The World Bank and HIV/AIDS

Sophie Harman

• Publisher: Routledge
• Year: 2010
• ISBN:
  9781136958687
• Edition: 1
• Topic: Politique et relations internationales
• Subtopic: Politique

The governance of the HIV/AIDS pandemic has come to represent a multi-faceted and complex operation in which the World Bank has set and sustained the global agenda for by the World Bank. The governance of HIV/ AIDS. Through economic incentive they have restructured the is a political foundations of countries in sub-Saharan Africa and the pursuit of change in state, project that seeks to embed liberal practice through individual, state, and societal community behaviour. At the heart of this practice is the drive to impose blueprint neoliberal market-based solutions on a personal-global issue.

This book unravels how the Bank's good governance agenda and commitment to participation, ownership and transparency manifests itself in practice, through the Multi-Country AIDS Program (MAP), and crucially how it is pushing an agenda that sees a shift in both global health interventions and state configuration in sub-Saharan Africa. The book considers the mechanisms used by the Bank – and the problems therein – to engage the state, civil society and the individual in responding to the HIV/AIDS crisis, and how these mechanisms have been exported to other global projects such as the Global Fund and UNAIDS. Harman argues in conclusion that not only has the Bank set the global agenda for HIV/AIDS, but underpinning this is a wider commitment to liberal governance reform through neoliberal incentive.

Making an important contribution to our understanding of global governance and international politics, this book will be of interest to students and scholars of politics, international political economy, international relations, development studies and civil society.

1
The complexity of HIV/AIDS governance

The governance of HIV/AIDS has come to represent a multifaceted and complex operation that is not working. Instead of reversing the spread of HIV and AIDS, it is restructuring the political foundations of countries in sub-Saharan Africa through the pursuit of change in state, individual and societal behaviour through economic incentive. In some countries contributions to combating HIV/AIDS can constitute up to a third of the total of all foreign aid. States are introducing new mechanisms of governance to manage and distribute this aid. This often involves altering their perceptions of and relationships with the civil society actors they have often ignored or suppressed. Communities that have long self- organised to educate and care for the sick have received significant financial support and shifted to models of financially driven service delivery. The private sector has introduced HIV/AIDS components to various training manuals, health and safety, pension plans and non-discriminatory practice. This has also entailed a substantive shift towards the non-state service economy as the pandemic becomes big business. People are aware of HIV/AIDS: people are taking measures to address HIV/AIDS.

However, despite all of these changes and such a widespread upsurge in participation, levels of HIV/AIDS prevalence and new HIV infection rates remain relatively unchanged in sub-Saharan Africa. What we have now is an already complicated disease made more complex by the quantity and type of funding directed towards it. At the heart of this complexity that has come to constitute ‘the global response’ is the World Bank. The World Bank does not give as much money as other private and public donors, does not have the high co-ordination profile of the Joint United Nations Programme on HIV/AIDS (UNAIDS), or the funding profile role of the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria (the Global Fund). Yet while it is widely ignored within the public health or politics literature for its role in HIV/AIDS, the Bank has carefully orchestrated the response to HIV/AIDS at every level of governance: the global, the state, the community and the individual. It has done so through a combination of timing, perceived expertise and knowledge, and a commitment to ‘good’ state-led and community-owned interventions. The type of ‘good’ governance applied by the Bank is a constraint for effective HIV/AIDS management. The problem is that what the Bank means by such leadership and ownership in HIV/AIDS reveals several contradictions to the World Bank’s approach to development. This approach applied to such an extreme personal–global issue such as HIV/AIDS has led to several negative long-term outcomes in terms of both attempts to reverse the epidemic and the institutional fabric of poverty alleviation. This book unravels how and why the Bank has come to occupy this position, what it means for our understanding of the HIV/AIDS response, and crucially our understanding of the role and application of (good) governance reform in sub-Saharan Africa through HIV/AIDS interventions.

