In the Journals

HIV Scale-Up and the Politics of Global Health — A Special Issue of Global Public Health

A recent issue of the journal Global Public Health was a notable double special issue on “HIV Scale-Up and the Politics of Global Health,” edited by Nora J. Kenworthy and Richard Parker. As the editors write in their introduction:

[W]e embark on this special issue at a particular disjuncture in the history of the epidemic. Just over 10 years ago, the President’s Emergency Plan for AIDS Relief (PEPFAR) was launched, shortly after the introduction of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). What followed was a race to treat and prevent HIV in resource-poor contexts – a global ‘scale-up’ that set the stage for many subsequent global health initiatives. For many, scale-up represented a primarily technocratic and infrastructural challenge: a focus on how donors, agencies, NGOs and community-based organisations (CBOs) could develop the kinds of health system capacities necessary for the large-scale implementation of treatment regimens. Now, however, we appear to be at the twilight of this acute period of scale-up: many perceive the long-awaited expansion of treatment as unfinished, cut short by the global financial crisis. Many now speak of ‘scale-down’ as an inevitability, rather than the potential consequence of shifting funding priorities. Other global health concerns seem well-poised to eclipse the once exceptional focus on HIV/AIDS.

The fourteen articles that compose the issue work across a range of disciplines, geographic foci, and particular questions to flesh out a portrait of the global ‘scale-up’ response and where it has left those funding, fighting, and living with HIV. The details of the articles are as follows:

‘All they do is pray’: Community labour and the narrowing of ‘care’ during Mozambique’s HIV scale-up
Ippolytos Kalofonos

This paper tracks the intertwined biographies of a community home-based care (CHBC) volunteer, Arminda, the community-based organisation she worked for, Mufudzi, and the HIV scale-up in Mozambique. The focus is on Arminda – the experiences, aspirations, skills, and values she brought to her work as a volunteer, and the ways her own life converged with the rise and fall of the organisation that pioneered CHBC in this region. CHBC began in Mozambique in the mid-1990s as a community-level response to the AIDS epidemic at a time when there were few such organised efforts. The rapid pace and technical orientation of the scale-up as well as the influx of funding altered the practice of CHBC by expanding the scope of the work to become more technically comprehensive, but at the same time more narrowly defining ‘care’ as clinically-oriented work. Over the course of the scale-up, Arminda and her colleagues felt exploited and ultimately abandoned, despite their work having served as the vanguard and national model for CHBC. This paper considers how this happened and raises questions about the communities constituted by global health interventions and about the role of and the voice of community health workers in large-scale interventions such as the HIV scale-up.

Participation, decentralisation and déjà vu: Remaking democracy in response to AIDS?
Nora J. Kenworthy

Participation, decentralisation and community partnership have served as prominent motifs and driving philosophies in the global scale-up of HIV programming. Given the fraught histories of these ideas in development studies, it is surprising to encounter their broad appeal as benchmarks and moral practices in global health work. This paper examines three intertwined, government-endorsed projects to deepen democratic processes of HIV policy-making in Lesotho: (1) the ‘Gateway Approach’ for decentralising and coordinating local HIV responses; (2) the implementation of a community council-driven priority-setting process; and (3) the establishment of community AIDS councils. Taken together, these efforts are striking and well intentioned, but nonetheless struggle in the face of powerful global agendas to establish meaningful practices of participation and decentralisation. Examining these efforts shows that HIV scale-up conveys formidable lessons for citizens about the politics of global health and their place in the world. As global health initiatives continue to remake important dimensions of political functioning, practitioners, agencies and governments implementing similar democratising projects may find the warnings of earlier development critics both useful and necessary.

Elusive accountabilities in the HIV scale-up: ‘Ownership’ as a functional tautology
Daniel E. Esser

Mounting concerns over aid effectiveness have rendered ‘ownership’ a central concept in the vocabulary of development assistance for health (DAH). The article investigates the application of both ‘national ownership’ and ‘country ownership’ in the broader development discourse as well as more specifically in the context of internationally funded HIV/AIDS interventions. Based on comprehensive literature reviews, the research uncovers a multiplicity of definitions, most of which either divert from or plainly contradict the concept’s original meaning and intent. During the last 10 years in particular, it appears that both public and private donors have advocated for greater ‘ownership’ by recipient governments and countries to hedge their own political risk rather than to work towards greater inclusion of the latter in agenda-setting and programming. Such politically driven semantic dynamics suggest that the concept’s salience is not merely a discursive reflection of globally skewed power relations in DAH but a deliberate exercise in limiting donors’ accountabilities. At the same time, the research also finds evidence that this conceptual contortion frames current global public health scholarship, thus adding further urgency to the need to critically re-evaluate the international political economy of global public health from a discursive perspective.

