Global Public Health issues paper

FIGHTING HIV/AIDS: RECONFIGURING THE STATE?
SOPHIE HARMAN
According to received wisdom by academic research and the international community,
effective responses to the HIV/AIDS crisis in sub-Saharan Africa rest on the role of the
state. Governments have been identified as the main leaders and managers of HIV/AIDS
programmes, and have been sought by donors and international organisations to accept
and internalise dominant approaches to responding to this crisis. What is of concern,
however, is that this over-arching emphasis is not initiated by the individual governments
themselves, but is donor-led and donor-designed. This is evident from national strategic
plans to combat HIV/AIDS, to the priorities and activities of community AIDS
committees. Understandings of the state and HIV/AIDS focus upon the socio-economic
impact of the epidemic, whilst failing to consider the effect of the international financial
commitments and organisations that have come to form the global response. This paper
begins to question the impact the global HIV/AIDS response – namely the role of
international finance and international organisations - is having upon the state in sub-
Saharan Africa by exploring the role of the President, line ministries at the national and
district levels, and the role of civil society organisations (CSOs) in three specific
countries: Kenya, Tanzania and Uganda.1 The state in this context refers to the
government and governmental structures as passed in law of each of the countries
examined, and the national bureaucracy, namely civil servants and district
commissioners. The main findings of the paper are predominantly based upon research
into the activities of the World Bank’s Multi-Country AIDS Program (MAP) from
2004-2007 however, the evidence does draw upon a range of HIV/AIDS donors, and the
general experiences of government agencies and CSOs within East Africa.
1 Please note research in Kenya was conducted between 2005-2006, before the 2008 general
election and ensuing violence. The findings thus apply to similar countries within the region that
are relatively peaceful and stable.
The paper proceeds in the following manner. First, the paper positions itself within
current debate surrounding the inter-relationship between HIV/AIDS interventions and
the state, highlighting what is known, and what is ignored about the impact of the global
response. Second, the paper outlines how directives by international organisations have
placed the role of the state at the centre of HIV/AIDS responses. Third, the paper
explores the impact of the response upon the role of the President, the National AIDS
Councils (NACs), the Ministries of Health, and CSOs and how it has confronted
boundaries of state sovereignty, and governments’ ability to govern. The paper’s main
findings are drawn together in conclusion.
What We know about the State and AIDS
Questions of the impact of HIV/AIDS upon the state are not new. Research into the
socio-economic measures and outcomes of the epidemic raise concerns over the capacity
of states to address HIV/AIDS. Capacity in this instance has mainly referred to the money
and political commitments needed to ensure widespread healthcare provision from basic
palliative care to the availability of testing kits and anti-retroviral therapy (ART), and
universal free primary education, specifically to target girls. The ability of states to
address these issues has been undermined by a number of factors. First, 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 under-staffing, Moreover,
death of elected officials undermine democratic practice and the realisation of long term
strategic plans in combating the epidemic (Chirambo, 2007).
Second, countries with high HIV/AIDS prevalence rates are often poor ‘fractured
societies (Poku and Sandkjner, 2007) with weak state infrastructure and often lacking in
the financial resources to provide healthcare for all. As Whiteside argues, state capacity
in healthcare provision has been weakened by the IMF and World Bank prescribed
structural adjustment policies of the 1980s and early 1990s, which opened provision to
the market and thus reduced state intervention in basic services (Whiteside, 2002). The
link between poverty and HIV/AIDS cannot be extrapolated from wider structural
impacts and inequalities resulting from globalization. Health care and education
structures have been weakened through the transfer of resources from African countries
in the form of debt - $13.5 billion in debt per year - and the World Bank/International
Monetary Fund (IMF) structural adjustment policies of the 1980s that reduced welfare
provision (Cheru, 2002, 300 & 303). Structural adjustment exacerbated poverty and
reduced budgetary spending on health, thus undermining the capacity of African
governments to deal with the HIV/AIDS epidemic (Peet, 2003, 141). Export promotion
and debt repayment resulted in cuts in public welfare spending. The impact of debt
burden and structural adjustment has seen a shift away from approaches to health that
were based upon social justice and equity in provision to approaches that view such
provision as a threat to public finances and therefore not productive for human
development and economic growth (Poku, 2002, 531; Whiteside, 2002, 191-192).
Subsequently, the conditionalities placed on countries that received structural adjustment
loans have framed the welfare systems of countries that are now tackling high HIV/AIDS
prevalence levels, and, as a result, the majority of such countries suffer from understaffed
and under-funded health systems (Schoepf et al, 2000, 108). As Poku has
explained the situation, ‘at a time when up to 70 per cent of adults in some hospitals are
suffering from AIDS-related illnesses. Many African countries have had to cut their
health expenditure in order to satisfy IMF and World Bank conditionalities’ (Poku, 2002,
538)
Third, high death rates of people of working age, affects countries’ labour productivity
and position within global knowledge economies. This particularly impacts upon small
business and micro-enterprise as a tool of poverty reduction that bear the cost of this high
prevalence rate (Poku and Sandkjaer, 2007). 90% of deaths from HIV/AIDS affects
adults aged 20-49 and half of those infected are aged 15-24 - the most productive
working age for labour based economies (Schoepf et al, 2000, 107). Thus, productivity is
reduced as absenteeism through sickness increases, people die, recruitment and training
costs increase, and investors lack incentive to commit funds to countries where
HIV/AIDS compromise returns (Barnett & Whiteside, 2002, 242). Businesses avoid such
problems by investing in areas and setting up production sites where there is no, or a low
prevalence rate of HIV/AIDS; mandatory testing of potential employees; and movement
towards low labour production methods (Barnett & Whiteside, 2002, 266). Thus, global
corporations lack incentive to invest in countries with high prevalence levels, and job
opportunities within the global economy are reduced, and the cycle of poverty continues.
This is compounded by a ‘brain drain’ of highly skilled workers from developing
countries with high rates of HIV/AIDS that travel abroad for better wages. According to
Barnett, it is important not to over-generalise the impact of the epidemic on the state, as it
is a ‘long wave’ event that will have a differing impact upon the types of states it affects
(Barnett, 2007).
Despite these factors, academic emphasis upon the role of government and the state in
leading the response to HIV/AIDS remains (Poku, 2001; Barnett and Whiteside, 2002).
The role of the government is crucial as only they 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 people, who believe that if
the government is not taking the epidemic seriously then neither should they; doubts are
subsequently reinforced, and stigma and misunderstanding continues (Caldwell &
Caldwell, 1992, 1179). This emphasis has been met by a series of incentives by
international organisations such as the United Nations (UN) and World Bank to place
states, or more particularly governments, at the centre of the HIV/AIDS response.
