Donor Assistance for AIDS in South Africa: Many Actors, Multiple Agendas

ABSTRACT Given the scale and severity of AIDS in South Africa, and (until recently) the highly contested policy environment of a government in denial about the basic causality of HIV and AIDS, bilateral and multilateral overseas development assistance donors have come to play a critical role in the shaping of AIDS policy in terms of its formulation, implementation and evaluation. In the context of debates regarding the effectiveness of aid in global health, one measure of such effectiveness is its impact on the domestic policy agenda. In the first half of 2007 we conducted 30 interviews with key AIDS donors and their civil society partners in South Africa. This ethnographic study provides an analysis of these respondents' views regarding their role in the AIDS policy process--in particular as they work towards a change in the policy agenda. The analysis is guided by John Kingdon's Multiple Streams framework, which explains policy change in terms of agenda-setting. The findings illustrate the interplay between domestic and international actors in the context of global health assistance and provide a rich insider's perspective on the machinations around agenda-setting. The article concludes that national-level politics was the most fundamental impediment to real effectiveness in South African AIDS policy in the period up to 2008. 1. INTRODUCTION In 1982 the first two AIDS deaths in South Africa were recorded. Today more than 5.7 million South Africans are HIV-positive, of a population of 48 million people. The average estimated adult HIV prevalence is 18,8 per cent. Every day, around 1 000 of these people die (Cow, 2009), while at the same time, more than 1 200 people become HIV-positive. Clearly South Africa has not yet reached a point where incidence levels have dropped below the attrition rate--the worst is still to come. The national Department of Health has estimated the HIV prevalence for pregnant women attending public health facilities every year since 1990; prevalence among pregnant women escalated from 0,7 per cent in 1990 to 29,3 per cent in 2008 (National Department of Health, 2009a). Within this context successive South African governments have crafted a variety of policy responses. Since democratisation in 1994 these responses have included broad, national strategies, updated every five years, and developed in consultation with civil society. From 2003, treatment-specific strategies were added to enable the roll-out of life-saving medication. In 2007 the South African government included specific numeric targets in terms of fiscal spending and treatment rollout over the next five years. Through this same period bilateral and multilateral donors (collectively referred to as 'donors') have been enthusiastic in funding and delivering prevention, treatment and care programmes, to support and supplement the government's policy responses. It is widely agreed that, in terms of the contents of the actual policy documents, the South Africans have consistently got it right. However, as the statistics cited above indicate, policy measures and donor assistance have not been as effective in lowering the levels of incidence and prevalence of AIDS in South Africa as in other countries experiencing mature epidemics, such as Brazil and Uganda (UNAIDS, 2008). Despite the abundant availability of donor funding in the health sector, the indicators of South Africans' quality of life have been on a consistent downward trajectory (UNDP, 2009). With some notable exceptions, donors for the most part have funded their partners in country directly, bypassing the Mbeki government's (1999-2008) recalcitrant health ministry. However, as noted by the lead donor on AIDS in Southern Africa, the Swedish Agency for International Development (Sida), this money has mostly been used in a rather reactive and uncoordinated way, focusing on mitigation measures rather than being able to have impact at scale (Swedish Ministry of Foreign Affairs 2008). …