Regional Responses to Hiv/Aids

REGIONAL RESPONSES TO HIV/AIDS

IN SUB-SAHARAN AFRICA:

AGLOBAL PUBLIC GOODS APPROACH

Franklyn Lisk and Desmond Cohen

Introduction

Epidemic diseases have at least since the 19th century been seen as appropriate areas for public policy action that extends in many cases beyond issues of health into important related fields, such as public housing and water and sanitation. Examples of public policy to control the conditions in which epidemic diseases spread are common in the history of UK. Indeed a potent and powerful influence behind social investigations of poverty was to better understand the causal role that dreadful living conditions had in the spread of diseases such as cholera and smallpox, and to make the case for increased social investment that would protect everyone – including those with political and economic power. Inter-dependence of interests was thus seen as fundamental to a public policy response, and health was seen as a “public good” where everyone gained from effective responses.

The concept of public good relates to the provision of a good or service that serves the common interest, but will not be provided or distributed if left to “the market” because of lack of incentives. Nationally, the production of public goods is usually assured by government intervention; at the global level where there is no sovereign global government to undertake that role, the concept of “global public goods” is not that straightforward and is still a relatively new process. Growing international pressures in recent years concerning the adverse consequences of globalization for poor countries, have increased the need for a public policy response to the challenges posed to international development by globalization. Today, the concept of global public goods relates to global issues which cover the broad spectrum of the sustainable development agenda. They include global environment, international financial stabilization, trade liberalization and market efficiency, knowledge, peace and security, human rights and health.

To a degree, health conditions in one country are independent of those in others, but this has never been absolute and epidemics have a long history of spread from one country to others, e.g. in the case of the bubonic plague. Economic activities have always linked countries and historically populations were to a limited extent mobile. But costs of transport and information deficiencies acted as barriers to the rapid transmission of disease from an epidemic “node” to other countries and regions. The limited capabilities of the state constrained effective responses where epidemics occurred, and in many cases epidemics simply worked there way through populations until natural factors brought the processes to an end.

Largely because of the impact of globalization on international travel [increase in package tours and the advent of budget airlines] these conditions to a great extent no longer apply, and levels of interaction between populations in one country and populations elsewhere are such now as to create ideal conditions for the rapid transmission of epidemics such as HIV/AIDS. In part this is the result of the greater mobility of people both within and between countries, and the intensification of social and economic interaction that is reflected in vastly increased levels of trade and financial flows between countries. The enormous increase in global economic activity over the past quarter-century has generated increasing inter-dependence of countries, and this has entailed also the risk of increased transmission of epidemic diseases such as HIV/AIDS across borders.

As will be shown in the following sections, the inter-dependence of economic and other interests which is what globalization is, carries not only risks which are health-related but also a threat to global population that threatens economic and social development and security. Globalization thus becomes a factor in the rapid transmission of epidemic diseases, and is itself threatened by the consequent economic and other consequences of epidemics. Globalization also paradoxically holds out the possibilities of effective responses to HIV/AIDS through the mobilization of financial and human resources, but for this to happen countries would need to recognize their common interest in a coordinated and effective global response. A global public policy approach will be required for addressing the growing globalization of health, from the unique perspective of the economic concept of public goods.

This recognition that epidemics threaten everyone, as in the case of HIV/AIDS, and that the consequences are much greater than those of public health alone, have been understood in the case of HIV/AIDS albeit rather late in the day by global leaders. These delays in mobilizing resources for a global response to AIDS have not only contributed to a humanitarian disaster, especially in Africa, but have also made it much more difficult to control HIV transmission globally. HIV/AIDS is now widely accepted as an international public policy issue from several perspectives: public health, human rights, labour rights, sustainable development, etc. The international community and organizations have a vital role to play in assuring the provision of public goods that serve the common interest of both poor and rich countries by controlling the spread of the global HIV epidemic. This will require innovative mechanisms based on the principle of collective responsibility and principles that put people at the centre of equitable and sustainable development.