The role of government became the nucleus of HIV/AIDS activity during the late 1990s
and early 2000s. This was in part reaction to evidence from countries such as Brazil and
Uganda that were deemed ‘success stories’ by the international development community
in their handling of the epidemic (Int. Garrison, 27th April 2006). A, if not the, key
component of their success was the role governments - and crucially President’s - took in
speaking out about HIV/AIDS. Up to this point, the central focus of the HIV/AIDS
response was concerned with the medical side of the epidemic, with the World Health
Organisation’s (WHO) Global Programme on AIDS (GPA) concentrating upon a health
response, ignoring the social side affects until they themselves became costly health
problems (Ankrah, 1991, 967 & 973). The role of government and the state became a part
of the agenda with the creation of the Joint United Nations Programme on HIV/AIDS
(UNAIDS), and efforts led by the United Nations to co-ordinate all state and international
structures to address the socio-economic causes and consequences of the epidemic.
However, it was not until the World Bank recognised this issue and built a project of
unprecedented financial magnitude and scope that the role of the state and the impact of
the global response upon it, came to the fore.
The Bank established its US$1billion Multi-Country AIDS Program (MAP) commitment
to fighting HIV/AIDS in early 2000. The purpose of the MAP was to make funds
available for any country in sub-Saharan Africa with a high HIV/AIDS prevalence rate
and to engender a widespread ‘multi-sectoral’ response to the epidemic that involved
every aspect of state and society. As such, funds were made available to those states that
would accept and commit to the following conditions: presence of a national strategic
plan to fight HIV/AIDS; a national co-ordinating body; a commitment to directing 40-60
per cent of funds to civil society organisations (CSOs) and agreement by the government
to use multiple implementation agencies, especially national non-governmental
organisations (NGOs) and community groups. Key to the MAP’s intervention was the
role of governments and the state, and to reflect this role the Bank implemented NACs in
the highest political office of each of the 28 countries that have received MAP funding.
These authorities were to co-ordinate the national response, select CSOs appropriate for
funding, and implement the Bank’s project (World Bank, 2007)
The MAP was the first project of its kind to establish governmental structures and
promote the inclusion of CSOs. The project existed before Goal 6 of the UN Millennium
Development Goals, the UN’s commitment to multi-sectoralism and CSO inclusion, and
the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). Since its
inception, the MAP’s commitment to state responses and multi-sectoralism has come to
underpin and lead the global response to HIV/AIDS as evidenced in the parallels between
the project and the Global Fund’s working mechanisms and priorities, and UNAIDS’
‘The Three Ones’ that all actors within the response subscribe to (Harman, 2007).2 All
bilateral donors such as the Department for International Development (DFID), UK, and
multilateral donors such as the Global Fund have acknowledged and subscribed to the
principle of government – in most cases the NACs - at the centre of the response. The
most notable exception to this trend has been the United States’ President’s Emergency
Plan for HIV/AIDS Relief (PEPFAR), a project that commits US$15 billion to the
HIV/AIDS response. PEPFAR does not by rule work through the pre-established state coordinating
bodies such as the NACs, but does aim to strengthen systems within the
Ministry of Health. The exceptionalism of the US in this regard does not undermine the
central argument of this paper, but as will become evident, impacts upon the state
rivalries and inter-agency complexities born of international intervention.
Academic research and global commitments to state-centric responses to HIV/AIDS
within the context of a ‘multi-sectoral’ approach that facilitates widespread state and
society involvement reflects the importance of the state within responses to the epidemic.
What is not clear, however, is the impact these globally-designed state-led initiatives are
having upon the government and the state, particularly in sub-Saharan Africa. This paper
considers the impact of global interventions within HIV/AIDS on the state and questions
of sovereignty and state/civil society boundaries. It does so by focusing upon the position
of the President, the role of the National AIDS Councils, the rivalries between line
ministries, and the proliferation of civil society organisations (CSOs) as the main
providers of basic healthcare and HIV/AIDS prevention methods.
Presidents and the War on AIDS
Since the inception of the MAP, and the increased availability of HIV/AIDS financing,
Presidents within sub-Saharan Africa such as Mwai Kibaki of Kenya, Jakaya Kikwete of
Tanzania, and Yoweri Museveni of Uganda have all called for a ‘war on AIDS’.
Museveni was unique in the leadership role in combating HIV/AIDS at the outset of his
Presidency, which has since become a key component in Uganda’s labelling as a ‘success
2 ‘The Three Ones’ have become the central co-ordinating mechanism within the HIV/AIDS
response that all actors working on the epidemic subscribe to. ‘The Three Ones’ are national and
international commitments to: one co-ordinating body, one monitoring and evaluation system, and
one strategic plan.
story’ in the fight against HIV/AIDS. Explanations as to why Museveni adopted such a
role are blurred. A popular argument is that at the time of Museveni’s rise to power
through military coup in 1985, soldiers and civilians began to exhibit symptoms of
HIV/AIDS. Aware of the fragility of his power – and according to rumours in Uganda,
under the advice of Fidel Castro - Museveni sought to encourage voluntary testing and
counselling first within the army and then within the wider aspects of society as a means
of maintaining political stability. What is clear, however, is that Museveni’s role led to
wider financial commitments and support from the donor community. Those Presidents
and states that were willing to declare ‘war’ against the epidemic were seen as
appropriate countries in which to invest resources and international ‘expertise’.
Political leaders have thus come to adopt the ‘war on AIDS’ approach and shape their
HIV/AIDS agendas within the language of donors, whilst continuing to demonstrate a
necessary level of leadership and commitment to receive much needed funds. Stigma is
the main justification used by international donors to prioritise Presidential leadership
within the response. Political leaders within sub-Saharan Africa – with the notable
exception of Thabo Mbeki – have been vocal in the need to break the stigma surrounding
HIV/AIDS, yet activities in which they do so, and the origins of this commitment are
directed by international involvement and intent. What occurs is a cyclical pattern of
donor-led directives, and Presidents maintaining a certain language and priorities in line
with these commitments, to maintain international financial support, and thus the
legitimacy and leadership of these donors. The wives of Presidents are of equal
importance in maintaining this language and signals of commitment. Wives participate in
fun-runs, engage in state visits with communities, and maintain the message of breaking
with stigma. This is an important and commendable role for the partners of Presidents;
however, what becomes of interest is what happens when the wives deviate from donor
objectives and concepts of good leadership of the response. Uganda’s relationship with
international donors became strained in response to allegations of corruption and mis-use
of Global Fund monies during 2005-2006, however often overlooked and of interest
during this time was reports on Janet Museveni’s behaviour in regard to the role of
condoms in the ‘ABC’ – Abstinence, Be faithful, use a Condom - of prevention. It was
widely reported that Janet Museveni would physically pull down prevention messages
that addressed condoms, adverts for specific brands, and would widely disclaim their role
as a method of prevention. In response, President Museveni went on the condom
offensive to re-assert his government’s commitment to ABC, and the role of the
President’s wife was notably reduced.