Evidence and AIDS activism: HIV scale-up and the contemporary politics of knowledge in global public health
Christopher J. Colvin

The HIV epidemic is widely recognised as having prompted one of the most remarkable intersections ever of illness, science and activism. The production, circulation, use and evaluation of empirical scientific ‘evidence’ played a central part in activists’ engagement with AIDS science. Previous activist engagement with evidence focused on the social and biomedical responses to HIV in the global North as well as challenges around ensuring antiretroviral treatment (ART) was available in the global South. More recently, however, with the roll-out and scale-up of large public-sector ART programmes and new multi-dimensional prevention efforts, the relationships between evidence and activism have been changing. Scale-up of these large-scale treatment and prevention programmes represents an exciting new opportunity while bringing with it a host of new challenges. This paper examines what new forms of evidence and activism will be required to address the challenges of the scaling-up era of HIV treatment and prevention. It reviews some recent controversies around evidence and HIV scale-up and describes the different forms of evidence and activist strategies that will be necessary for a robust response to these new challenges.

Up-scaling expectations among Pakistan’s HIV bureaucrats: Entrepreneurs of the self and job precariousness post-scale-up
Ayaz Qureshi

Existing research has documented how the expansion of HIV programming has produced new subjectivities among the recipients of interventions. However, this paper contends that changes in politics, power and subjectivities may also be seen among the HIV bureaucracy in the decade of scale-up. One year’s ethnographic fieldwork was conducted among AIDS control officials in Pakistan at a moment of rolling back a World Bank-financed Enhanced Programme. In 2003, the World Bank convinced the Musharraf regime to scale up the HIV response, offering a multimillion dollar soft loan package. I explore how the Enhanced Programme initiated government employees into a new transient work culture and turned the AIDS control programmes into a hybrid bureaucracy. However, the donor money did not last long and individuals’ entrepreneurial abilities were tested in a time of crisis engendered by dependence on aid, leaving them precariously exposed to job insecurity, and undermining the continuity of AIDS prevention and treatment in the country. I do not offer a story of global ‘best practices’ thwarted by local ‘lack of capacity’, but an ethnographic critique of the transnational HIV apparatus and its neoliberal underpinning. I suggest that this Pakistan-derived analysis is more widely relevant in the post-scale-up decade.

HIV testing as prevention among MSM in China: The business of scaling-up
Elsa L. Fan

In this paper, I examine the emergence of goumai fuwu, or contracting with social organisations to provide social services, in the HIV/AIDS sector in China. In particular, I interrogate the outsourcing of HIV testing to community-based organisations (CBOs) serving men who have sex with men (MSM) as a means of scaling-up testing in this population, and how the commodification of testing enables new forms of surveillance and citizenship to emerge. In turn, I tie the scaling-up of testing and its commodification to the sustainability of CBOs as they struggle to survive. In recent years, the HIV/AIDS response in China has shifted to expanding testing among MSM in order to reduce new infections. This response has been catalysed by the transition to sexual contact as the primary transmission route for HIV and the rising rates of infection among MSM, leading government institutions and international donors to mobilise CBOs to expand testing. These efforts to scale-up are as much about testing as they are about making visible this hidden population. CBOs, in facilitating testing, come to rely on outsourcing as a long-term funding base and in doing so, unintentionally extend the reach of the state into the everyday lives of MSM.