The paper focuses the problems of sub-Saharan Africa where the HIV epidemic is most severe. The first part of the paper (Part A) outlines the conceptual foundation of global public goods and how it applies to relevant policy issues. The intention is to explore the public policy case for effective response to HIV/AIDS at national, regional and global levels, and to show that the process of public policy-making is key to managing globalization better in terms of greater economic well-being and social justice for all. It is in no way intended as a description of the epidemic and its causes and consequences, but has the aim of identifying some of the factors that generate “spillovers” and generalized impacts of HIV/AIDS as part of the case for national, regional and global action.

The second part of the paper (Part B) looks at the impact of HIV/AIDS on the stock of human capital, which is of paramount importance for the future development of the poorest countries in Africa [and also in Asia]. Some of the consequences of attrition of human capital for sustainable development are identified, and examined in terms of the implications for public policy both at national and regional levels.

The third part of the paper (Part C) reviews the regional response to HIV/AIDS in Africa, both by regional organizations such as the African Union (and sub-regional economic communities such as SADC) and UN agencies. The efforts of these diverse organizations are assessed with reference to the economic, social and political dimensions important for securing a comprehensive and effective response to the HIV epidemics. A regional approach to the response also emphasizes the point that no one country on its own can successfully provide the necessary global public goods (knowledge, drugs and vaccine) to control the spread of HIV/AIDS, and neither can the global market place. Regional efforts to combat AIDS in sub-Saharan Africa reflect, in some ways, the increasing cooperation between the most advanced and the least developed countries in the world, as will be necessary to achieve global, regional and national objectives.

PART A: Understanding the Response to HIV/AIDS in Sub-Saharan Africa

1. HIV/AIDS as a development problem

In many countries in Africa the response to HIV and AIDS by governments and by other key stakeholders has been far from what is required. Clearly the threat posed by the epidemic for social and economic development is still not fully appreciated both regionally and at country level. The issue of how to ensure that HIV/AIDS policies and programmes reflect a coherent understanding of the epidemic as a development problem has still to be addressed. Although increasing numbers of countries in the region are engaged in the design of multi-sectoral programmes, there continues to be far too little commitment to comprehensive national and regional approaches to HIV/AIDS.

Part of the explanation for the lack of commitment by many African governments in responding to HIV/AIDS as a development problem lies in the rather narrow conceptualization of the problem by those involved. The issue has continued to be seen as one of health in most countries; even where comprehensive strategic plans have been developed, these have often not always received much political support and nor have most of their elements been operationalised. Indeed the current focus on increasing access to ARV therapy for those infected with HIV has, if anything, increased the degree to which the problems of HIV/AIDS are seen by policy-makers and others involved as largely about health and health infrastructure.

This is unfortunate in that effective responses to HIV/AIDS need to be located in a more general understanding of causes and effects, and of the bi-directional linkages between poverty and AIDS which exist in many African countries. An understanding of these linkages is necessary for making the case to address HIV/AIDS as essential for policies and programmes to reduce poverty. Furthermore, policies need also to be located in a space that is not simply national, but which recognizes the mutual benefits to be derived through regional coordination and regional action.

Looking for an explanation as to why the response to HIV/AIDS in Africa has been limited itself raises a number of questions. Is it the quality and range of the evidence that has been marshaled by professionals that have failed to convince stakeholders of the importance of the epidemic as a problem? How it is that even under conditions of widespread morbidity and mortality which affect all social classes [for the epidemic is not confined to only the poorest in society], that stakeholders are still not addressing the problems of AIDS in a comprehensive way and with the urgency they deserve? It was predicted that once the experience of the epidemic became more generalized that this would activate an expanded response, but why has this not happened in many cases?

Part of the explanation must lie in the inadequacy of the general case that has been made by professionals working in the area of HIV and AIDS, and those working on development [Chambers,1993]. In the case of the former group, the general case has been inadequate at best, and even where a broader based analysis has been presented of the impact of HIV/AIDS it has scarcely been convincing. An observation of the large number of economic impact studies that were made from the early 1990s showed that these were often based on methodologies that were questionable, and which seem to have been unsuccessful as instruments for increasing the commitment of countries and donor organizations [Cohen, 1992]. This is not to argue that they had no value at all, for they clearly did, but they were unable to generate a sustained and informed commitment by stakeholders to a set of policies and programmes that represented a well-funded comprehensive response to the epidemic.