The impact of HIV/AIDS funding on the President in sub-Saharan Africa is pertinent, as
a leader’s ability to effectively respond to and manage an epidemic that affects so many
of the population is important to their approval ratings and electorate. However, it is the
latent prioritisation of combating stigma and the need for Presidential leadership that
emerged at the same time as an increase in donor funding across sub-Saharan Africa that
becomes of interest. Presidents must be seen to commit to combat stigma to receive donor
funding and approval from the international community that the country is taking the
epidemic seriously and is thus willing to commit to international objectives. This in itself
does not lead to any systematic reconfiguration of the state, or breaches of sovereignty,
however it is the associated measures conditional to donor funding that Presidents
commit to that ultimately undermines their leadership and position of power. The most
pertinent of which is the introduction of National and local AIDS Councils within the
office of the President/Prime Minister.
The NACs and DACs: the new armies in the war on AIDS
National, District, Regional and Community AIDS Councils co-ordinate the national
response to HIV/AIDS at every level of government in line with each country’s national
strategic plan. They were established in 2000 and are a pre-requisite of any country in
receipt of World Bank MAP funds. The main role of the NACs is to co-ordinate the
national response to HIV/AIDS by identifying those CSOs that should receive funds;
strengthening the District AIDS Councils; working with partners to articulate the strategic
plan; mobilising partners and working with line ministries and donors in strengthening
capacity and filling the gaps in the national response to HIV/AIDS (Int. Bahati, 14th
November 2005; Int. Byenka, 11th October 2005; Int. Kalinga, 14th February 2006; Int.
Temba, 10th February 2006; Int. Tembele, 6th January 2006). The NACs are the main
focal point of the HIV/AIDS response, and are the subject of much capacity building by
UNAIDS and UNDP, and have, in some countries, accommodated the Global Fund’s
country-co-ordinating mechanism (CCM) within their structure.
However, since their inception the NACs have suffered from problems of CSO mistrust,
bureaucracy, corruption, capacity, direction and ownership of their national responses.
Each of these issues has undermined their ability to respond to problems within the
national response and are underpinned by questions of sovereignty and international
influence. A ‘healthy mistrust’ exists between the NACs and CSOs (Int. Anon. 4).
Discontent is more in evidence when exploring the CSOs’ views in more detail. The
research shows that mistrust is based upon specific CSOs’ views that the NACs are
political entities conditioned by wider government spending plans and objectives (Int.
Kalimire, 17th October 2005) or a political institution that distorts outcomes and
achievements to make the government look successful (Int. Mwai, 29th November 2005;
Int. Ruranga, 31st October 2005). Such views reflect traditional divisions between the
state and civil society in East Africa.
CSOs, such as the National Guidance and Empowerment Network of People Living with
HIV/AIDS (NGEN+) in Uganda, prefer not to be involved in the Uganda National AIDS
Council – the Uganda AIDS Commission (UAC)’s - partnership committees as once
involved they have to agree to government policy and its financial and political
‘monopoly’ of the AIDS agenda under collective responsibility, when in certain instances
the government acts against the needs of PLWHAs (Int. Ruranga. 31st October 2005).
Other CSOs interpret the actions of the NACs as directed by donor demands, and that for
states to realise their objectives in the response to HIV/AIDS they must be more dynamic
in the management of such demand (Int. Mwai, 29th November 2005). Competing
demands reduce the NACs disposition to actual governance of community empowerment,
thus reducing the already limited space for social activity that exists in East African
society (Int. Southern, 9th January 2006). CSOs feel that mistrust could be better managed
by CSOs through improved co-ordination (Int. Hervey, 27th January 2006); presence
within the community to gain first hand experience of the problems CSOs face; greater
publicity of their work (Int. Ogen, 19th October 2005; Int. Kaloli, 4th January 2006; Int.
Simbaya, 7th February 2006), and the promotion of transparent funding methods to get rid
of ‘briefcase NGOs’ (Int. Mubondo, 20th January 2006; Int. Mulimila, 19th January 2006).
These factors would minimise mistrust and as a consequence strengthen the response at
the national level (Int. Hervey, 27th January 2006).
A commonly perceived problem within state sponsored activity in sub-Saharan Africa is
corruption. The perception of corruption presents a powerful obstacle to the effectiveness
of the NACs. In 2005, Uganda was tarnished by the Global Fund’s withdrawal of support
resulting from the discovery of mis-managed funds by independent auditors
PriceWaterhouseCoopers. The Global Fund suspended all of its five grants to Uganda
until the Ministry of Finance had established a structure that would ensure effective
management of the funds (Global Fund, 2007). This issue has since been rectified, and
the Global Fund was quickly re-established in the country. Accusations of corruption are
not commonly linked to Uganda and the Global Fund issue was minor in comparison to
the problems experienced by the Kenyan National AIDS Council – the National AIDS
Control Council (NACC) - and the country’s wider reputation for corruption (Int. Kinzett,
23rd November 2005).3 Levels of misappropriation were such that national NGOs alleged
the then Head of the NACC was reputedly paying herself KSh2million (approximately
UK£13,500) out of MAP funds earmarked for the community (Int. Mwai, 29th November
2005). The corruption scandal led to all senior NACC management having to re-apply for
their jobs, removing the NACCs funding decision-making capability, the then Head of
the Council being imprisoned, and an external audit conducted by
PriceWaterhouseCoopers. CSOs were consulted, involved and recruited within the rehiring
process (Int. Austen, 18th November 2005). The NACC continues to face
accusations of preferential treatment to CSOs of similar tribal identity (Int. Owenga, 28th
November 2005) and there are claims that ‘there have been bigger thefts than that of the
3 In 2005 Sir Edward Clay, the then UK High Commissioner to Kenya made a speech documenting the
levels of corruption within the Kenya government, accusing the government of bribery, accounting for 8%
of Kenya’s Gross Domestic Product (GDP), that is undermining Kenya’s economic growth and donor aid
commitments. Such an accusation made international headlines because of the comment ‘they can hardly
expect us not to care when their gluttony causes them to vomit all over our shoes’ (BBC News, 2004)
NACC’ (Int. Lenya, 10th November 2005), although there is no clear evidence of this
happening.