This book is about how the World Bank has set the global agenda on HIV/AIDS and what this agenda looks like. It argues that the Bank has established a strategy for combating the disease through a specific form of ‘multi-sectoralism’ that identifies the disease as a non-health-specific, development issue, involving the state, civil society, the individual and the international community. This approach is encapsulated and promoted throughout sub-Saharan Africa and the Caribbean by the Bank’s flagship HIV/AIDS project, the Multi-Country AIDS Program (MAP). Underpinning this is the project of governance reform that promotes liberal good governance through neoliberal means. The book draws on critical governance debates to argue that HIV/AIDS is a medium used by the Bank to extend a specific brand of liberal governance reform beyond the state to local communities and individuals. It does so through (i) the promotion of a multi-sectoral approach that emphasises the role of multiple actors – the state, civil society, the private sector and non-health actors – in the implementation of HIV/AIDS projects; and (ii) through the introduction of new governance structures and systems which embed the MAP as the framework that states, civil society and international donors adhere to as the model of accepted HIV/AIDS practice. It is the institutional arrangements within the MAP and the problems of sovereignty, bureaucracy and competition that limit funds reaching local communities and people infected and affected by HIV/AIDS that highlights the contention between exporting a specific brand of liberal good governance through neoliberal economic incentive. In being the first significant multilateral commitment to HIV/AIDS and establishing processes of governance, the World Bank and the MAP have set and sustained the global agenda for HIV/ AIDS. This agenda is problematic and thus raises the question: is a problematic agenda for HIV/AIDS better than none?

If the HIV/AIDS epidemic is so complex why isn’t its governance?

The ability of the World Bank to set and sustain the global agenda for HIV/AIDS through the application of multi-sectoralism stems from the complexity or ‘exceptionalism’ of the disease. It is this complexity that explains the shift of HIV/AIDS away from health-based approaches to the framing of the disease as a development issue and gives the Bank justification for its involvement and extension of governance reform to the people infected and affected by it. It is thus important to explore what is meant by HIV/AIDS exceptionalism, and how the role of governance in regard to the state and the international community has been understood.

HIV/AIDS is understood as an exceptional global health problem because it necessitates monitoring and regulating the sex lives and habits of individuals and how these very personal habits are shaped by social, political and economic forces. Development and security concerns combined with migratory flows has made HIV/AIDS a global epidemic: one that threatens the world’s population, and one that needs to be addressed through state and non-state co-operation at the global scale. The construction of HIV/AIDS along the development–security trajectory is a particularly pertinent factor in shaping responses to the global epidemic. Previous to this association, constructions of both the HIV virus and the full-blown AIDS epidemics in sub-Saharan Africa had been predominantly explained in relation to ‘the behavioural approach’ relating to high levels of multiperson relationships, polygamy and ‘the sexual roving of men’ (Boserup 1986: 37; Caldwell et al. 1992: 1172; Lawson 1999: 394). This approach has since been widely criticised for characterising all African males as ‘hyper-sexualised’ (Packard and Epstein 1991: 781; Poku 2002: 533; Stillwaggon 2003: 811 and 830). Although issues of polygamy and serial monogamy (Epstein 2007) remain influential factors for high rates of HIV transmission and underpin many interventions in sexual health, the over-arching paradigm in which HIV/AIDS policy operates is within development. The development approach is grounded within the cyclical relationship between HIV/AIDS and poverty. Poverty is both a driver of higher rates of HIV infection, affecting the lives of people living with HIV and AIDS. The epidemic itself deepens and exacerbates poverty (Ankrah 1989: 272; 1991: 970; Barnett and Whiteside 2002: 73; Poku 2001: 192; Whiteside 2002). It is this relationship with a two-way poverty cycle that illustrates the exceptionalism of HIV/AIDS as a health issue, as it is both driven by and drives poverty, and is rooted within human behaviour affected by the socioeconomic context in which people live.

Compounding this relationship to poverty are the economic drivers specific to developing countries in sub-Saharan Africa with high rates of HIV/AIDS prevalence. Neoliberal structural adjustment policies of the 1980s have had a long-term impact on the retraction of state services, specifically within healthcare, where many public hospitals and health centres closed or were chronically understaffed (Cheru 2002: 300; Peet 2003: 141; Poku 2002: 531; Whiteside 2002: 191–192). Shifts in employment trends away from agriculture to service industry and management jobs have seen migratory flows away from the rural community towards city-based centres of economic activity and opportunity. This leads to people moving away from their local communities and families to new and unfamiliar social contexts. These trends have been matched by regional and international migration as educated members of the workforce move to states with better paid jobs (Brockerhoff and Biddlecom 1999; Lawson 1990), resulting in the ‘brain-drain’, affecting countries with high HIV/AIDS prevalence as medical professionals move abroad to seek better pay.