In retrospect we should consider what was missing from the kind of arguments that have been presented in the past, and which still needs to be made if stakeholders are to respond more effectively. This is important because there are many countries in Africa and other regions that have a window of opportunity, in that HIV prevalence is still low and they can learn from the experience of others who now face much more mature epidemics.

The elements of an effective response to HIV/AIDS in Africa are clearly linked to action that is comprehensive, multi-sectoral and regionally coordinated Underlying this is the fundamental point that unless relevant and effective policies and programmes are followed, many countries in the region will face social, economic and political consequences that will undermine sustained human development. But this is not inevitable and that there is good deal of evidence of successful policies and programmes now available globally and regionally on which to build effective responses.

As already observed, it is also evident that effective responses in one country may have beneficial effects for others. Controlling the spread of HIV/AIDS and its devastating consequences, and the challenges they pose, is now a global public policy issue. In terms of a global public goods approach, there are thus mutually supporting arguments for funding and otherwise supporting responses between countries since there are “spillovers” or external benefits. Given that there are externalities [social benefits] from which all countries can gain, then a case can readily be made for subsidies/external transfers from richer nations so as to ensure that effective policies are put in place and implemented by those countries that are resource-constrained.

The alternative for richer countries would be to face the probability of much higher economic and social costs, as a consequence of the spread of HIV infection to their own populations that would be more or less inevitable in a globalized world. Self interest would thus lead richer nations to seek to support through resource transfers the development of effective responses to HIV/AIDS in countries that are experiencing more mature epidemics. This would be a cost-effective response on their part and would at the same time yield benefits to those countries facing deep and intractable developmental challenges due to HIV/AIDS.

1. Why HIV/AIDS demands a Public Policy Response

There are four different but overlapping arguments that can be made for prioritizing the response to HIV and AIDS. These are as follows:

• That the HIV epidemic is a threat to public health in that a deadly infectious disease can spread rapidly from any existing concentration in those with high risk behaviours to others in the general population. In African countries with mature epidemics this has already happened, with HIV prevalence rates in increasing numbers of countries in excess of 20% of the adult population. The result is pressure on public health resources, and increasing morbidity and mortality.

To prevent this set of outcomes, what are needed are policies and programmes that increase public awareness through information and communication, screening of the blood supply to eliminate HIV-infected blood, improved control of Sexually Transmitted Infections [STIs], and access to HIV testing and counseling. Other policies may also be included along with epidemiological surveillance to track what is happening to the spread of HIV in the population. These health-related activities need to be supported by an extensive set of other programmes that address issues of prevention, care and support and access to treatment, together with actions to address the causal factors (e.g. poverty and gender inequality) that are operating to transmit HIV, and activities to mitigate the social and economic effects of the epidemic[WHO, 2004].

• That the epidemic is a threat to social and economic development. This argument for intervention is predicated on the impact of the epidemic on the level and distribution of savings and investment in the economy, where HIV and AIDS reduces the quantity available for productive use [and thus reduces the rate of economic growth that is achievable]. Furthermore, the epidemic also reduces the stock of human resources through its effects on the level of skills in the labour force and through its effects on morbidity and mortality – so that human capital is eroded. The above is significant, as studies of the causes of economic growth and development identify the stocks of savings and labour as being crucial for achieving economic and social goals.

Thus the HIV epidemic will over time reduce the potential for improving living standards for the population as a whole, and on this basis it is worthwhile devoting adequate resources now to preventing a future lower level of GNP.

• That there is a moral case for public policy action which is independent of public health and economic justifications. Those who are infected by HIV and those who are affected [the close families, and especially children] are all entitled to access to public resources to enable them to cope with the effects of HIV and AIDS, independently of whether there are economic benefits/avoidance of economic costs or not. This case for public policy action is based on concepts of human rights, embedded in the UN Charter and similar global declarations, which state that everyone has a right to good health status [and thus access to quality public health services]. Related to this argument is the scale of the impact on those countries enduring mature HIV/AIDS epidemics in Africa, in that what they are currently facing amounts to a humanitarian disaster.

This self-evidently requires the mobilization of global resources so as to contain the personal and societal distress that is affecting millions of the world’s poorest people.