The bureaucratic structures and processes within the NACs make corruption hard to
detect. Bureaucracy complicates transparency and perceptions of NAC activity and thus
does little to dispel CSO concerns over corruption. Upon implementation, the structures
and processes of the NACs were cumbersome and bureaucratic (Int. Kataka, 23rd
November 2005), as management units, they added an additional layer of bureaucracy to
already complex government-donor relations (Int. Tayyab, 25th April 2005). The levels of
day-to-day bureaucratic inertia range within the NACs, TACAIDS seems consistent in its
processes, deadlines and ability to keep appointments, UAC follows a similar patter in
consistency and transparency, yet could be problematic in terms of deadlines and
appointments, however, the bureaucratic structures of the Kenyan NACC resemble a
complex ad-hoc system of protocol that is seemingly without process or procedure,
varying by the day. Access to information depends on who you engaged with in the
NACC, with some individuals being open; some changing the requirements necessary as
if they were making them up, and other representatives denying any knowledge of
individuals or previous processes.4
The institutional capacity of the NACs have been marked by under-funding, lack of staff
and a rapid accumulation of responsibility, for example in Tanzania ‘TACAIDS
(Tanzania Commission for HIV/AIDS) is still put upon in this country… its just volume
of expectation… it is simply the expectation of that organisation, and that doesn’t mean
they deliberately don’t fulfil that requirement, its just unrealistic’ therefore TACAIDS
has to operate in limited space ‘as the Mother of all deliverables’ (Int. Southern, 9th
January 2006). Initially established to manage the MAP, the NACs now have the
4 These findings are based on extensive visits to the NACC: in one instance the NACC was open to
participation in the Joint Annual HIV/AIDS Programme Review and were extremely accommodating and
helpful in this respect; the corollary of this was attempting to access information on the District Technical
Committees and being told that the information i.e. names and addresses were classified without a letter of
introduction from the British High Commission, British Council or whoever they then chose. In a separate
incident when attending the NAC for information on the NGOs nationally funded under the MAP the
researcher was left waiting for 6 hours after being told the person she needed was in a meeting, and then
eventually that that person had gone home.
responsibility of bilateral basket funds, the Global Fund and co-ordinating all HIV/AIDS
activities in-country (Int. Malangalila, 20th January 2006). International organisations
such as UNAIDS and CSOs view this as a result of their inability to delegate
responsibility to their partners, such as the Ministry of Health (Int. Mubondo, 20th January
2006; Int. Tembo, 25th May 2006). Staff members within the NACs are targeted as
lacking the skills and ability needed to support the community and partner CSOs
effectively (Int. Margery, 6th January 2006). Capacity issues are the responsibility, not the
fault, of the NACs. Fault lies in the design and responsibilities placed upon them by
international donors, principally the Bank, and CSOs arising out of the empowerment and
government-ownership models advocated by such donors. The need for one co-ordinating
body within the response, the rapid demands of funding disbursal, preference towards
CSO funding not government funding, and the multiplicity of actors involved in the
response, all place stress upon the NACs’ capacity and confuse their initial mandate.
Confusion as to the NACs’ mandate exists over their role as co-ordinators of the national
response and implementers of the MAP (Int. Malangalila, 20th January 2006; Int. Austen,
18th November 2005; Int. Tembo, 25th May 2006). Representatives of the NACs, the
World Bank and UN agencies all stress that the NAC’s role is co-ordination not
implementation (Int. Bahati, 14th December 2005; Int. Lekule, 4th January 2006).
However, in articulating the strategic plan, selecting those CSOs to receive MAP funds,
monitoring and training the DACs, and strengthening public sector responses, the NACs
are heavily involved in operational implementation (Int. Lekule, 4th January 2006; Int.
Tembele, 6th January 2006; Int. Zewdie, 3rd May 2006). Initially the NACs were not
supposed to engage in such activities, but the demands of the MAP resulted in them
doing so, MAP-1 established the NACs as implementers and MAP-2 reinforced this role
(Int. Mohammed, 24th April, 2006; Int. de Regt, 20th April 2006). The NACs present their
roles as co-ordination, but on further enquiry admit that they have become involved –
unintentionally – in implementation. This presents a conflict of interests, confusion, and
over-burden on the part of the NACs, rendering them unable to do either co-ordination or
implementation successfully (Int. Kibamba, 20th January 2006; Int. Kinzett, 23rd
November 2005). As co-ordinating bodies, the NACs should not house projects as it
contravenes their legal mandate (Int. Cunningham, 25th October 2005). This is
problematic in the NACs wider relations with CSOs, as in implementing the project the
NACs are directly competing for funds with the project’s traditional implementation
partners - CSOs (Int. Mugumya, 1st November 2005). As one CSO characterises the
situation ‘how can you referee when you are a player?’ (Int. Mulimila, 19th January
2006).
The key factor that underpins the problems surrounding NAC capacity and their mandate
is the discrepancy over ownership. Contrary to Bank and NAC affirmations of state
ownership of the MAP and the national strategic plans, such ownership is articulated and
directed by the Bank and international donors. The objectives and CSO engagement
structures within the NACs were first created by the World Bank, and have since been
developed by international organisations and donors under the rubric of ‘capacity
building’. This is evident in the Bank’s implementation of the MAP in East Africa. First,
the Bank used the MAP to establish or re-craft the NACs. The UAC in Uganda
technically existed previous to the MAP but underwent an institutional reform and is now
fully funded by the Bank under MAP funds, the NACC in Kenya is funded by the Bank
and only existed in discussion paper form before the MAP, and TACAIDS in Tanzania
was established under the MAP but is supported by government funds (Int. Voetberg, 15th
November 2005; Int. Okwero, 1st November 2005). In Mozambique, a co-ordinating body
already existed within the government, however the task team leader of the MAP had to
keep to the overall blueprint and insisted on establishing an additional body and
subsequently causing friction with the government, if the government had refused it
would have not received the badly needed funds (Int. de Regt, 20th April 2006). In the
UAC, once work-plans were articulated they had to be approved by the Bank, once the
CSO proposals were reviewed the UAC prepared recommendations for approval to the
Bank, and once the MAP was accepted, the UAC had to sign an agreement to support
CSOs (Int. Byenka, 11th October 2005). In Tanzania, TACAIDS found the US$34million
out of the US$50million MAP budget earmarked to line ministries disproportionate to
that of the community fund. However the Bank has not changed its position on the
funding (Int. Lekule, 4th January 2006). In all three cases state-level response to
HIV/AIDS was inactive. The central objective of the Bank was to use MAP funds to give
states ‘the push that was needed’ to facilitate a high-level political commitment (Int.