The impact of a decline in public healthcare, migratory flows and high rates of HIV infection have been most acutely felt by women. HIV/AIDS has increasingly become feminised with women being physiologically more susceptible to HIV infection, socially more susceptible in regards to their ability to negotiate safe sex or refuse sex and their desire for motherhood, and economically in regard to their relative inability to secure financial independence from men. They are stigmatised for living with HIV/AIDS. Women face an increased burden of care for the sick without financial reward. Women care for orphans and vulnerable children, as well as sick relatives or members of their community. Combined with the lack of women’s access to land rights, this may limit their long-term employment opportunities (Ankrah 1991: 971; Becker 1990: 1605; de Bruyn 1992: 249; Lawson 1999: 393; Maman et al. 2000: 476; Poku 2001: 197; Ulin 1992: 64). Each of these factors embeds dominant social roles of women into that of mother, carer and dependant and restricts their access to education or financial capital.

To make matters even more complicated, HIV/AIDS is no longer just a complex health and development issue; it is now also framed as a security concern. Two factors are cited as evidence that AIDS is a global security threat: (i) Security Council Resolution 1308 and (ii) United Nations General Assembly Special Session on HIV/AIDS (UNGASS) 2001. The first ever health issue raised by the Security Council, Resolution 1308, expressed concern as to the impact of HIV/ AIDS upon international peacekeepers (SCRes 1308, 200). The security element of the 2001 UNGASS declaration refers to points 77 and 78 within the section on HIV/AIDS in conflict and disaster-affected regions. These points highlight the need for states to develop national strategies that address the spread of HIV among the armed services and for the inclusion of HIV/AIDS awareness training in guidelines for peacekeepers and other defence personnel (UNGASS 2001: 41). Hence the emphasis upon security and the disease has very much been situated within the context of state responsibility and international peacekeeping.

Conflict has long been seen as a vector for the spread of the disease (McInnes 2007), with international peacekeepers being seen as a potential source of infection and a high prevalence rates within militaries. This in turn impacts upon the state and the use of force as one of its primary sources of power (Singer 2002). However, HIV/AIDS transcends traditional notions of national and international dimensions of security in its relation to human security and biopolitics. Securitising HIV/AIDS raises questions of how the threat is being constituted or what is being securitised: the disease, HIV or AIDS, the body, the state, peacekeepers or the terrain. This is crucial to the two interpretations of the impact of securitising the pandemic upon health outcomes (Maclean 2008). The first sees securitisation as an effective way of increasing international awareness and thus helping to sustain much-needed funds for combating the disease. The second sees securitisation as diverting attention away from the rights of ordinary, non-military citizens, and has increased the role of institutions such as the United Nations (UN), and the World Bank, within the biopolitical economy of power (Elbe 2008). According to Elbe, the securitisation of the pandemic has potential dangers for racism, as the biopolitical character of populations becomes a matter of ‘high’ politics (Elbe 2005). All of this is bounded up with the notion of HIV and infectious diseases being posed as a biosecurity threat (McInnes 2007) that is both national and global.

Never one to be left out in matters pertaining to development and new forms of human security, the World Bank has got in on the security action. Often cited, ex-World Bank President James Wolfensohn (1995–2005) gave a speech to the Security Council in regard to Resolution 1308 in which he declared AIDS ‘a major development crisis, and more than that, a security crisis’ (Wolfensohn 2000). Framed along this all-encompassing development–security trajectory, these factors make addressing the problem of HIV/AIDS all the more difficult. Simply put, compared to other infectious diseases such as malaria, there are no bed nets for HIV/AIDS. There are condoms and clean needles but whether an individual has access to them, wants to use one, can use one, can make their partner use one, knows how to use one or is able to afford one is embedded in a complex interplay of rationality, gender relations, poverty, education, religion, culture, stigma and discrimination. Hence, the orthodoxy has been established that in order to solve a problem like HIV/AIDS you need to address issues of poverty and culture. This has been done by framing it as a ‘development’ issue, providing a comprehensive response to the epidemic that removes HIV/AIDS from the domain of public health and frames it as a rights-based development issue.

The complexity of the epidemic and the need to respond to it effectively within this approach requires the participation of all aspects of society: the local communities where the epidemic is most acute; the district and national governments where there is a need for leadership and direction in breaking stigma and co-ordinating the response; the private sector to mainstream non- discriminatory practices and increase awareness; the health sector in providing treatment, care and prevention, as well as surveillance of the epidemic; global donors to fund these activities; and co-ordinating agencies to maintain an element of order and evaluation to a multiplicity of interventions. Responding to HIV/AIDS thus becomes a free-for-all of activity that seeks to target the very foundations in which state–civil society relations in countries with high HIV/AIDS prevalence in sub-Saharan Africa are based. The war on HIV/AIDS can only be won by every person and institution taking some form of responsibility for the epidemic, hence sections of society that were previously anathema to collaboration have come together to form awkward alliances. What we have thus is a ‘multi-sectoral’ response to HIV/AIDS that involves every level of state and society to address the complex, multifaceted nature of the problem. The purpose of multi-sectoralism is to shift the response to HIV/AIDS away from solely health-based interventions, to include all aspects of society and the state. HIV/AIDS is thus not merely a health issue, but a multi-sectoral one that requires multiple actors to become involved in decision-making and implementation. The driving force behind such alliances and multi-sectoral interventions stem from international institutions, specifically the World Bank.