Bringing the state back in: Understanding and validating measures of governments’ political commitment to HIV
Radhika J. Gore, Ashley M. Fox, Allison B. Goldberg, and Till Bärnighausen

Analysis of the politics of HIV programme scale-up requires critical attention to the role of the state, since the state formulates HIV policies, provides resources for the HIV response and negotiates donor involvement in HIV programmes. However, conceptual and methodological approaches to analysing states’ responses to HIV remain underdeveloped. Research suggests that differences in states’ successes in HIV programme scale-up reflect their levels of ‘political commitment’ to responding to HIV. Few empirical measures of political commitment exist, and those that do, notably the AIDS Program Effort Index (API), employ ad hoc scoring approaches to combine information from different variables into an index of commitment. The indices are thus difficult to interpret and may not have empirically useful meaning. In this paper, we apply exploratory factor analysis to examine whether, and how, selected variables that comprise the API score reflect previously theorised dimensions of political commitment. We investigate how variables associated with each of the factors identified in the analyses correspond to these theorised dimensions as well as to API categories. Finally, we discuss potential uses – such as political benchmarking and accountability – and challenges of factor analysis as a means to identify and measure states’ political commitment to respond to HIV.

‘Low-hanging fruit’: Counting and accounting for children in PEPFAR-funded HIV/AIDS programmes in South Africa
Lindsey J. Reynolds

The article traces the social life of a policy that aimed to define and circumscribe the ambiguous and contested category of ‘orphaned and vulnerable children’ (or OVC) in South Africa at the height of the ‘emergency response’ to HIV/AIDS. Drawing on several months of institutional ethnographic research conducted over the course of five years with South African organisations receiving funding from the US President’s Emergency Plan for AIDS Relief to provide services to ‘OVC’, the project interrogates the influence of governmental forms of counting and accounting on health policy and practice in South Africa. Focusing on the experiences of one organisation, the article describes a process of policy ‘translation’ typified by a series of disconnects between the intentions of a policy and the exigencies of implementation, structured by the ambiguous and flexible nature of the ‘OVC’ category. In this context, the article argues that the uncertainty produced by the implementation of the guidelines was not simply an artefact of a poorly designed policy, but rather signals an underlying epistemological tension in the practice of ‘global health’, in which quantitative metrics designed for monitoring and evaluation are often incapable of approximating the complexities of everyday life.

Towards the embodiment of biosocial resistance? How to account for the unexpected effects of antiretroviral scale-up in the Central African Republic
Pierre-Marie David

At the fringes of the unprecedented medication scale-up in the treatment of HIV, many African countries have experienced dramatic antiretroviral drug stock-outs. Usually considered the result of irrational decisions on behalf of local politicians, programme managers and even patients (who are stigmatised as immoral), these problems seem not to be so exceptional. However, ethnographic attention to the social consequences of the presence and absence of antiretroviral drugs in the Central African Republic (CAR) suggests that these stock-outs entail far more than logistical failures. In 2010 and 2011 in the CAR, major antiretroviral treatment (ARV) stock-outs resulted in the renewal of ‘therapeutic’ social ties and also significant social resistance and defiance. While this paper explores reasons for the shortage, its focus is on subsequent popular reactions to it, particularly among people who are HIV-positive and dependent on ARVs. The exceptional and ambiguous consequences of these drug stock-outs raise new concerns relevant to the politics of global public health.

Meaningful change or more of the same? The Global Fund’s new funding model and the politics of HIV scale-up
Anuj Kapilashrami and Johanna Hanefeld

As we enter the fourth decade of HIV and AIDS, sustainability of treatment and prevention programmes is a growing concern in an environment of shrinking resources. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) will be critical to maintaining current trajectories of scale-up and ultimately, ensuring access to HIV treatment and prevention for people in low/middle-income countries. The authors’ prior research in India, Zambia and South Africa contributed evidence on the politics and impact of new institutional and funding arrangements, revealing a ‘rhetoric-reality gap’ in their impact on health systems, civil society participation, and achievement of population health. With its new funding strategy and disbursement model, the Fund proposes dramatic changes to its approach, emphasising value for money, greater fund predictability and flexibility and more proactive engagement in recipient countries, while foregrounding a human rights approach. This paper reviews the Fund’s new strategy and examines its potential to respond to key criticisms concerning health systems impact, particularly the elite nature of this funding mechanism that generates competition between public and private sectors and marginalises local voices. The authors analyse strategy documents against their own research and published literature and reflect on whether the changes are likely to address challenges faced in bringing HIV programmes to scale and their likely effect on AIDS politics.