Zewdie, 3rd May 2006). Thus not only did the Bank use the MAP as a catalyst for the
NACs inception, it promoted an agenda that structured NAC practice alongside Bank
working principles.
Upon implementation of the MAP at country-level states did not have a role in
articulating the project’s main objectives. States are only able to articulate the agenda by
choosing to accept the terms and conditions of the initial contract (Int. Lagerstedt, 14th
November 2005). When asked how the UACP was devised, Peter Okwero, the World
Bank’s task team leader in Uganda, responded ‘I can’t really say how it developed, it just
came by itself. When we were sitting, it was never, the Bank did not come with any idea,
I don’t think the government came with any particular idea’ (Int. Okwero, 1sr November
2005). The Kenyan Bank team were adamant that ‘the Bank has no objectives behind the
TWOA, it is the government, we are supporting the government. That’s the point, and
don’t forget it’ (Int. Lagerstedt, 16th November 2005). The task team leader for Tanzania
provided a more contradictory response to the question of ownership, suggesting it should
be the Tanzanian government that designs the project, but in practice it is always the
Bank,
The preparation has to be with the country. Actually the project should be prepared,
ideally it should be prepared by the government, ideally, you know, we are not
preparing the project as a Bank, I mean this is, but in most cases you find that it is
the Bank preparing, doing most of it, it is supposed to be the government preparing
a project and the Bank assisting, providing you know, assisting the country to
prepare a project, so that there is ownership of that project, right from the word go
and throughout the implementation and even after implementation. So that is how it
should look like but for most of the projects of the Bank you will find that because
of the capacities of the country er, a lot is being done by the Bank. (Int.
Malangalila, 20th January 2006).
The requirement to channel 40-60 per cent of funds to CSOs was heavily resisted by the
governments of Kenya, Tanzania and Uganda, who have little practice of CSO
engagement fostered by mutual distrust and dislike (Int. Malangalila, 20th January 2006).
As such, the Bank made states recognise the role CSOs had in the national responses to
HIV/AIDS and the need to adopt a new approach to development work (Int. Zewdie, 3rd
May 2006). The Bank was able to make states recognise the use of CSO and adopt
suitable mechanisms of engagement through the promise of desperately needed funds.
Hence, the imposition of the CSO principle and the NACs under the MAP represented
stringent conditionalities. Keen to dispel any use of conditionality on account of its
association with controversial structural adjustment policy, ACT Africa avoided the issue
by stressing that requirements such as the implementation of the NACs were not ‘a
conditionality, if you read the MAP what it says is to put the co-ordinating body at the
highest level of government, what did we mean by that? Its that it should not come under
the Ministry of Health’ (Int. Zewdie, 3rd May 2006) and preferring to characterise such
influence as ‘arm twisting’ or working with NACs to ‘remind them ruthlessly’ of their
role (Int. Mohammed, 24th April 2006).
The origins, roles, and problems of the NACs reveal several key concerns over state
sovereignty and the impact of international financial commitments and organisations
upon the state. First, the creation of a Bank-funded governmental body at the height of
political office, established to implement a Bank mandate, presents an unprecedented and
significant confrontation of state boundaries within understandings of global governance.
The NACs are characteristic of the second generation reform measures depicted by
Graham Harrison (Harrison, 2004), in which the Bank utilises government agencies to
implement its reform packages through subscription to, and ownership of, a shared
ideology. The national application of the MAP represents a sophisticated incarnation of
such reform through its systematic use of CSOs and a specific form of CSO
empowerment model. Second, this creation is undermining state objectives and
government legitimacy, which ultimately threatens governments’ position within its
electorate. The ability of state structures such as the NACs to respond to community
concerns are bounded by the conditionalities agreed upon at the outset of donor funding
commitments. Under the rubric of state ownership, states have to assume responsibility
and implement what is perceived by international organisations to be in the state’s best
interest. If government objectives refute donor interests or the mandate prescribed for
them to implement, governments are framed in a moralistic renunciation of their
commitment to help the sick. Third, state attention towards the provision of basic services
is channelled to the non-state sector, and the emergence of service economies throughout
the country, as opposed to strengthening state mechanisms directly. The desperate
situation HIV/AIDS has led to, binds governments in a vicious cycle of dependency upon
foreign aid and a loss of sovereignty that infers a growing legitimacy upon non-state and
international interventions. This situation is enhanced by competition and mistrust
between state agencies, and the decline of the health sector.
Ministry of Health: the old guard
The implementation and prioritisation of multi-sectoral approaches to HIV/AIDS with
NACs at the centre of leading state responses has undermined the position and capacity
of traditional state agencies, most notably, the Ministries of Health. In all three countries
studied, the Ministry of Health provides the technical arm of the response; addressing
medical issues of anti-retroviral therapy (ART), opportunistic infections, voluntary
counselling and testing (VCT), prevention of mother-to-child transmission (PMTCT),
procurement, logistics, and technical support for hospitals and health centres. Each of the
Ministries of Health, except Uganda, have a special HIV/AIDS section: National STD
and HIV/AIDS Control Programme (NASCOP) of Kenya; National AIDS Control
Programme (NACP) in Tanzania; and Zanzibar AIDS Control Programme (ZACP) in
Zanzibar. However, the global response did not consider these agencies as suitable actors
in which to co-ordinate the response due to a commitment to non-health based responses
and the problems faced by Ministries of Health across the region. In Tanzania, the
Ministry of Health reflects the knock-on impact of structural adjustment, in that 40% of
health staff positions are under-filled (Int. Southern, 9th January 2006). Managerially,
Ministries of Health are seen as inefficient throughout the world (Int. Southern, 9th
January 2006). In countries such as Nigeria, the public health system has all but collapsed
(Int. Okafor, 27th April 2006). These systems are strengthened with WHO technical
support, resource mobilisation, training materials, and policy guidance (Int. Gavyole, 13th
February 2006). However they remain clinically oriented with few sectoral ministries
accepting their authority (Int. Lagertstedt, 16th November 2005). The Bank recognised
these issues and the need for a regulating body that prioritised a multi-sectoral approach
to HIV/AIDS alongside the health sector dimension (Int. Lagerstedt, 16th November
2005).
