Recipient States in Global Health Politics

PEPFAR in Africa

Ricardo Pereira

• Publisher: Palgrave Macmillan
• Year: 2014
• ISBN:
  9781137442970
• Topic: Política y relaciones internacionales
• Subtopic: Política africana

Even if constrained in their international choices, recipient countries of global health programmes hold the capacity to autonomously define and pursue their own strategies, policies, and ultimately attain political goals. This is comparatively demonstrated through the analysis of PEPFAR's implementation in Botswana, Ethiopia and South Africa.

1

Introduction: Agency in Global Health

Introduction

Traditionally, states – and the conflicts that have been associated with them in terms of military, economic and ideological expansion – have been the major topic of study in the discipline, as the classical literature by Edward H. Carr (1939), Hans Morgenthau (1948) or Kenneth Waltz (1979) shows. However, the emergence of research agendas diverging from a strict focus on the state have started to gain currency since the 1990s to the point where they are now challenging the relevance of the state as a major factor in international affairs.

Arguably this is a consequence of the rise of the human security policy paradigm with the publication of the first United Nations Human Development Report (1994). Defined as ‘freedom from need’ and ‘freedom from want’ it points to a whole range of phenomena that pose direct and indirect threats to the integrity of the individual and populations, such as hunger, disease, social disruption and violence. Born within the United Nations system it gradually spilt onto the foreign policy agendas of a number of governments in the late 1990s, particularly in Western Europe and so-called ‘Middle Powers’, as Canada or Japan (Behringer, 2005; Debiel and Werthes, 2006).

This policy shift took place parallel to socio-economic developments associated with the demise of the Soviet Union, the concomitant end of the Cold War bipolar confrontation and perceived hegemony of the United States of America. As a process of integration of markets, territories and populations at a worldwide scale, globalisation was exacerbated from the 1980s onwards thanks to increasingly sophisticated means of communication and information. The relevance of non-state actors in that process, namely private companies and nongovernmental organisations (NGOs), conglomerated around an idea of ‘retreat of the state’ and supremacy of ‘social and economic forces’ in terms of core objects of study. At the same time, ideological structures and forces such as liberalism and neoliberalism became increasingly at the heart of analysis rather than individual states (Cox, 1981). Certainly, states remained very important actors, yet not as sovereign policy-making entities as they used to be (Jessop, 2003). In a context of expanding mechanisms of social, political and economic organisation based on public-private partnerships, states are rendered the role of facilitators and mediators of an assemblage of public and private actors (Jessop, 2003).

As a result, the focus on human security, globalisation and social forces has resulted on the growing primacy of populations over states in terms of major actors of analysis. Eminently, population-related topics such as international development, migrations, epidemics, or human rights, became absolutely central in the day-to-day policy and analysis of international affairs. This character of the post-Cold War international world is exemplified by the realm of global health, in which this book’s analysis is situated. Global health constitutes the space where manifold actors (states, international organisations, nongovernmental organisations, private companies, populations) and phenomena (for example, epidemics) interact according to their different conflicting agendas, which nevertheless are subject to no central government. Often the powerful actors correspond to funders of global health initiatives of different sorts, whereas the weak are generally the recipient of such initiatives. Still, the idea of population – its needs, duties and rights – lies at the core of global health debates, often hindering the issue of interstate asymmetry.

Prominence of populations is visible in the recent readings, mostly by critical authors across the social sciences, of the practice of development or human rights based on the frameworks of biopower and biopolitics (Foucault, 1978; 1984), which reflect precisely on the issue of the population, and the management that it is subjected by global social forces (Douzinas, 2007; Duffield, 2007; Jabri, 2007). These social forces have macro and micro dimensions that, altogether, demonstrate a transfused sovereign power among diverse units, as several works in anthropology have been suggesting in the area of development, health and HIV/AIDS (Escobar, 1984/1985; Ferguson, 1994; Nguyen, 2010). Sovereignty is not solely characteristic of state institutions, but of different actors, whose power ‘to give life or impede it to the point of death’ (Foucault, 1984) is absolutely crucial.