After the Global Fund: Who can sustain the HIV/AIDS response in Peru and how?
Ana B. Amaya, Carlos F. Caceres, Neil Spicer, and Dina Balabanova

Peru has received around $70 million from Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund). Recent economic growth resulted in grant ineligibility, enabling greater government funding, yet doubts remain concerning programme continuity. This study examines the transition from Global Fund support to increasing national HIV/AIDS funding in Peru (2004–2012) by analysing actor roles, motivations and effects on policies, identifying recommendations to inform decision-makers on priority areas. A conceptual framework, which informed data collection, was developed. Thirty-five in-depth interviews were conducted from October to December 2011 in Lima, Peru, among key stakeholders involved in HIV/AIDS work. Findings show that Global Fund involvement led to important breakthroughs in the HIV/AIDS response, primarily concerning treatment access, focus on vulnerable populations and development of a coordination body. Nevertheless, reliance on Global Fund financing for prevention activities via non-governmental organisations, compounded by lack of government direction and weak regional governance, diluted power and caused role uncertainty. Strengthening government and regional capacity and fostering accountability mechanisms will facilitate an effective transition to government-led financing. Only then can achievements gained from the Global Fund presence be maintained, providing lessons for countries seeking to sustain programmes following donor exit.

Confronting ‘scale-down’: Assessing Namibia’s human resource strategies in the context of decreased HIV/AIDS funding
Liita-Iyaloo Cairney and Anuj Kapilashrami

In Namibia, support through the Global Fund and President’s Emergency Plan for AIDS Relief has facilitated an increase in access to HIV and AIDS services over the past 10 years. In collaboration with the Namibian government, these institutions have enabled the rapid scale-up of prevention, treatment and care services. Inadequate human resources capacity in the public sector was cited as a key challenge to initial scale-up; and a substantial portion of donor funding has gone towards the recruitment of new health workers. However, a recent scale-down of donor funding to the Namibian health sector has taken place, despite the country’s high HIV and AIDS burden. With a specific focus on human resources, this paper examines the extent to which management processes that were adopted at scale-up have proven sustainable in the context of scale-down. Drawing on data from 43 semi-structured interviews, we argue that human resources planning and management decisions made at the onset of the country’s relationship with the two institutions appear to be primarily driven by the demands of rapid scale-up and counter-productive to the sustainability of interventions.

HIV scale-up in Mozambique: Exceptionalism, normalisation and global health
Erling Høg

The large-scale introduction of HIV and AIDS services in Mozambique from 2000 onwards occurred in the context of deep political commitment to sovereign nation-building and an important transition in the nation’s health system. Simultaneously, the international community encountered a willing state partner that recognised the need to take action against the HIV epidemic. This article examines two critical policy shifts: sustained international funding and public health system integration (the move from parallel to integrated HIV services). The Mozambican government struggles to support its national health system against privatisation, NGO competition and internal brain drain. This is a sovereignty issue. However, the dominant discourse on self-determination shows a contradictory twist: it is part of the political rhetoric to keep the sovereignty discourse alive, while the real challenge is coordination, not partnerships. Nevertheless, we need more anthropological studies to understand the political implications of global health funding and governance. Other studies need to examine the consequences of public health system integration for the quality of access to health care.

AIDS policy responsiveness in Africa: Evidence from opinion surveys
Ashley M. Fox

As a result of massive scale-up efforts in developing countries, millions of people living with HIV are now receiving antiretroviral therapy (ART). However, countries have been uneven in their scale-up efforts with ART coverage rates exceeding expectations in some places and lagging behind expectation in others. This paper develops a model that explains ART scale-up as a function of the responsiveness of political parties to their primary constituents. Specifically, the paper argues that, faced with a perilous ‘threat to the nation’, countries responded in one of two ways, both of which were designed to appeal to their primary constituents – either adopting a ‘Geneva Consensus’ response, or depicting the epidemic as a Western disease and adopting a ‘pan-African’ response. The article tests this theory using Afrobarometer data for eleven countries. The paper finds that HIV/AIDS is generally a non-partisan issue in most countries. However, the analysis does uncover some differences in partisan support for HIV/AIDS responses in both countries that have adopted Geneva Consensus and pan-African responses, though not in the direction hypothesised. The lack of congruence in policy preferences between the public and their governments suggests a democratic deficit in that these governments have acted independently of the preferences of core constituents.