectoral component of current and future agendas. This has increasingly trickled down to communities who have increasingly begun to state their commitment to a multi-sectoral approach to HIV/AIDS. What is known about multi-sectorality is its increased relevance to HIV/AIDS governance and interventions. What is not evident is where the concept came from, the ideology in which it is based, and what the practical ramification of its application are.
The World Bank: The Basis of Multi-sectoralism
The proliferation of multi-sectoralism at every level of HIV/AIDS governance suggests it is a form of retrofit labelling designed to explain and contextualise practices of CSO engagement and widespread inclusion in the response. However, this paper argues that multi-sectoralism is not a description of Global Fund and UN practice that has since been accommodated by the global response to the epidemic, but is a World Bank-distinct approach to HIV/AIDS that is grounded within the history, culture, practice and ideology of the Bank and expressed through its flagship programme, the MAP. The main tenets of the MAP are funding to any country in sub-Saharan Africa that has a national strategic plan to fight HIV/AIDS; a national co-ordinating body; and a commitment to directing 40-60 per cent of funds to civil society organisations (CSOs). The project currently operates in 28 countries, with 8 further countries awaiting approval. The MAP works through the disbursal of funds to NACs responsible for the co-ordination of the national response, that then issue funds to CSOs through local government structures. The decentralised nature of the MAP allows wide participation from a number of organisations, and precipitates an upsurge of actors within the response under the notion of multi-sectorality.
There are three key factors that precipitated the emergence of the MAP and the current expression of multi-sectoralism. The first was the Bank’s previous involvement in sexual reproductive health and family planning. Previous to the MAP, the Bank had mainly approached HIV/AIDS as part of wider family planning issues. During the 1990s, neither the World Bank World Development Reports or UNDP’s Human Development Reports had considered the long term effects of HIV/AIDS development in sub-Saharan Africa (Barnett & Whiteside, 2001, 369); up to this point it was the World Health Organisation (WHO)’s Global Programme on HIV/AIDS (GPA) that represented the global response to the epidemic (Barnett & Whiteside, 2002, 74). The Bank did have three individual HIV/AIDS projects in Brazil, India and Zimbabwe. The Brazil project was seen as a World Bank success; the Bank had assisted in the establishment of an HIV testing and treatment system which became the model for ART provision in a developing country. Government commitment and political openness – a central factor in the multi-sectoral approach - was identified by the Brazilian government and the Bank alike as the key component to Brazil’s success, and would later form one of the founding pillars of effective multi-sectorality: government ownership. The India project in 1992 was less successful, with the Bank wanting to fight stigma and denial and the Indian government preferring to prioritise blood safety. The Bank’s third HIV/AIDS project up to this point was in Zimbabwe in 1993 which involved a freestanding loan to pay for STI treatment, however, this project was implemented with minimal research into the spread of the disease or wide participation from ever aspect of society (Mallaby, 2005, 316). Further to these specific projects, the Bank had started conducting research into the epidemic with the release of its 1997 report, ‘Confronting AIDS: Public priorities in a Global Epidemic’ which focused on a theoretical concept of how the Bank should move forward (Int. Mohammed, 24th April 2006), involvement in the launching of the AIDS Vaccine Task Force in April 1998, and partnership with MTV and UNAIDS’ ‘Staying Alive’ project (World Bank, 2005, 256-260). These initiatives, however, were isolated issue or country-specific and not part of or reflective of a wider HIV/AIDS agenda by the Bank.