Some critical scholars of postcolonial theory inspiration (Richmond, 2010; Ginty, 2010; De Goede, 2010) have researched agency inside states, at the population level, as expressions of local resistance against a hegemonic liberal structure. Smaller, weaker states appear as plain facilitators of the hegemonic structure of major states and other institutions. Alternatively, those smaller, weaker states are rendered the category of ‘rogue,’ ‘failed’ and other assertions. Nevertheless, one finds this assertion troublesome, since it often suggests that states, including so-called ‘weak states’, typically from the developing world, are already embedded in that hegemonic structure. In fact, this book argues that, despite being highly constrained by the external structure, states are characterised by agency when behaving with other states, including smaller, weaker states when dealing with stronger ones. Even in a context of international asymmetry, states retain their ability to take decisions of their own and pursue strategies and policies autonomously, with a view to the accomplishment of national interests. As it is shown throughout the book, they are not necessarily ‘hijacked’ (Richmond, 2010) by the structural hegemonic powers in terms of policies and practices.

In fact, such reading of the post-Cold War liberal order is found wanting for the fact that it does not allow for a perspective of human agency in it (Chandler, 2009a). In this book, human agency is formulated in terms of a deliberative power of states as political communities, no matter how complex they might be domestically, to institute its own policy vis-à-vis the constraints that affect their action. Eventually, this invites a reassessment of current population-centred approaches and shifts analytical focus back to states, particularly states more prone to subordination to the international powers. For the purpose of this book, this comprises recipient states of global health programmes and their ability to exert their agency when dealing with their donors. To an extent, this implies revisiting some traditional tenets of international politics on interstate behaviour and how they respond to the problem of absence of agency.

Method and framework of analysis

This book aims at demonstrating that recipient countries hold the capacity to autonomously define and purse their own strategies and policies, and ultimately attain political goals, even if highly constrained in their choices internationally. However, so this objective can be meaningful and to some extent successful, it requires a method of analysis that takes those smaller states as normal states in international relations. This means engaging seriously with the prolific, powerful literature enumerated above, but also to propose another analytical framework. This is one that combines some key tenets of International Relations theory, particularly the neorealist theory of Kenneth Waltz, yet with concern for both internal and external spheres of the states involved and social forces that affect them as well.

Concepts of agency and structure in International Relations were originally theorised by Kenneth Waltz (1979) in Theory of International Relations. States are the units in the international structure, and they hold agency when acting with other units. In that regard, they are sovereign; however, no matter how powerful the state, such sovereignty is constrained by the structure. Later authors in the same theoretical tradition as Waltz, that is, structural neorealism (Keohane, 1984; Mearsheimer, 2001), as well as in other traditions (Bickerton, 2007), have argued that from the 1980s onwards the structure has become the hegemony of the United States of America, allies in Western Europe, and Japan. However, just like there is no absolute sovereignty, there is no absolute hegemony either. This means that a country, no matter how weak it can be in economic and military terms, still enjoys a degree of agency, especially when behaving with powerful states. However, this understanding of agency needs to bear in mind the context of asymmetry between powerful, hegemonic states and weaker states. One needs to recognise weaker states’ ‘subalternity’ (Ayoob, 2002). This asymmetry is primarily understood in function of the disparities of wealth and human development between regions, but also the origin of influential epistemologies and policies consubstantiating the actual relationship. In the particular case of postcolonial sub-Saharan African states in this book, the question of context is very crucial.

Moreover, one ought to connect both external and internal dimensions of states in order to understand their behaviour with powerful states, reversing the neorealist postulate that both spheres should remain detached (Rosenberg, 1990; 1994). States’ actions need to be informed by their historical and sociological experience. Furthermore, despite their specificities associated with the European colonial project, states in sub-Saharan Africa are certainly part of the international system, and should be subject of analysis in the discipline like states anywhere else (Brown, 2006).

Therefore, weaker, smaller states act as normal states, that is, as units in the international system featured with agency, in which their behaviour in theory is not any different when compared to stronger states in the same system. In practice, even if subject to a large degree of subordination to strong states’ policies, they are capable to autonomously identify their own policy issues, strategise against them and ultimately pursue political goals. In other words, they act in terms one could qualify as rational.

