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Institutions and Identities:Institutions and Identities:Explaining Government Responses to Explaining Government Responses to HIV/AIDS in Brazil and South AfricaHIV/AIDS in Brazil and South Africa
Varun GauriVarun Gauri
DECRGDECRG
Evan LiebermanEvan Lieberman
Princeton UniversityPrinceton University
Motivation for Research on HIV/AIDSMotivation for Research on HIV/AIDS
Total: 34 – 46 million>90 percent in developing countries
2.5-3.5 million died in 2003 alone
Western Europe520 000 – 680 000
North Africa & Middle East
470 000 – 730 000
Sub-Saharan Africa25.0 – 28.2 million
Eastern Europe & Central Asia1.2 – 1.8 million
South & South-East Asia
4.6 – 8.2 million
Australia & New Zealand
12 000 – 18 000
North America790 000 – 1.2 million
Caribbean350 000 – 590 000
Latin America1.3 – 1.9 million
East Asia & Pacific700 000 – 1.3 million
Adults and children estimated to be living with HIV/AIDS as of end 2003Adults and children estimated to be living with HIV/AIDS as of end 2003
Source: UNAIDS (2003)
33
Life expectancy in Life expectancy in Brazil and South AfricaBrazil and South Africa
68.6
66.2
54.8
46.5
62.9
49.2
30
35
40
45
50
55
60
65
70
75
19
60
19
63
19
66
19
69
19
72
19
75
19
78
19
81
19
84
19
87
19
90
19
93
19
96
19
99
20
02
Brazil
SouthAfrica
Source: World Bank, World Development Indicators (2004)*Adult HIV Prevalence estimates, UNAIDS epidemiological factsheets (2004)
(HIV+ : 0.7%)*
(HIV+ : 21.5%)*
44
Theoretical relevance for political Theoretical relevance for political economy of developmenteconomy of development
Politics of development (Sen, Przeworski Politics of development (Sen, Przeworski et. al., Haggard & Kaufman)et. al., Haggard & Kaufman)Origins of state capacity (Tilly, Levi, Origins of state capacity (Tilly, Levi, Migdal, Evans)Migdal, Evans)Politics of public policy making, especially Politics of public policy making, especially social policy (Steinmo and Thelen, Bates social policy (Steinmo and Thelen, Bates & Krueger, Van de Walle, Grindle)& Krueger, Van de Walle, Grindle)Very limited published political science Very limited published political science research on HIV/AIDSresearch on HIV/AIDS
55
The PuzzleThe Puzzle: : Might have expected similar Might have expected similar
government responses…government responses…
Life-threatening pandemic has touched virtually every corner of the Life-threatening pandemic has touched virtually every corner of the globeglobeNarrow time frame (1982-present)Narrow time frame (1982-present)General agreement about scientific and policy best practice General agreement about scientific and policy best practice (“Geneva Consensus”)(“Geneva Consensus”)Wide dissemination of informationWide dissemination of information
… … But we observe wide variation.But we observe wide variation.
66
AIDS Response RegimeAIDS Response Regime
Total national government effort to curb Total national government effort to curb the AIDS epidemicthe AIDS epidemic
As distinct from NGO, sub-national As distinct from NGO, sub-national government, international responsesgovernment, international responses
Aggressiveness (speed, scope)Aggressiveness (speed, scope)– Bureaucratic developmentBureaucratic development– Prevention policies, as implementedPrevention policies, as implemented– Treatment of PLWHA, as implementedTreatment of PLWHA, as implemented
77
Case Selection Strategy:Case Selection Strategy:Brazil and South AfricaBrazil and South Africa
Author familiarityAuthor familiarityControl for level of developmentControl for level of developmentControl forControl for similar epidemic onset similar epidemic onset– Somewhat earlier in Brazil (1982 vs 1985)Somewhat earlier in Brazil (1982 vs 1985)– Initially prevalent among gay men in urban centersInitially prevalent among gay men in urban centers– But fear of major generalized epidemic in both But fear of major generalized epidemic in both
countries by 1991countries by 1991
Initially select cases with high variation on the Initially select cases with high variation on the dependent variable (expenditure and reputation)dependent variable (expenditure and reputation)
88
Expenditures on HIV/AIDSExpenditures on HIV/AIDS
National Program Expenditures on HIV/AIDS
0102030405060708090
100
1987
1989
1991
1993
1995
1997
1999
2001
Mil
lio
ns
of
US
Do
llar
s, 2
002
South Africa
Brazil
99
Expenditures on ARVsExpenditures on ARVs
Expenditures on ARVs
050
100150200250300350400
1997
1998
1999
2000
2001
2002
2003
2004
Year
US
Do
llar
s, m
illi
on
s
Brazil
South Africa
1010
Table 1: Aggressiveness of Government Responses to HIV/AIDS (1982-2004) South Africa Brazil Policy Areas Much more
aggressive More
aggressive
About same
More aggressive
Much more aggressive
Bureaucratic Development Timing and authority of national program
X
Level of historical expenditures
X
Scope and timing of research and surveillance
X
Scope of NGO partnerships
X
Prevention Timing of blood safety
X
Scope of testing
X
Scope of condom distribution and use
X
Timing of programs to prevent mother to child transmission
X
Timing and scope of programs targeted at local risk groups
X
Treatment of PLHAs Timing of monotherapy
X
Timing and scope of triple therapy
X
Scope of laboratory system