The shift in focus from a medical to a multi-sectoral response to HIV/AIDS resulted in a
contention between the NACs and the Ministries of Health. This contention was in part
based upon an overlap in implementation and an unclear delineation of roles and
responsibilities (Int. Quiery, 31st December 2005; Int. Duolf, 4th January 2006; Int.
Hervey, 27th January 2006) as George Tembo of UNAIDS describes the turf wars and
friction at the outset of the MAP:
Their roles and responsibilities vis-a-vis them and the line ministries are not clear,
particularly the Ministry of Health. So in most of the countries its push and pull,
between the Minister, the Ministries of Health were initially the leaders of the
response, they were the ones who were leading everything, then we started talking
about the multi-sectoral approach, then the Ministry of Health felt threatened, ‘oh
you’re taking our turf’ so there’s friction (Int. Tembo, 25th May 2006)
A great force for contention was over who had ultimate authority over the national
response, principally arising out of who had greater funds (Int. Nyantahe, 9th January
2006). In terms of authority, a representative of USAID in Uganda described the Ministry
of Health as ‘pissed’ that they did not house the Uganda MAP; and Awene Gavyole, the
World Health Organisation’s representative in Tanzania explained ‘there is some sort of
‘I am the authority and I am the technical person’’ (Int. Gayole, 13th February 2006; Int.
Anon. 4). The conflict between these two agencies is widely recognised as problematic in
that they do not work together generating further overlap and distrust (Int. Quiery, 21st
December 2005; Int. Kariuki, 16th December 2005; Kibamba, 20th January 2006).
However, despite suggestion of conflict, representatives of the NACs and the Ministries
of Health acknowledge a degree of initial animosity (Int. Lekule, 4th January 2006; Int.
Chale, 10th January 2006; Int. Malangalila, 20th January 2006) but then consistently state
their co-operative relationship, as Rustica Tembele of TACAIDS describes the
relationship, ‘for me, we are just a wedding’ (Int. Tembele, 6th January 2006) and issue
examples of their joint working practices and inter-linkages between staff and committees
(Int. Kamet, 11th November 2005; Int. Temba, 10th February 2006; Int. Saadat, 31st
January 2006).
The division and conflict between the Ministries of Health and the NACs has been
heightened by the arrival of PEPFAR and a re-medicalisation of the epidemic. PEPFAR
is a US$15 billion, five year strategy that integrates care, treatment and prevention
programmes across the world, with a focus upon rapid disbursement and results, that is,
large commitments to the provision of anti-retroviral therapy (ART), and strengthening
Ministry of Health capacity. Its main expenditures are channelled to the management of
the chronically ill, which is seen as problematic and economically unviable in terms of
productive years added and the benefits of prevention. The financial capacity alone has
led the US to subsequently dominate HIV/AIDS efforts at the risk of UN marginalisation.
To stress its relevance, the UN must now align its interests and activities within a US led
framework (Morrison & Summers, 2003, 188). PEPFAR does not function within preestablished
processes or co-ordination mechanisms such as the NACs, yet is does
integrate system strengthening and procurement practices within health ministries to
facilitate the widespread scaling up of anti-retroviral treatment. The financial
commitment of PEPFAR and its shift away from the NAC approach assists in the
schizophrenic position of governments trying to appease multiple international actors,
whilst maintaining their own objectives and political mandates. The consequence of this
is further division and competition of state agencies to prove their legitimacy not only to
central government as is often the case within line ministries wanting to secure parts of
the state budget, but to the priorities of international donors. Divisions between state
agencies and the balance governments must strike between international initiatives and
national priorities are made more complex by the mushrooming of non-state actors, and
the impact their role within service delivery has upon the functioning and role of the
state.
CSOs, the State and the Service Economy
At the core of multi-sectoral responses to HIV/AIDS has been the role of CSOs. CSOs in
this regard refer to community groups of varying scale and size, national NGOs, regional
networks, and international non-governmental organisations. Projects such as the MAP,
international non-governmental organisation, and Global Fund grants specifically target
CSOs in-country to provide a variety of care, treatment, prevention and support services.
This has led to the upsurge of civil society actors throughout sub-Saharan Africa, and it is
the role of the government and state structures such as the National, District and
Community AIDS Councils to monitor and facilitate their involvement. Relations
between governments and civil society within sub-Saharan Africa, specifically the case
study countries, have been traditionally marked by distrust. However, under the ‘ruthless
reminders’ (as conditionalities were referred to in an interview with a member of the
World Bank’s AIDS Campaign Team Africa) of the Bank and international influence,
governments not only have to reach out to CSOs, but accommodate them within wider
state structures of health, education and the Office of the President. States have thus
become the managers of non-state actors, mapping their work, sponsoring their activities,
and then monitoring their interests, needs and success as if they were a central part of the
state structure. This point is particularly pertinent when looking at the inter-relationship
between District and Community AIDS Councils and international non-governmental
organisations.
In response to problems with funding disbursement from the government to the
community, NACs in some of the MAP countries have established Regional Facilitating
Agents (RFAs). The introduction of these agents was made in response to suggestions by
the Bank to speed up funding disbursal through the use of private consultancies or
international non-governmental organisations. The RFAs would operate as an extension
of the NACs mandate thus increasing the working capacity of the MAP and the national
strategic plans at the national and district level. The central role of RFAs is to build the
capacity of the regional secretariat, the Local Government Authority (LGAs), the DACs
and the community (Int. Tembele, 6th January 2006) and oversee and co-ordinate the
overall implementation of the MAP community component (Int. Mwaduma, 6th January
2006; Int. Kalinga, 14th February 2006). RFAs build capacity by mapping the number of
CSOs in the area, their activities, shortfalls and successes, demonstrating successful
models for implementation and monitoring of projects to both the DACs and the
community, assisting the DACs with project appraisal and subsequently disbursing funds
to communities (Int. Tembele, 6th January 2006; Int. Mwaduma, 6th January 2006; Int.
Mukama, 8th February 2006). The RFAs see their central role as facilitators of community
participation (Int. Mushi, 9th January 2006). The introduction of these bodies blurs the
distinction between the state and civil society, as private actors become an extension of
the state, and work in line with international donor-led, government mandates. What we
thus see, is a mechanism introduced by international donors to conduct and implement
the mandate of international donors, within the sovereign structures of the state and
individual governments’ mandates to wage a war on AIDS through the disbursal of funds
to the community at the district and local levels.