Case study

The book’s argument is explored in the realm of international development relations, specifically global health programmes, featured by intense donor-recipient exchange. Among the plethora of global health initiatives, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) stands out quite strongly. For one, it is an initiative which has enjoyed large-scale political and financial attention – arguably the largest bilateral programme aimed at a single disease ever. Furthermore, it has been driven by significant high-level political dialogue between the United States (US) administration and representatives in countries hosting projects, beyond plain HIV/AIDS relations. Indeed, PEPFAR is the product of different interrelated security and humanitarian concerns that emerged among the William ‘Bill’ Clinton administration (1993–2001), crystallised around the political elite led by George W. Bush (2001–2009) and continued under the current Barack Obama presidency (since 2009). It constitutes a striking example of United States foreign policy in the area of global health and development and diplomacy, in which asymmetric relations between the United States of America and countries under implementation stand out. Moreover, given its all-encompassing character in terms of types and quantity of organisations involved and sectors of activity approached, PEPFAR holds a cross-cutting impact on recipient countries’ external, internal and local dimensions of governance.

Launched in 2003, PEPFAR was inserted in the context of the United States’ ‘War on Terror’, and more broadly within the emerging nexus linking epidemics to security that came to the fore through several intelligence and think tank reports (National Intelligence Council, 2000; Gordon, 2002; Schneider and Moodie, 2002). The fear of an expanding global jihad exploiting social vulnerabilities provoked by AIDS in the worst-affected territories of Muslim majority or of Muslim ‘large minorities’, such as Nigeria, South Africa and Ethiopia, constitutes a serious motivation for action and scaling up the response (Lyman and Morrison, 2006). Yet, linkages to security precede, not only 11 September 2001 terrorist attacks, but also the very Bush administration (Pereira, 2009).

Nevertheless, preventing global jihads and local instability through HIV/AIDS implementation does not represent, as such, the sole justification for PEPFAR, which has allocated for its first phase (2004–2008) close to 15 billion US dollars. Other reasons were important too. First, there were domestic dynamics, that is, arguably the need faced by the Bush administration to respond to its pressuring Christian conservative constituency (the so-called Christian Right) vastly engaged in HIV/AIDS politics and broadly in development in the Third World (Dietrich, 2007). Second, in the latest period of his mandate, President Bush has arguably ‘necessitated’ to deposit a positive policy-making legacy vis-à-vis very low popularity levels at home and abroad (Feffer, 2008). Nevertheless, as United States Global AIDS Coordinator between 2006 and 2009, Mark Dybul (2009) aptly highlighted during the 2009 presidency’s transitional period, the United States’ reputation was very high across PEPFAR’s focus countries and should be maintained.

Finally, philanthropy – often expressed as ‘compassion’ – has guided both fund allocation and implementation by a wide range of nongovernmental organisations across the 15 focus countries and a number of others where the United States Agency for International Development (USAID) carries out activities in the field too. Various respondents with United States government implementing agencies have emphasised this aspect.

PEPFAR constitutes the largest financial bilateral initiative to fight a single disease ever. Building on the experience of the Ryan White Comprehensive AIDS Resources Emergency Act of 1990, whose scope was the growing AIDS epidemic in the United States (Bowen et al., 1992), PEPFAR was established by the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003. Five years later, it was continued by the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, and currently functions under the framework of the PEPFAR Stewardship and Oversight Act of 2013. PEPFAR is managed by the Office of the United States Global AIDS Coordinator and gathers several implementing US government agencies: USAID, Peace Corps, and Departments of State, Defence, Trade, Labour, and Health and Human Resources.

Channelled through United States government agencies (primarily USAID) and diplomatic missions, PEPFAR has virtually reached the vast majority of countries where USAID is present. However, in the beginning, it focused on 15 countries which accounted for half of the global number of infections by HIV, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS), most of them in Southern and Eastern Africa.¹ Irrespective of the particularities associated with the individual countries, all were generally presented by Dybul (2009) as the ‘future’ of United States-led global order.

