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African Development Forum 2000 AIDS: The Greatest Leadership Challenge |
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> Partnership in Leadership
Table of ContentsPART ONE: AT INTERNATIONAL LEVEL
PART ONE: AT INTERNATIONAL LEVELIntroductionThe war against HIV/AIDS Africa will be won in Africa - country-by-country, community-by-community. But Africa will not win this fight alone. HIV/AIDS is a global epidemic with global ramifications. As such, it needs a global response to complement national efforts. The international community needs to fight side by side with Africa - out of self-interest, if not solidarity. A global response implies `scaling-up' action. But what does "scaling-up" really mean? It does not just mean more elaborate technical interventions or more resources, but rather, more effectiveness in intervention and application of resources. A closer look at the way the scaled-up response is being touted or implemented in some circles raises questions as to whether they meet effectiveness criteria. This is an important issue because the HIV/AIDS epidemic represents a crisis. There is no room or time for cute experimentation and expensive mistakes. How can global leadership, in all domains, build a better partnership with African countries to defeat the epidemic? How can the contributions of international partners be made more effective? How can international partners assist African countries to avoid errors? It is true that African leaders need to demonstrate commitment? There is also the issue of "donor commitment"? Can this be elicited or enhanced? This paper seeks answers to these questions. It is intended to provoke international leaders as well as their African counterparts to challenge themselves on the question of commitment. It demands a closer look at existing or proposed strategies and interventions that external partners are encouraging African countries to adopt. We propose a simple litmus test for any intervention, namely, asking the question "will it work?" Will it help arrest the spread of the epidemic and reverse its course in the short to medium term? Part one of this paper examines the role, activities and potential contribution of six categories of global partners with leadership responsibility in combating HIV/AIDS. These are: a) The United Nations (UN) and other development partners; b) Organization for Economic Co-operation and Development (OECD) countries; c) Global corporations; d) Foundations and philanthropists; e) Media and advocacy groups; and f) The scientific research community. 1. Partnership in LeadershipThese six groups each have specific and valuable contributions to make. Many are already involved in significant ways. Suggestions are made to render their efforts even more effective. (a) UN and other development partners: UNAIDS, IPAA and beyondThe discussion in this section covers not just UNAIDS and the International Partnership Against AIDS (IPAA). Significantly, it covers the role and recent actions of key UN institutions, notably the Security Council, the General Assembly and the Economic and Social Council (ECOSOC). Their involvement shows how critical the UN considers HIV/AIDS. The leadership role of the Secretary-General of the United Nations is highlighted. IPAA is cited for its innovativeness and as evidence of the willingness of traditional and non-traditional partners to break organizational taboos to combat HIV/AIDS together. Successes are highlighted, notably in fund-raising. UNAIDS is commended for its leadership in collating, packaging the scientific and technical know how, as well as for its leadership and advocacy. The Bretton Woods institutions have contributed through upstream advocacy and, in the case of the World Bank, the development of intervention packages to be introduced into macro-development programmes, such as poverty alleviation. While commending these laudable efforts, the paper cautions against technical complacency and arrogance. The debate around the implementation of the multisectoral response is highlighted to indicate that all the answers may not have been found yet. For instance, is it more effective, as Ainsworth et al argue, to focus on a few interventions proven to work rather than dissipate scarce resources on minor actions by a broad range of actors? ( b) OECD countries and their development and financial institutionsUSA President, Bill Clinton, has declared HIV/AIDS a national security threat. It is the first time in living memory that any disease has been so cited. Other OECD countries, which among them control some $22 trillion annually, have indicated or demonstrated their support for HIV/AIDS prevention efforts. This support usually comes by way of additional funds or realignment of existing commitments disbursed through their bilateral development agencies. This approach sounds suspiciously like business as usual. If HIV/AIDS is a security threat, the "moral equivalent of war", so to speak, then where is the "HIV/AIDS Marshall Plan"? (c) Global corporations - pharmaceutical companies and othersPharmaceutical companies, responding to advocacy from IPAA, have surprised many observers by their willingness to discuss contributing to eradication of the threat of HIV/AIDS. Some, such as Bristol Myers Squib, have committed significant resources to research, programme support and drug giveaways. Yet, the skepticism among the HIV/AIDS advocacy community is so strong that their motives are still questioned. Will pharmaceutical corporations