The mushrooming of CSOs working within the remit of globally-designed state
objectives and the introduction of international non-governmental organisations and
private actors as extensions of state activity at the District level not only blurs the
boundaries of what is and what is not the state, but confronts conceptions of the ‘third
sphere’ position of CSOs within global governance popularised by the work of Jan Aart
Scholte (Scholte, 1999; 2000; 2002; 2004). The relationship between international
financial institutions and CSOs within the HIV/AIDS response does not reflect a
distinction between the family/the state/civil societies but sees the intertwining of all
these three spheres. The overlap between CSOs and traditional state boundaries are
justified as just a part of the multi-sectoral response to HIV/AIDS. The blurring between
these distinctions and the omnipresence of CSO groups within sub-Saharan Africa sees a
shift in the types of economies promoted by the state. What has emerged in response to
the large sums of money channelled to HIV/AIDS is an AIDS business, in which
economies of production are shifting to service economies, and the establishment of
CSOs as a means of profit-making activity. Profit in this sense does not refer to
substantial capital gain, but does enable unemployed workers to gain a low salary,
globally-inferred prestige of working in the fight against HIV/AIDS, and in some cases a
company four-wheel drive vehicle. This vision is re-enforced and to a degree sanctioned
by the state in the quantity of money it directs to this service economy.
Conclusion: What does this mean for the state?
This paper has begun to consider the impact the financial commitment and international
involvement of the global HIV/AIDS response is having upon the state in sub-Saharan
Africa. It has done so by examining several aspects of the state and key components of
the HIV/AIDS response – the President, the National AIDS Councils, the Ministry of
Health, and Civil Society Organisations – to see how they are impacting upon state
structures, sovereignty, and boundaries between state and non-state activity, and the
ability of governments to govern. The paper has explored this within the loose concept of
the state as the elected government and state structures as passed in law of each of the
countries examined, and the national bureaucracy, namely civil servants and district
commissioners of local authorities.
In conclusion, the multi-sectoral approach to combating HIV/AIDS led by the World
Bank, adopted by the international community, and articulated as the global response, is
having the following effects on the state in sub-Saharan Africa. First, it is positioning the
role of the President as a ceremonious head of state that publicly promotes the
international agenda on HIV/AIDS, and endorses donor-led state strategies to combat the
epidemic. This will ultimately foster wider discontent within the public and electorate and
undermine the authority and legitimacy of leader in responding to HIV/AIDS and related
health crises, and question the genuine nature of the anti-stigma message they are trying
to promote. Second, state sovereignty has become a loose concept and institutionally
eroded under the rubric of the HIV/AIDS response. The need to prioritise HIV/AIDS as
an emergence and as a development project has given international organisations license
to transcend sovereign boundaries and establish agencies of international organisations
within the state structure. Third, this transcendence of boundaries has been extended to
the community level, with civil society actors becoming intertwined with the service
sector aspect of state provision. As such these actors promote and internalise the
initiatives of international organisations and donors, once more under the justification of
the HIV/AIDS emergency. The scale of CSO inclusion and the nature of their activities
confronts ‘third sphere’ boundaries of the separation between the family, state and civil
society. Of pertinent importance is the global absorption of the policies that enact these
changes to the state.
The impact of the HIV/AIDS response upon changes in government, state structures and
boundaries confronts both how this dynamic is important to understanding the
governance of HIV/AIDS and its implications, and the need to consider the
unprecedented nature of this financial and global political commitment when attempting
to make any theoretical conception of the state in sub-Saharan Africa. HIV/AIDS is only
one aspect of government activity, and thus to talk of reconfiguration may be rash.
However, the epidemic is a hyper snapshot of the interventions of international financial
institutions and the paradox between state ownership and conditionality. The impact and
previous lack of government involvement, gives the international community license to
contravene sovereign boundaries. The need for government leadership is important and
goes without question. However, the current form of state ownership will detrimentally
affect the long term ability of states to combat HIV/AIDS in sub-Saharan Africa, and the
ability of governments to respond to emerging structural issues of poverty and
governance. The relationship between global responses to HIV/AIDS and the state in sub-
Saharan Africa should thus be of concern to scholars of the epidemic and the political
economy of the continent.
Bibliography
AIDS Campaign Team for Africa (ACTAfrica). (2006) Implementing Multi-Country
HIV/AIDS Programs (MAP) in Africa: Report on Africa Region HIV/AIDS Consultation
in Civil Society Responses in MAP Projects, Washington DC: World Bank
Ankrah, E. Maxine. 1991. ‘AIDS and the social state of health’ Social Science and
Medicine 32(9): 967-980
Austen, Anne. 18th November 2005. Futures Group – Kenya
Bahati, Ursula. (Interview). 14th November 2005. National AIDS Control Council -
Kenya
Barnett, Tony .2007. ‘HIV/AIDS, a long Wave Event: Sundering the
Intergenerational Bond’ in Nana K. Poku, Alan Whiteside, Bjorg Sandkjaer AIDS and
Governance Hampshire: Ashgate 29-48
Barnett, T. and Whiteside, A. (2002) AIDS in the twenty-first Century: Disease and
Globalization London: Palgrave.