X
Timing and scope of human rights legislation
X
Overall: Bureaucratic Development
X
Overall: Prevention X Overall: Treatment of PLHAs X
1111
Model of AIDS Policy Making:Model of AIDS Policy Making:Preliminary Assertions (Constants)Preliminary Assertions (Constants)
Inherently undesirable agenda item for national government leaders/ Inherently undesirable agenda item for national government leaders/ policy makerspolicy makers– Internal and external stigmaInternal and external stigma– Sex, sexuality, drug useSex, sexuality, drug use– ““Silent” epidemicSilent” epidemic– Implies asking citizens to do things they would rather not doImplies asking citizens to do things they would rather not do
Policy response increasingly aggressive when political influence of Policy response increasingly aggressive when political influence of proponents supersedes that of policy opponentsproponents supersedes that of policy opponents– ProponentsProponents: International organizations; HIV+ individuals; health care : International organizations; HIV+ individuals; health care
professionals; activists/NGO’sprofessionals; activists/NGO’s– OpponentsOpponents: Competing interests; moral conservatives: Competing interests; moral conservatives
Political arena mediates influence of such groups such that Political arena mediates influence of such groups such that resources or extent of problem provide limited predictive powerresources or extent of problem provide limited predictive power
1212
Explaining cross-country variation:Explaining cross-country variation:I) Political institutionsI) Political institutions
Decentralization of decision-making autonomy provides Decentralization of decision-making autonomy provides policy “surface area” for policy entrepreneurs in low policy “surface area” for policy entrepreneurs in low priority policy areapriority policy area
Early sub-national adoption highlights threat, provides Early sub-national adoption highlights threat, provides template for action, leading to template for action, leading to faster faster response at national response at national levellevel
Minimum of centralized state capacity necessary, but Minimum of centralized state capacity necessary, but contra Nathanson, increasingly centralized state does contra Nathanson, increasingly centralized state does not always lead to faster, more expansive responsenot always lead to faster, more expansive response
1313
Comparing political institutionsComparing political institutions
Brazil:Brazil:
Decentralized/ High Decentralized/ High Policy AutonomyPolicy Autonomy
South Africa:South Africa:
Centralized/ Low Policy Centralized/ Low Policy AutonomyAutonomy
Federal constitutionFederal constitution
(federal tradition)(federal tradition)
YesYes
(Strong/long)(Strong/long)
YesYes
(Weak/new)(Weak/new)
Taxation powers of Taxation powers of sub-national sub-national governmentsgovernments
ExtensiveExtensive MinimalMinimal
Election of provincial Election of provincial (estado) (estado) leadersleaders
DirectDirect Indirect (ultimately, Indirect (ultimately, choice of party leaders)choice of party leaders)
Party systemParty system Fragmented; no majority Fragmented; no majority party; regional power party; regional power basesbases
Single-party dominant: Single-party dominant: ANC controls 66% of ANC controls 66% of parliament; 7/9 provincesparliament; 7/9 provinces
1414
The impact of institutions on AIDS The impact of institutions on AIDS politics and policypolitics and policy
Decentralized Brazilian institutions facilitate rapid Decentralized Brazilian institutions facilitate rapid responseresponse– Federal government initially resisted responseFederal government initially resisted response– Early and aggressive Early and aggressive EstadoEstado and and municipo municipo responses in responses in
Southeast: testing, education, ARV, treatment, counselingSoutheast: testing, education, ARV, treatment, counseling– Central government Central government follows, follows, facing mounting pressurefacing mounting pressure
Centralized South African institutions inhibit true Centralized South African institutions inhibit true policy autonomy, stifling actionpolicy autonomy, stifling action– Entrepreneurial municipalities and provinces are branded renegades Entrepreneurial municipalities and provinces are branded renegades
(e.g. Global Fund debacle w/ KwaZulu-Natal)(e.g. Global Fund debacle w/ KwaZulu-Natal)– ANC rank and file dares not challenge NEC (e.g. Durban municipality on ANC rank and file dares not challenge NEC (e.g. Durban municipality on
Nevirapine for MTCT)Nevirapine for MTCT)
1515
Hypothesized impact of institutionsHypothesized impact of institutions
Centralization/concentration of political authority
NoHigh
Predicted speed of AIDS policy response by central government(ceteris paribus)
Slow/none
RapidBrazil
So. Africa
Consolidated state?Local policy autonomy
YesHigh
YesMedium
YesLow
YesNone
1616
Explaining cross-country variation:Explaining cross-country variation: II) National Political communityII) National Political community
National Political Community= state-sponsored definition of nationNational Political Community= state-sponsored definition of nation– Strength of NPC rooted in sum of attachments to and tolerance Strength of NPC rooted in sum of attachments to and tolerance