have the courage to move their commitment to the next big level? What actions will they take to demonstrate their good faith? Other global corporations seem to have chosen to let their local affiliates deal with the epidemic as they see fit. Thus, Unilever affiliates in Malawi and Nigeria have initiated and funded work site HIV/AIDS prevention programmes. However, this is an inadequate response. The combined clout of global corporations is immense. Their voice, money and managerial expertise would go a long way to buttress prevention and control measures. (d) Foundations and philanthropistsPhilanthropic organizations and foundations have significantly increased their impact on international development since Turner, Gates, Packard and others came on board. Their financial contributions have been significant. There is obviously more where these funds came from. Also thus far, insufficient funds have been earmarked for the fight against HIV/AIDS. Thirdly, many of the biggest givers have chosen to hand over management of their funds to the UN or another well established development institution. This approach may be depriving development bureaucracies of the brush with a magic touch that defines the success of these titans. Combating HIV/AIDS needs a special magic touch. (e) Media and advocacy groupsUNAIDS and other specialized agencies have been successful in building a partnership with international media in putting HIV/AIDS at the top of the international development agenda. Can even more be achieved, through collaboration with HIV/AIDS advocacy groups? (f) The scientific research community.Is sufficient research attention being given to HIV/AIDS in universities and national research institutions in rich countries? How much of current research is driven by corporate financial or national economic and security interests? 2. Africans as partners and recipientsAfrican countries and their leaders must become true partners in the global fight against HIV/AIDS. This year, three African leaders made a passionate plea to the G-8 for debt reduction. Will advocacy for HIV/AIDS be next? Under the aegis of the Organization of African Unity (OAU), African countries must devise strategies and actions to engage each of the six groups identified above. Eminent elder statesmen, such as ex-Presidents Mandela and Ahmani Toure should be pressed into service. African business and religious leaders should be invited to join in as well. 3. ConclusionAIDS CAN BE BEATEN. International leaders can become true partners with African countries by demonstrating commitment and focusing their assistance on effective interventions and not just politically expedient ones. This is a historic opportunity for statesmanship and a place in history. Are today's global leaders up to the challenge? PART TWO: AT NATIONAL LEVELIntroductionPoor countries of the developing world are faced with the scourge of HIV/AIDS, a human tragedy that is threatening their development. At this point in time, there is no cure or vaccine for AIDS, but we know that with the necessary tools to control the epidemic, prevention works. Ninety-five per cent of the 34 million people infected with HIV worldwide live in developing countries and more than two thirds are in sub-Saharan Africa. HIV/AIDS strikes the most productive part of the population in the poorest countries, robbing economies of scarce skills, families of their breadwinners, and children of their parents. Life expectancy in developing countries rose from 40 to 63 between 1950 and 1990, the result of enormous investments by families, governments and the international community in improving the quality of life. A single fatal infectious disease has erased these gains in the hardest-hit countries. Life expectancy is 10 to 20 years shorter than it would have been without AIDS. A preventive vaccine, we are told, is at least a decade away from being realized. Even with the best will in the world, there is no way that the developing countries, especially those in sub-Saharan Africa, where the epidemic is at its highest, can stop this AIDS epidemic by themselves. We strongly believe that only a partnership between ourselves in the developing countries and with the international community of nations can succeed in fighting against HIV/AIDS. ADF 2000 is calling for globalization of the fight against AIDS in practical terms. Helpless people are desperate people, and desperate people are dangerous people. People become dangerous when they feel that in whatever they do, they have nothing to loose. The human suffering and effect of AIDS on poverty and health systems alone should be adequate motivation for national governments to act. Part two of this paper examines critically, those actions that are essential to stopping the epidemic, particularly those measures that only governments can ensure. The long latent period of HIV infection contributes to delayed action and governments are reluctant to act until many people are visibly affected, since there are many other urgent health problems. It is, after all, far less controversial for governments to act when large numbers of people fall ill. But, by then, it will be too late to prevent an AIDS epidemic. Treatment programmes do not require public discussion of taboo subjects. In fact, politicians as representatives of the people should always make it a point to talk about HIV/AIDS whenever they address voters. Reluctance to act by some governments is perhaps caused by the fact that AIDS prevention treads on sensitive topics that neither the