"Who Governs Public Health? Donor Retreat and the Shifting Spheres of Influence in Southern African HIV and AIDS Policy-Making"
Background: For the last decade, discussions about who governs African HIV/AIDS policy have revolved around Western donors and their influence over local aid recipient countries. However, these dialogues are increasingly less relevant due to declining HIV funding from the West, combined with growing financial ownership of the epidemic within Africa. This project tested the hypothesis that the shift in HIV financing has prompted countries in Africa to move their National Strategic Plans (NSPs) away from global policy indicators, in favour of domestic approaches.
Methods: Data was collected from analyzing the NSPs of eight African countries with HIV prevalence rates >10% (Botswana, Lesotho, Malawi, Namibia, South Africa, Swaziland, Zambia, Zimbabwe). Based on 34 policy indicators (adapted from the Global Fund 2009 M&E Toolkit), the NSPs were evaluated on their compliance with the global policy, measured on a 5-point nominal scale. This was carried out for three successive policies in each country, to show change in global policy compliance over time.
Results: Botswana and South Africa have moved their NSPs away from global indicators in the last five years. Where Botswana's NSP was 65% compliant in 2003, it was 42% compliant in 2010. Similarly, South Africa's newest NSP exhibits a 19% drop in policy compliance. The remaining countries in this study continue to align themselves with global indicators. These trends can be partially explained though significant correlations with explanatory variables, such as perceived corruption (-0.5241) and health expenditure per capita (-0.7311).
Conclusions: The implications of these results may well be crucial in evaluating policy efficacy. In the last five years, the correlation between change in global policy compliance and change in HIV prevalence is also significant (-0.5174). The purposefully provocative conclusion of this project is that heavier national compliance with global policy indicators is connected with larger decreases in HIV prevalence. These findings disrupt many mainstream ideas about the benefits of cultural relevance and grassroots policy-making.