The second factor leading to the emergence of the MAP was a chance meeting between two Bank staff members, Debrework Zewdie and Hans Binswanger, on a bus returning from a staff retreat in 1997. Binswanger, an AIDS activist within the Bank, was committed to community-driven development. Zewdie was an Ethiopian Doctor who worked on public health and had witnessed the effect of HIV/AIDS on sub-Saharan Africa. After being approached by the governments of Ethiopia and Kenya for financial assistance to help fight HIV/AIDS, Debrework Zewdie, ‘raised the flag’ of the crisis to the Board of Directors. At this stage, Zewdie had to convince the Board that: (i) the Bank had done little to fight HIV/AIDS; (ii) the Bank is a development agency and HIV/AIDS is eroding the past 50 years of development, it is therefore the Bank’s business and (iii) community support was key to tackling the epidemic (Int. Zewdie, 3rd May 2006). Despite the prevalence of these issues, the Board was not initially forthcoming, as Jacomina de Regt, Sector Lead Specialist for Social Development, Africa Region, describes
I recall one leadership team meeting where she had gone in, she had given a speech and she basically walked out in tears saying ‘you guys don’t care’, ‘you guys don’t care’ and this had an enormous impact. I mean this is a female saying that you feel like you shouldn’t be doing, it wasn’t in the meeting itself but it was after the meeting in the corridors where she was stood with tears in her eyes saying ‘I don’t think it makes any difference to any of them’. That was something I remember as having an impact on the people who saw her so passionate, so committed and so disappointed by this blah blah blah that we gave her at the end. So we had a regional vice president who actually did listen to her and did give her more of a leadership role and she also got to Wolfensohn, one way or another… how she got to Wolfensohn I don’t know… she seems to be on a mission, and in that sense she’s a self-made leader of this, of this whole AIDS thing (Int. de Regt, 20th April 2006)
Three months later Zewdie and Binswanger and a team of three other staff members had drafted the MAP as a concept that would only go to the board once, as an adaptable programme loan where the Bank would commit $1billion to the overall project and the vice president for the region would approve individual credits to individual countries. The concept of this process was grounded in knowledge that the process of inception to implementation within the Bank could take anywhere between six months to three years; as HIV/AIDS was seen to elicit an emergency response, this new approach to Bank funding was approved. The announcement of a new HIV/AIDS Strategic Plan was launched in September 1999 and the first US$500 million MAP funds, ‘MAP 1’ were approved the following year. The story of Zewdie and Binswanger is perpetuated by the Bank, however, the agency ascribed to these two staff members is over-emphasised when considering the top-down nature of the Bank’s bureaucracy. The ability of these two actors to influence decision-making would no have been possible at a different time in Bank practice and Presidency.
These prescriptions stemmed from the Bank’s wider institutional development culminating in the third explanation, the CDF approach. The MAP encapsulates the central features of the World Bank President James Wolfensohn-era (1995 - 2005) reform package. The emphasis placed on partnership, state ownership, sharing of knowledge, and civil society inclusion within the Bank at this time present the third explanation as to the origins of the MAP and multi-sectorality. Upon his appointment on the 16th March 1995, Wolfensohn emphasised a change in philosophy that would focus upon development, aid, and the relationship between the Bank and borrower countries (Stiglitz, 2003, 122). Bank effectiveness through better managed and implemented projects was to occur through a more holistic partnership with borrowing countries and wider inclusion of CSOs as a means of promoting institutional and project transparency. Each of these ideological principles were to be operationalised through the Comprehensive Development Framework (CDF).
The CDF is the Bank’s flagship programme under Wolfensohn. According to the Bank, the CDF ‘emphasizes the interdependence of all elements of development’ and is based upon four pillars: long-term, holistic approach to development; country ownership; country led partnership; and a strong focus on results (World Bank, 2007a). The CDF was an approach to development that was implemented through poverty reduction strategy papers (PRSPs). PRSPs combine an individual country’s macroeconomic, structural and social policies and the financial needs of the country to attain growth and poverty reduction. The main ethos of the PRSP process mirrors that of the MAP and multi-sectorality; they are drawn up by the Bank ‘in partnership’ with governments, civil society actors and other development agencies such as the IMF (World Bank, 2007b) and represent ashift from the stringent conditionalities of structural adjustment to be more accommodating of an individual country’s needs.