government nor the public are eager to discuss, namely, sexual behaviour, marital fidelity, prostitution, sexual orientation and injecting drug use. Almost every country has at some point engaged in denial; leaders typically assert that the moral values of their society would not permit transmission of an agent such as HIV that is associated with risky sexual behaviour, homosexuality or injecting drug use. But behaviour that spreads HIV exists in every country and denial merely delays the response and worsens the epidemic. Even when denial is conquered, some governments still hesitate to undertake the interventions that are most likely to have impact. Furthermore, in the absence of any sense of priority, activities that tend to get done are those that have more political support and are less controversial. Prevention programmes among high-risk groups that are likely to have the greatest impact on the epidemic are usually the lowest on the political agenda. The failure by national governments and their development partners to prioritize and coordinate has resulted in panic, a lack of focus on specific objectives and a lack of results. 1. GovernmentsGovernments need to confront HIV/AIDS and prioritize activities that will help control the epidemic. When policy makers act early, even in countries with high HIV infection rates in the high-risk groups, the spread of the pandemic into the general population can be dramatically slowed through systematic national programmes focused on preventing transmission. Various levels of government need to be partners and lead in the fight against HIV/AIDS. They have to lead because they have been given a mandate to lead. Also, they have to lead because we have entrusted them with our tax money to be used in looking after our welfare. At the level of the local authorities we have mayors councilmen and women who are well respected and influential first citizens who, at that level, should form partnerships, find resources and lead in taking some action in their constituencies. The tools at their disposal are increased condom use, treatment of sexually transmitted diseases, reduction in the number of sexual partners, safe injecting behaviour and drugs to prevent mother to child transmission. They have all been shown to be effective in preventing HIV/AIDS. To stop the epidemic, sustained behavioral change among those likely to contract and spread HIV should be closely monitored. Achievement of this objective should be a core responsibility of a national AIDS programme. It is important to note however, that even though AIDS mortality strikes every sector of the economy, this does not necessarily mean that adding prevention programmes in every ministry programme by itself will be a cost-effective way of reducing the epidemic. An initiative such as UNDP's "Mayors against AIDS" initiative can also be used within countries with the mayors bringing together their resources and using their influence in the fight against HIV/AIDS. Provincial and national governments have both the human and financial resources to make these partnerships work. Key government departments in charge of health, education, the youth, prisons, defense and others should form interdepartmental committees to look into pooling of resources, and formation of alliances and partnerships that can supply leadership in the fight against HIV/AIDS. Combating AIDS is very often left to the departments of health, but AIDS is everyone's problem. For the interdepartmental committees to work effectively, they should be led by heads of department able to take resource allocation decisions. Inter-ministerial committees should also be formed so that the minister, as the peoples' representative, can make a commitment on behalf of his/her department. An inter-ministerial committee should have the President as the chair, so as to give it the clout, resources and legitimacy it needs, to have significant impact. Thailand, Senegal and Uganda are often cited by experts as the remarkably few policy success stories on a national scale. Strategies have to be defined and developed by their concrete and achievable targets and outcomes. Thailand for example, set itself a clear objective, that of lowering transmission via commercial sex. Key ministries, programmes and policies were mobilized to achieve this objective. Action included a massive campaign to make condom use socially acceptable and to gain 100% condom availability. In the case of Thailand, this was an intense national campaign to raise condom use in commercial sex. The condom use rate for brothel-based sex workers reached more than 90 per cent; STD cases declined precipitously, and, HIV prevalence among army conscripts dropped by more than one half. Infection rates among pregnant women have since declined. These accomplishments were sustained throughout the East Asian financial crisis. All this was supported by government's monitoring activities in STD clinics and in behavioral and HIV surveillance among sex workers and their clients. Countries with few resources, such as those in the sub-Saharan region, should focus government efforts on a smaller set of achievable outcomes that will have the greatest effect. They should also develop capacity to sustain those results as the programme expands. In Uganda, HIV prevalence has declined among pregnant women and young people are delaying sexual activity. These outcomes cannot, of course, be attributed only to public policy. It may also be due to heightened mortality among HIV- positive individuals, or the natural