According to the Government Accountability Office (GAO) (2008: 10), budgetary allocations for the 2004–2008 five-year period had mostly been oriented towards antiretroviral (ARV)-based treatment (55 per cent), the rest being dedicated to palliative care (15 per cent), prevention (20 per cent) and orphans and vulnerable children (10 per cent). For most of its first phase, PEPFAR treatment funding, rather than contracting preferably less expensive, generic ARVs (and thus expanding scale-up efforts), was oriented for the purchase of US ‘Big Pharma’ branded ARVs, comparatively more expensive (Thompson, 2007). As such, PEPFAR worked as a governmental protectionist scheme for US pharmaceutical companies to enter African markets, despite the reported inclusion over time of generic drugs in PEPFAR-funded programmes.

It is important to underscore that, as a public-private partnership, host countries’ institutions are equally very relevant. As any annual report to the United States Congress demonstrates, ‘partnership’ has been a buzzword in the process of PEPFAR (2011a). PEPFAR policy documents have always been very keen in terms of ‘horizontalising’ relations, showing that, in these difficult times of AIDS, the United States government and proud NGOs stand together with the world’s least advantaged populations. Illustratively, photographs line side by side President Bush or a United States ambassador with their counterparts or ‘civil society members’, especially children and young people. In turn, the flag of the United States of America stands side by side with the host country’s flag. However, despite this rhetoric of horizontal relations, it becomes clear that the United States government maintains the material hegemony over the partnership, the host governments, and nongovernmental organisations, remaining the weakest link in it.

Over the years, PEPFAR has advanced different models of partnership. However, the year 2009 witnessed the consolidation of a concept of partnership that has featured relations between the United States global AIDS coordination and its numerous stakeholders around the world. ‘Partnership compact’ gives meaning to the proposals of partnership that have been offered ever since to governments of affected countries. After several years under emergency mode, the 2009 annual report to the United States Congress launches the concept of ‘partnership compact’:

To build on the success the American people’s partnerships have achieved to date and reflect the paradigm shift to an ethic of mutual partnership, the USG [United States Government] is working with host countries to develop Partnership Compacts: agreements that engage governments, civil society, and the private sector to address the issues of HIV/AIDS. The goal of Compacts is to advance the progress and leadership of host nations in the fight against HIV/AIDS, with a view toward enhancing country ownership of their programs. ... PEPFAR will continue to be part of this new era of development that champions friendship and respect, mutual understanding and accountability – and trusts in the people on the ground to do the work. (PEPFAR, 2009a: 58)

This piece is historically decisive as it marks transition towards PEPFAR’s second phase (2009–2013) and launches five-year, co-joint, strategic partnership frameworks between the Unites States Global AIDS Office and its programmes’ host countries. Such frameworks are to fulfil principles of country ownership, flexibility, transparency, accountability, and the active participation of other key partners from civil society, the private sector, other bilateral and multilateral partners, and international organisations, and should support and strengthen national HIV/AIDS strategies. This includes support to the Global Fund to Fight AIDS, Malaria and Tuberculosis and UNAIDS. Yet, PEPFAR is also articulated with the African Growth and Opportunity Act of 2000. According to its 2008 report, such trade-related initiative ‘has helped African firms become more competitive internationally, thereby bolstering sub-Saharan African economic growth and helping to alleviate poverty in one of the poorest regions of the world’ (Office of the United States Trade Representative, 2008: 7). In this regard, PEPFAR is made part of a larger effort of reducing poverty and enhancing economic chances for Africans,...

Table of contents

• Cover
• Title
• 1  Introduction: Agency in Global Health
• 2  Global Health Governance and Role of States
• 3  Recipient States in an Asymmetric System
• 4  International Developments of States in Africa
• 5  PEPFAR: Project of Global Transformation
• 6  Botswana: National Survival against HIV/AIDS
• 7  Ethiopia: Self-Help with External Support
• 8  South Africa: Changing HIV/AIDS Policies
• 9  Conclusion: Recipient States Being Sovereign
• Notes
• References
• Index