A main component of the CDF was the re-assertion of the Bank’s position as a leader of development knowledge. The Knowledge Sharing Programme that underpinned Wolfensohn’s commitment to ‘The Knowledge Bank’ was established so as to promote the sharing of information both within the Bank, with its development partners and with states. The role of developing countries is intrinsic to the ‘re-appropriating and adapting knowledge for development’ (Stiglitz, 2001, 209) in terms of the ‘right knowledge’ that would fit in with the culture of the Bank. The Bank viewed its role as ‘scanning globally’ to identify effective methods and procedure of alleviating poverty and then playing a ‘brokerage role’ in facilitating learning practices and procedures between countries. The Bank sees its position as establishing best practice in a sea of differing approaches and practices within all aspects of development, including health.
This era marked the first full integration of CSO activity within the Bank. Engagement with CSOs was to occur through five mediums: consultation, dialogue, partnering, direct funding and a Community Outreach Program in WashingtonDC. Dialogue and consultation is carried out through consultation meetings such as Strategic Policy Workshops; ‘electronic dissemination tools’ (e.g. video conferencing through the Development Forum), e-newsletter, and web-based exchanges; and CSO attendance at the Bank’s annual spring and fall meetings. The flagship examples of such consultation have been within the PRSP process, the Heavily Indebted Poor County (HIPC) initiative and annual World Development Reports. Involvement within the annual meetings refers to discussion within seminars, and informal dialogue meetings with the president of the Bank and managing director of the IMF.Funding of CSOs is either direct from the Bank’s headquarters or through a particular project. Direct funding occurs in partnership with other donor agencies; through community-driven development projects which refer to either the annual community-driven development account of US$1 billion that is disbursed directly to community groups on an annual basis (World Bank, 2007c) or through country-based projects such as the MAP. A combination of this approach to civil society engagement and the working ideology of the CDF and PRSP process underpin the central tenets of the MAP and multi-sectoralism: government ownership and participation, scaling up of civil society, the Bank as a leader of development knowledge, and flexible lending. The MAP was the first international multilateral project to commit to this agenda.
The foundations of multi-sectorality established by the MAP are often overlooked in comparison to other organisations such as the Global Fund. This is because the Bank’s brand of multi-sectoralism is interpreted as referring to CSOs and HIV/AIDS only. The Global Fund engages and integrates the private sector more widely - through the Global Business Coalition and its Project RED campaign - as a means of sustaining funds, in a manner that the MAP fails to. In focusing upon Malaria and Tuberculosis as well as HIV/AIDS the Fund presents a more holistic response to health concerns. Crucially, people living with HIV/AIDS (PLWHAs) and CSO representatives have presence within decision-making structures through their presence within the main co-ordinating and implementing mechanisms of the Fund – the CCMs, whereas they do not within the MAP. The Fund, however, is not a co-sponsor of the Joint United Nations Programme on HIV/AIDS (UNAIDS), and crucially, it has no direct in-country presence; instead the Fund has representatives for specific regions, normally about five countries per person. The lack of in-country presence has led to difficulties in co-ordination between the different agencies on a regular basis; minimal knowledge of what the Global Fund actually does, who they are, how they work, and their intentions; and a delay in funding disbursement (Int. de Regt, 20th April 2006; Int. Wong, 10th May 2006). This has resulted in a minimal uptake of CSO activity and government-partnerships, as the Global Fund and its programmes remain an uncertain mystery. Issues of tokenism and inclusion of the ‘usual suspects’ continue to be a problem, but are at times unavoidable. For example, PLWHA participation has been marred by sickness, and confusion over the jargon and acronyms used within such meetings (Int. Matsha, 25th May 2006). These differences, however, are minor caveats to the otherwise exact replication of the MAP: the CCMs have been included within or provide the same function as the NACs established within the MAP, emphasis within both projects fall to CSO inclusion and implementation, and both adhere to the MAP-shaped national strategic plans. The Fund is thus not the first expression of multi-sectoralism, but has developed the foundations established by the Bank.