evolution of human behaviour faced with a generation of high mortality, associated with sexual behaviour. Lack of action on one hand may be explained by the reluctance of national governments to take responsibility for preventing HIV infection. On the other hand, there is the failure of both national governments and international agencies to set realistic priorities that can have an effect on the overall epidemic in countries with scarce resources and weak implementation capacity. In mobilizing the developed world to join the fight it is important from the onset to make it very clear to the developed nations that AIDS threatens the security not only of the affected nations but also that of the developed nations too. The international community has the responsibility for ensuring the generation of knowledge and technology that are an essential part of the fight against HIV/AIDS on an international scale. AIDS has reduced the citizens of the developing nations to a state of helplessness. As we are continuously reminded that we are one family in a global village, it is a very dangerous situation indeed when some members in the same family feel helpless in the face of HIV/AIDS. 2. International development partnershipsIn the present climate of scarce resources and urgent social needs, governments and donors need to prioritize. Governments are often thrown into a panic state by international donors who emphasize strategies that are reinforced by technical best practices on specific interventions that may only be able to support interventions that address their institutional mandates. Here, objectives are usually expressed in terms of components and not outcomes. Programme elements are typically not ranked in terms of their effectiveness in preventing the overall epidemic, given their costs. The result of all this is that governments embrace everything, taking on projects and activities on a scale that fails to register an impact on the overall epidemic. The selected activities are usually not those that will yield the greatest returns. In mobilizing the developed world to join the fight, it is important from the onset to make it very clear to the developed nations that AIDS threatens the security not only of the affected nations but also that of the developed nations too. The international community has the responsibility for ensuring the generation of knowledge and technology that are an essential part of the fight against HIV/AIDS on an international scale. AIDS has reduced the citizens of the developing nations to a state of helplessness. In today's world, we are continuously reminded that all of humanity is one family in a global village. It is a very dangerous situation indeed when some members in the same family feel helpless in the face of HIV/AIDS while the others do not care. The international community has responded by launching what is commonly referred to as an "expanded response". This strategy aims to generate greater political commitment by national governments, to mobilize more resources from within and outside countries, and to replicate a more comprehensive programme on a national scale, that includes an increased number of interventions targeted to virtually all groups in society. It also calls for more interventions to more national constituencies, involving sectors with even more limited capacity to act and that often have limited ability to realize their existing mandates effectively. This approach, of course, runs the real risk that implementation capacity may be stretched even thinner in the most affected areas and therefore even less gets done. The expanded response emphasizes prevention as well as treatment policies and programmes. Policies that will change the societal factors that influence vulnerability to HIV in the long run are also targeted. Proponents of this approach tend to not rank the components of an AIDS programme according to relative costs and impact, but rather, to prioritize by describing essential components of a programme from a technical point of view. This approach usually gets them political consensus to act among key decision-makers and removes one of the main constraints to effective programmes. This is very important, particularly for prevention programmes, where incentives to act are always the weakest. 3. Partnerships with civil society and the private sectorFor the fight against HIV/AIDS to be effective, we have to involve all structures and sectors at various levels of society from local to national. To expand or scale-up response, all the various units of society have to be mobilized in the hardest-hit countries. Civil society, NGOs and the private sector can all be involved in the response to AIDS, but without government involvement the epidemic cannot be beaten. Policies regarding fair and humane treatment and care for those who are infected should be central to strategies to cope with the epidemic because they reinforce prevention. Where government implementation capacity is very stretched, it should share the responsibility of coordination with responsible NGOs. Some international agencies have worked through NGOs to the exclusion of the government and its agencies and this has had the effect of marginalizing the governments. NGOs have a crucial role in the effective delivery of AIDS prevention and care services, particularly to marginalized groups who may actually fear contact with any government agency. Even in such cases, it is still the government's responsibility to coordinate and monitor responses, to do disease control