towards fellow citizenstowards fellow citizens– Negatively related to group-based intolerance of citizensNegatively related to group-based intolerance of citizens
Government AIDS response depends on domestic political support, Government AIDS response depends on domestic political support, which hinges on perceived risk of infectionwhich hinges on perceived risk of infectionPerceived risk= f (“actual” risk; information, interpretation)Perceived risk= f (“actual” risk; information, interpretation)In weak NPCs/divided societies, politically salient divides create In weak NPCs/divided societies, politically salient divides create space for mis-information, discounting of threat:space for mis-information, discounting of threat:– Risk of infection depends on Risk of infection depends on intimateintimate contact with HIV+ individuals contact with HIV+ individuals– In divided societies, such contact is presumed to be In divided societies, such contact is presumed to be within within groupsgroups– Risk assigned to “them” Risk assigned to “them” – Risk discounted as conspiracy by “them”Risk discounted as conspiracy by “them”– Marginalized group leaders distance group from disease [Cohen 1998]Marginalized group leaders distance group from disease [Cohen 1998]– Result: less overall demand from society, and lowered perceived threat Result: less overall demand from society, and lowered perceived threat
from government (and vice versa)from government (and vice versa)
1717
Measuring National Political CommunityMeasuring National Political CommunityWorld Values Survey (1980, 90, 95-7 waves): World Values Survey (1980, 90, 95-7 waves):
Who would you Who would you not not like to have as a neighbor?like to have as a neighbor? Percent mentioning “Someone of a different race”Percent mentioning “Someone of a different race”
0
5
10
15
20
25
30
Brazil 1990 Brazil 1995-7 South Africa1981
South Africa1995-7
NB: Higher values indicate weaker National Political Community
1818
Measuring National Political CommunityMeasuring National Political CommunityWorld Values Survey (1995-7): World Values Survey (1995-7):
Who would you Who would you not not like to have as a neighbor?like to have as a neighbor? Percent mentioning “homosexuals”Percent mentioning “homosexuals”
49
16
0
10
20
30
40
50
60
Brazilians South Africans
NB: Higher values indicate weaker National Political Community
1919
Self-reported inter-racial marriageSelf-reported inter-racial marriage
0%
5%
10%
15%
20%
25%
Brazil South Africa
Source: Telles 1994, analysis of Brazil 1991, South Africa 1996 census dataNB: Higher values indicate stronger National Political Community
2020
The Impact of NPC on AIDS The Impact of NPC on AIDS Politics, PolicyPolitics, Policy
South AfricaSouth Africa– All HIV/AIDS statistics, even blood, reported along racial linesAll HIV/AIDS statistics, even blood, reported along racial lines– Racial discourseRacial discourse
Blacks: White, gay disease; plot (AIDS =“Blacks: White, gay disease; plot (AIDS =“AAfrikaner frikaner IInvention to nvention to DDeprive us of eprive us of SSex”)ex”)Whites: Black/ African disease; terroristsWhites: Black/ African disease; terrorists
– Civil society disunity: TAC/NAPWA race conflictCivil society disunity: TAC/NAPWA race conflict– Result: Only 13% of South Africans said AIDS should be priority for Result: Only 13% of South Africans said AIDS should be priority for
government (2002)government (2002)
BrazilBrazil– Virtually no race-based HIV/AIDS statistics reportedVirtually no race-based HIV/AIDS statistics reported– Almost no discussion of race in context of HIV/AIDSAlmost no discussion of race in context of HIV/AIDS– Promotion of Promotion of solidarisolidariéédade dade strategy (“Whitening” public health legacy)strategy (“Whitening” public health legacy)– Possible for gay groups to organize, demand actionPossible for gay groups to organize, demand action– Result: wide popular support for and pride in AIDS Result: wide popular support for and pride in AIDS respostaresposta
2121
Hypothesized impact of National Hypothesized impact of National Political CommunityPolitical Community
Tolerance for other groups in NPC/Mixing
Low/divided society High
Predicted aggressiveness of AIDS policy response by central government(ceteris paribus)
Low/none
High
Brazil
So. Africa
2222
Rival hypotheses: Weak/no evidenceRival hypotheses: Weak/no evidence
Political regime type/ civil society (Sen)Political regime type/ civil society (Sen)International linkages/influenceInternational linkages/influenceState capacity, especially in healthState capacity, especially in healthExecutive leadership (‘the Mbeki hypothesis’)Executive leadership (‘the Mbeki hypothesis’)– Tautology? Cannot measure leadership in terms of Tautology? Cannot measure leadership in terms of
action on AIDSaction on AIDS– By any standard, better general “leadership” in South By any standard, better general “leadership” in South
Africa as compared with BrazilAfrica as compared with Brazil– Wouldn’t have had similar effect in more Wouldn’t have had similar effect in more
decentralized polity (e.g., Brazil)decentralized polity (e.g., Brazil)