This form of multi-sectoral intervention has led to the emergence of a large volume of actors involved in the HIV/AIDS response and an increase in research attempting to characterise its governance. This research can be loosely characterised as that which seeks to understand (i) the role of the state; and (ii) that of civil society and global interventions.

The role of the state

The role of the state within HIV/AIDS governance predominantly relates to the capacity of governments to address the socioeconomic factors associated with the epidemic. Capacity in this instance has mainly referred to the money and political commitments needed to ensure widespread healthcare provision. The ability of states to address these issues has been undermined by a number of factors. State infrastructure is weak where a high death rate of state workers or civil servants exists (Barnett and Whiteside 2002; Chirambo 2007; deWaal 2003). Death in this instance reduces government consistency and experience, and leads to understaffing. Moreover, death of elected officials undermines democratic practice and the realisation of long-term strategic plans in combating the epidemic (Chirambo 2007). Countries with high HIV/AIDS prevalence rates are often poor ‘fractured societies’ (Poku and Sandkjaer 2007) with weak state infrastructure and lacking in the financial resources to provide healthcare for all. High death rates of people of working age, affect a country’s labour productivity and position within global knowledge economies. This particularly impacts upon small business and micro-enterprise as a tool of poverty reduction, which bear the cost of this high prevalence rate (Poku and Sandkjaer 2007). Productivity is reduced as absenteeism through sickness increases, people die, recruitment and training costs increase, and investors are often unwilling to commit funds to countries where HIV/AIDS compromise returns (Barnett and Whiteside 2002: 242). Thus, global corporations lack incentives to invest in countries with high prevalence levels, job opportunities within the global economy are reduced and the cycle of poverty continues. This is compounded by the ‘brain drain’ of highly skilled workers as discussed above.

Both despite and because of these factors, academic emphasis on the role of government and the state in leading the response to HIV/AIDS remains (Poku 2001; Barnett and Whiteside 2002). Analyses of HIV/AIDS governance have consistently returned to the role of the state, and, moreover, what governments should be doing (Strand 2007). The role of the government is crucial as only it can put HIV/AIDS at the centre of the national agenda, create favourable conditions for other actors to play their role, and protect the poor and vulnerable (Poku 2001: 199). Lack of government ownership and response to their individual country’s crisis sets a model for citizens, who believe that if the government is not taking the epidemic seriously then neither should they; doubts are subsequently reinforced, and stigma and misunderstanding continue (Caldwell et al. 1992: 1179). This emphasis has been met by a series of incentives by international organisations such as the UN and World Bank to place states, or more correctly governments, at the centre of the HIV/AIDS response. When understanding the role of the state in this context, responsibility is firmly placed in the hands of governments.

The silence and denial of governments surrounding the HIV/AIDS epidemic is of significant concern and should not be underestimated. Perhaps the most extreme case of this has been the denial that HIV causes AIDS by Thabo Mbeki’s government in South Africa (for more on this see Youde 2007). However, as this book shall argue, focusing solely on government silence has several important consequences. First, it constructs states as ‘good’ or ‘bad’, depending on a government’s previous ability to take a leadership role. This type of labelling is irrespective of shifts in government process or attitude in respect to HIV/AIDS. For example, Uganda has long been heralded a success story for the role of President Yoweri Museveni in taking a strong role in acknowledging the problem, especially in comparison to neighbouring states. However, this labelling has become increasingly outdated as neighbouring states such as Tanzania come into line with global leadership directives. Despite demonstrating responsibility and leadership in this regard, research into the role of states in combating the epidemic revert back to notions of ‘good’ and ‘bad’ states. Second, this approach shifts the focus away from the global, intergovernmental dimension of governance and responsibility where much of decision-making takes place and the origins of government decision- making lie. Third, it gives licence for donors and international organisations to restructure aspects of the government that are labelled as anti-AIDS, or in some way HIV denialists by the wider HIV/AIDS community. Those governments that are labelled good states receive more funding and international support the more they concur to these shifts in structure. Space for independent decision-making on the part of the governmen...