and also make sure that the NGOs receiving public subsidies are fully qualified and evaluated, and to ensure that the objectives of all NGOs are being met in a cost-effective way. The youth need to be trained to be faithful to one partner, that prevention skills include use of condoms and that it is cool to delay having sex until they are mature enough to handle the consequences of such relationships. Peers have to be trained to be the ones that run these AIDS counseling programmes. With the trade unions, the same principle of training peers is used. A best practice is definitely that of training workers that are selected by their peers to be the trainers on prevention skills. Employers are trained to understand that for their own bottom line a healthy workforce is important. If they invest in training their workforce in various skills, they cannot allow that investment to be wasted. To make sure that their investment is not wasted, they should train their workforce to understand the dangers of HIV/AIDS. Employers should take part in the partnership against AIDS by investing in workplace AIDS programmes. 4. Partnerships among individualsWhen setting up partnerships, we need to start with the individual, for if the individual does not take responsibility for his/her actions, then that individual is not bringing value to the partnership. At a personal level, individuals have to practice safe sex, be faithful to their partners and use condoms whenever they engage in risky behaviour. An individual who practices these values is the type of person that will bring value to the collective effort. This local individual is a member of the civil society, local congregation, local school board, local sports club, trade union, national networks, and so on. Through the individual, we get access to the local church where we learn counseling skills and teach people about HIV/AIDS. At the local school, we teach school-going youth about HIV/AIDS and life skills. Individuals who are most likely to contract and spread HIV should be encouraged to adopt safer sexual behaviour through direct and indirect interventions. Both NGOs and government should do this. 5. What needs to be doneGovernments should provide information, epidemiological and behavioral surveillance, analysis of cost effectiveness of prevention and treatment, and the sectoral coordination for an effective response. National governments need to show commitment by investing substantially in STD, TB and HIV/AIDS prevention programmes, before seeking donor support. An increase in resources and training of human resources will enhance the implementation capacity and ability of programmes to expand rapidly. We should also remember that even with more resources and with acknowledgement of the impact and potential role of different sectors in a response, there is still a need to prioritize. National governments can encourage people to adopt safer behaviour through offering free or subsidized condoms, improved health information, STD treatment or needle-exchange programmes. It has been shown conclusively, for example, that STDs can be treated effectively using the syndromic management approach. Syndromic management is cost effective because it rules out more costly and time-consuming procedures such as microscopy. Taking care of STDs is a form of AIDS prevention in that people infected with STDs are more prone to becoming infected by HIV/AIDS. Tuberculosis (TB) should also be treated in a more holistic manner. Where TB patients are unemployed and cannot afford food to eat, there should be poverty alleviation programmes. TB-infected people easily get sick and die when they contract HIV. Treating HIV-positive pregnant women with cheap anti-retroviral drugs is an effective way of preventing newborn babies from getting HIV. Because prevention is cheaper and more cost-effective, governments of developing countries can afford to invest in prevention programmes. They can at least make sure that there are adequate supplies of STD and TB drugs and condoms. Realistic priorities for government action have to be set. To improve the performance of national AIDS control programmes, policy makers need to build on a smaller core set of objectives, defined in terms of measurable outcomes and impact and identify the most cost-effective set of activities and actors to meet them on a national scale. Scaling-up interventions to meet these core objectives may not completely halt the spread of HIV in hard-hit areas, but has the potential to have a huge impact on the overall epidemic, in terms of sustained interventions with the limited resources. However, AIDS programmes cannot be limited to these core objectives. As the fragile AIDS control programmes expand, the core set of objectives form a foundation for expansion. In addition to the main activities of providing coordination and monitoring, the government needs to ensure behavioral change among those with the riskiest behaviour. Again, Thailand has shown the effectiveness of reducing transmission among this group by preventing many secondary infections on a national scale. Epidemiological models have shown that even in a generalized AIDS epidemic such as the one in sub Saharan Africa, this strategy is key to lowering prevalence in the whole population. Yet, no African government has systematically attempted to reduce high-risk behaviour on the scale achieved in Thailand. An effective response may require both direct and indirect approaches, for example, peer-based prevention, condom promotion and STD treatment for