Brown, JC., Ayvaliki, D. and Mohammad, N. (2004) Turning Bureaucrats into Warriors:
Preparing and Implementing Multi-Sector HIV/AIDS in Africa, A General Operations
Manual. Washington, DC: The World Bank
Byenka, Julius. (Interview). 11th October 2005. Uganda HIV/AIDS Commission –
Uganda
Caldwell, John C. 2000. ‘Rethinking the African AIDS epidemic’ Population and
Development Review 26(1): 117-136
Caldwell, John C., Orubuloye, IO., and Caldwell, Pat. 1992. ‘Under-reaction to AIDS in
sub-Saharan Africa’ Social Science and Medicine 34(11): 1169-1182
Chale, Stella. (Interview). 10th January 2006. NACP – Tanzania
Cheru, Fantu. 2002. ‘Debt, adjustment and the politics of effective response to HIV/AIDS
in Africa’ Third World Quarterly 23(2): 299-312
Chirambo, Kondwani. 2007. ‘AIDS and Democracy in Africa’ in Nana K. Poku, Alan
Whiteside, Bjorg Sandkjaer AIDS and Governance Hampshire: Ashgate 67-92
Cunningham, Amy. (Interview). 25th October 2005. USAID – Uganda
deRegt, Jacomina. (Interview). 20th April 2006. World Bank – Washington DC, USA
deWaal, Alex. 2003. ‘How will HIV/AIDS transform African governance?’ African
Affairs 102(406): 1-23
Duolf, Bob. (Interview). 4th January 2006. Care International - Tanzania
Garrison, John. (Interview). 27th April 2006. World Bank – Washington DC, USA
Gavyole, Awene. (Interview). 13th February 2006. WHO - Tanzania
Harman, Sophie. 2007. ‘The World Bank: Failing the Multi-Country AIDS Program,
Failing HIV/AIDS’ Global Governance 13(4): 485 - 492
Harrison, Graham. 2002. Issues in the contemporary politics of sub-Saharan Africa: The
dynamics of struggle and resistance Basingstoke: Palgrave MacMillan
Harrison, Graham. 2004. ‘HIPC and the Architecture of Governance’ Review of African
Political Economy 31(99): 125-164
Harrison, Graham. 2004. The World Bank and Africa: the construction of governance
states London: Routledge
Hervey, Duncan. 27th January 2006. Save the Children - Zanzibar
Kalimire, Vincent. (Interview). 17th October 2005. Foundation for African Development
– Uganda
Kalinga, Hashim. (Interview). 14th February 2006. TACAIDS – Tanzania
Kalioli, Dorothy. (Interview). 4th January 2006. Dogodogo Centre - Tanzania
Kameta, Dorcus. (Interview). 11th November 2005. NASCOP – Kenya
Kariuki, Carole. (Interview). 16th December 2005. Kenya Private Sector Alliance - Kenya
Kataka, Hanningtone. (Interview). 23rd November 2005. KUSCCO – Kenya
Kibamba, Deus. (Interview). 20th January 2006. TGNP - Tanzania
Kinzett, Steve. (Interview). 23rd November 2005. JSI - Kenya
Lagerstedt, Adam. (Interview). 16th November 2005. World Bank – Kenya
Lekule, Morris. (Interview). 4th January 2006. TACAIDS – Tanzania
Lenya, Rowlands. (Interview). 10th November 2005. TAPWAK – Kenya
Malangalila, Emmanuel. (Interview). 20th January 2006. World Bank – Tanzania
Margery, Alex Pius. (Interview). 6th January 2006. TANEPHA - Tanzania
Mohammed, Nadeem. (Interview). 24th April 2006. World Bank – Washington DC, USA
Mubondo, Barabona. (Interview). 20th January 2006. WAMATA – Tanzania
Mugumya, Herbert. (Interview). 1st November 2005. Save the Children – Uganda
Mukama, Robert. (Interview). 8th February 2006. RFA Iringa and Ruvuma – Tanzania
Mulimila, Victor. (Interview). 17th January 2006. Faraja Trust Fund – Tanzania
Mwaduma, Nicodemus B. (Interview). 6th January 2006. RFA Lindi and Mtwara -
Tanzania
Mwai, Eve. (Interview). 29th November 2005. St John’s Ambulance – Kenya
Nyantahe, Samuel. (Interview). 9th January 2006. Utegi Technical Enterprises – RFA Dar
es Salaam, Mara, Shinyanga - Tanzania
Okafor, Chudi. (Interview). 27th April 2006. World Bank – Washington DC, USA
Okwero, Peter. (Interview). 1st November 2005. World Bank – Uganda
Ogen, Patrick. (Interview). 19th October 2005. Youth Alive – Uganda
Peet, Richard. 2003. Unholy Trinity: The IMF, World Bank and WTO London: Zed
Books
Poku, Nana K. 2001. ‘Africa’s AIDS Crisis in Context: ‘how the poor are dying’’ Third
World Quarterly 22(2):191-204
Poku, Nana K. 2002. ‘Poverty, debt, and Africa’s HIV/AIDS crisis’ International Affairs
78(3): 531-546
Poku, Nana K. and Sandkjaer, Bjorg. 2007. ‘HIV/AIDS and the African State’ in Nana K.
Poku, Alan Whiteside, Bjorg Sandkjaer AIDS and Governance Hampshire: Ashgate 1-28
Quiery, Aisling. (Interview). 21st December 2005. Merlin – Uganda
Ruranga, Rubaramira. (Interview). 31st October 2005. NGEN+ - Uganda
Saadat, Idi. (Interview). 31st January 2006. Zanzibar HIV/AIDS Commission - Zanzibar
Scholte, Jan Aart. 1998. ‘IMF meets civil society’ Finance and Development 35(3):
42-45
Scholte, Jan Aart 2000. ‘Global Civil Society’ in Ngaire Woods (ed.) The Political
Economy of Globalisation 173-202. London: MacMillan
Scholte, Jan Aart 2000b. ‘Civil society and governance in the global polity’ in Morten
Ougaard and Richard Higgott (eds) Towards a Global Polity London: Routledge 146-159
(check pages)
Scholte, Jan Aart 2002a. ‘Civil Society and democracy in global governance’ Global
Governance 8(3): 281-304
Scholte, Jan Aart. 2002b. ‘Civil society and the governance of global finance’ in Jan Aart
Scholte and Albrecht Schnabel (eds) Civil Society and Global Finance London:
Routledge 11 – 32
Scholte, Jan Aart 2004. ‘Civil society and democratically accountable global governance’
Government and Opposition 39(2): 211-233
Scholte, Jan Aart. 2005. Globalization: A Critical Introduction (2nd Edition) London:
Palgrave MacMillan
Scholte, Jan Aart, O’Brien, Robert and Williams, Marc 1999. ‘The WTO and civil
society’ Journal of World Trade 33(1): 107-123
Southern, Nick. (Interview). 9th January 2006. Care International – Tanzania
Simbaya, Kenneth. (Interview). 7th February 2006. SPW – Tanzania
Tayyab, Yasmin. 24th April 2006. World Bank – Washington DC, USA
Temba, Joseph. (Interview). 10th February 2006. TACAIDS – Tanzania
Tembele, Rustica. (Interview). 6th January 2006. TACAIDS - Tanzania
UNAIDS Three Ones’ Key Principles – ‘Coordination of National responses to
HIV/AIDS’ Guiding principles for national authorities and their partners (Geneva:
UNAIDS, 2004).
Voetberg, Albertus. (Interview). 7th April 2005. World Bank – Kenya
Voetberg, Albertus. (Interview). 15th November 2005. World Bank - Kenya
Whiteside, Alan. 2002. ‘Poverty and HIV/AIDS in Africa’ Third World Quarterly 23(2):
313-332
World Bank, “The Multi-Country AIDS Program” accessed March 2007, available at
www.worldbank.org/aids
Zewdie, Debrework. (Interview). 3rd May 2006. World Bank – Washington DC, USA