sex workers and their clients, reinforced through public campaigns to popularize the use of condoms. Governments may not have a comparative advantage in providing some services to hard-to-access populations, but it can subsidize others to ensure that they are delivered. Although there is no cure for AIDS, inexpensive treatments for palliative care, opportunistic infections and STDs are affordable even in low-income countries. Governments should ensure universal access to treatment of opportunistic infections. Making sure that these drugs are available in the public and private sectors would substantially improve the quality of life at relatively low cost for those living with AIDS. Many households would be prepared to buy these drugs if they were available, but in many cases they are not available. Availability of essential drugs is still not assured in many countries and the detection and cure rates for TB, the most common opportunistic infection of AIDS, are still often very low. Universal access to essential drugs for the treatment of opportunistic infections illnesses is the foundation on which additional interventions for treatment and care can be built, and this should be a core responsibility of national AIDS control programmes. Vaccination programmes should be fully funded and effectively carried out. For youth, there should be life skills programmes for at school and out of school youth. Donor money should be solicited to augment what the countries themselves have already started. Donors should help fund programmes that have proven successful in other countries. Prevention programmes have been proven to work and organizations that have been successful should be funded to help share and replicate these successful lessons. Vaccine research is another area where partnership such as that between the International AIDS Vaccine Initiative (IAVI) and the South African AIDS Vaccine Initiative (SAAVI) should be encouraged. This is an example of a partnership between developed and developing countries in vaccine research and development. Drugs are a very contentious issue because of the high costs involved. Without assistance from the international community there is no hope that any of the developing countries can by themselves afford the prices that are charged for these anti-AIDS drugs. The market in the developing countries for pharmaceutical products is a very tiny fraction of their global markets. In line with the TRIPS agreement of the World Trade Organization, pharmaceutical companies should allow developing nations to either import these drugs from countries where they are produced cheaply or allow these countries to manufacture these drugs locally. AIDS is, after all, a public health emergency. Instead of the developed countries supporting pharmaceutical companies in their pursuit of obscene profits, and blackmailing countries that endeavour to legally produce these drugs under license in their own countries or importing them from where they are sold cheaper, these countries should instead help developing countries buy these drugs for their poor communities. The case in point here is South Africa, a country that endeavoured to introduce laws in its parliament to enable the country to produce anti-AIDS drugs within South Africa or import them from countries such as India where they are sold much cheaper. Instead of assisting South Africa, the pharmaceutical companies took South Africa to court, challenging the country's right to enact these laws. They accuse the South African Government of not protecting their intellectual property rights. The type of support we need is not the conniving we see between developed countries and their pharmaceutical companies through their import/export banks. Nor do we need the type of loan schemes on offer from institutions such as the World Bank that further enslave and impoverish the citizens of the developing countries. As it is, this type of funding arrangement can only worsen the debt situation of our countries. Developing countries are already drowning under the burden of debt from World Bank and International Monetary Funds (IMF) loans. The solution to our problem is NOT to get more loans. 6. AIDS and the relationship with povertyThe relationship between AIDS and poverty needs specific attention in this section on actions to be taken. The stark relationship is so strong that countering the HIV/AIDS threat should be integrated into all poverty alleviation strategies. Among those affected by AIDS, those who are poor have the fewest resources to cope and not so poor families can become poor as a result of AIDS-related illness and death. HIV/AIDS unquestionably worsens poverty, and poverty alleviation is a core responsibility of government and of international development institutions. Poverty reduction policies should include raising incomes through economic growth in general, and improving the access of poor people to productive assets (land, equipment, work animals, schooling and training, and social and technical services). Such programmes usually suffer from the same resource constraints as AIDS programmes - not just financial but also in terms of implementation capacity. Those concerned about the economic effect of HIV/AIDS should not only focus on what should specifically be done for AIDS patients and their families but should also place emphasis on overall public policy on poverty. AIDS control should be appropriately integrated into national poverty alleviation programmes.
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