At a time when the AIDS pandemic has finally drawn the attention of – and is increasingly being defined by – the international community, the South African government has sought to develop a uniquely African response. Indeed, the persistence of patterns of African dependence on the West has been a key issue that has shaped the government's response to AIDS. While many of its neighbours have seen their health budgets dwarfed by foreign aid and their health policies in large measure determined by donor organizations, South Africa has sought to negotiate the tricky interface between self-help and dependence, partnership and paternalism. This has led to a series of policy positions and statements that sparked a furore of criticism and debate, exacerbating the AIDS crisis. While the country's response to the AIDS epidemic has been marred by controversy, confusion and policy inaction, it is also true that South Africa now boasts the world's largest public sector anti-retroviral treatment programme, one that is 90 per cent funded by government resources, not donor funding (Tshabalala-Msimang 2006).
South Africa provides an interesting and important case study through which to examine the impact of international donor funding in the fight against HIV/AIDS, and the changing relationship between foreign donors and African governments in the light of the AIDS pandemic. Since South Africa has the second highest population of HIV-positive people in the world, waging a successful campaign against HIV/AIDS is not only a priority for its government, but also high on the agenda of the international donor community. However, tensions between the government and the donors have a long history, fuelled in part by Western donors’ paternalism towards African countries and in part by the South African government's determination to avoid the trap of dependence at all costs and develop a response to the pandemic that is affordable and sustainable using domestic resources. This article examines donor funding for HIV/AIDS in the context of government efforts to develop an African response to the pandemic not determined nor primarily funded by foreign aid. It draws on primary data collected in South Africa through interviews with donor representatives, non-governmental organizations and government officials, as well as a detailed review of key reports, literature and websites that provide statistical data on the subject.
A WAR CHEST FOR FIGHTING AIDS?
After two decades of neglect, battling the HIV/AIDS pandemic has finally seized the attention of the international community. The Global Fund to Fight AIDS, Tuberculosis and Malaria estimates that some 40 million people are infected with HIV, 70 per cent of whom live in sub-Saharan Africa. To date, HIV/AIDS has killed more than 20 million people worldwide, with 3.1 million people dying of AIDS-related causes in 2004 alone.Footnote 1 AIDS is already beginning to undo many of the past human development advances. Life expectancy has plummeted by more than 20 years in those countries heavily affected,Footnote 2 and in sub-Saharan Africa it is estimated that per capita growth in half of the countries is falling by 0.5–1.2 per cent each year as a direct result of AIDS. Although AIDS is at the very heart of the global development crisis, the fight against it has been considerably under-financed by governments of the most heavily affected regions, and by the international donor community. A 2001 study by Amir Attaran and Jeffrey Sachs estimated that donor funding for AIDS prevention and management programmes amounted to only US$170 million annually between 1996 and 1998, with about US$69 million going to sub-Saharan Africa (Attaran and Sachs 2001). This latter figure amounted to about US$3 per HIV-positive person. To put this figure in perspective, American consumers spend US$8 billion per year on cosmetics, and European cows on average receive subsidies of US$2 each per day.
In recent years, however, international donor aid for combating AIDS has been rising rapidly, primarily in the form of bilateral development assistance and aid, as well as contributions to the Global Fund. The World Bank also provides substantial funding for HIV/AIDS, as does the private sector (foundations, corporations, international non-governmental organizations and individuals). Domestic public health spending by many affected-country governments, especially South Africa, has also grown tremendously, and households and individuals within these countries often shoulder at least some of the financial burden. Taken together, it is estimated that resources made available from all of these funding streams rose from approximately US$1.6 billion in 2001 to US$6.1 billion in 2004, and US$8.9 billion in 2006 (Kates and Lief Reference Kates and Lief2006; UNAIDS 2006b). UNAIDS estimates that approximately US$10 billion is currently being spent annually for all aspects of the global AIDS response. Despite the increase in funding, official estimates suggest that there is still a considerable financing gap that is likely to grow over time (Global HIV Prevention Working Group 2007; Kates and Lief Reference Kates and Lief2006; UNAIDS 2007).
The strong international response to HIV/AIDS can be seen at the country level in some of the nine hardest-hit sub-Saharan African countries. For example, during 2000–4, the average level of external funding increased significantly in Lesotho (1,100 per cent), Swaziland (951 per cent), Tanzania (394 per cent), and Zambia (698 per cent) (Lewis Reference Lewis2005). For some low-income countries in the most heavily affected regions, such huge sums of aid are effectively replacing government health budgets. A 2003 comparative analysis of the financing of HIV/AIDS programmes in Southern Africa, for example, revealed that over 80 per cent of total HIV/AIDS spending in Mozambique, Lesotho and Swaziland came from external bilateral and multilateral donors (Martin Reference Martin2003).
Dramatic increases have occurred in HIV/AIDS donor financing, while many Southern African government public health budgets have changed little and in some cases (for example Mozambique and Zambia) have actually declined (Lewis Reference Lewis2005). In Uganda and Zambia, for example, AIDS funds exceeded all public health spending by almost 185 per cent. This imbalance raises serious questions about how countries can accommodate and wisely allocate new resources for HIV/AIDS given the limited or declining public health capacity.
The implications of the growth of HIV/AIDS donor funding are likely to be far-reaching. For example, concerns have been raised as to whether such huge inflows of aid might undermine macroeconomic stability or fiscal management. It is also uncertain whether these countries can effectively utilize these resources given the institutional capacity and governance problems that often plague their healthcare systems. The volatility and unpredictability of funding is a further concern. The improvement of HIV/AIDS services will require an expansion of the civil service. But such expansion will not be sustainable through government budgets in many low-income countries once donor funding dries up. Furthermore, the reliance on imported anti-retroviral drugs for AIDS patients cannot be sustained with government resources in many Southern African countries. Given that AIDS patients are dependent on continued therapy for survival, interruptions in anti-retroviral treatment caused by funding gaps could lead to increased mortality rates (Compernolle Reference Compernolle2007).
Historically foreign aid as a percentage of government revenue in South Africa has been very small. In 1998, donor support accounted for 0.2 per cent of government revenue, and today it remains less than 1 per cent. External sources of health financing in 1998 likewise contributed less than 1 per cent of revenue for the public health sector, and their share remains very low today. But foreign aid for HIV/AIDS is significant. Of all recipient countries, South Africa, behind Uganda and the Democratic Republic of Congo, received the third largest allocation of aid for HIV/AIDS from OECD countries in 2004 (OECD/UNAIDS 2004). In 2002/3 it is estimated that donor funding comprised 40 per cent of allocations for HIV/AIDS in South Africa, totalling just over US$53 million (Ndlovu Reference Ndlovu2006b). While the total sum donated had nearly tripled by 2004 (OECD/UNAIDS 2004), unlike in neighbouring countries, donor funding as a percentage of allocations has remained steady or even declined, as the South African government has increased its budget allocations for HIV/AIDS exponentially as well (Tshabalala-Msimang 2006).
Furthermore, the government has been very strategic in accepting and utilizing foreign aid. In general, donor assistance has been viewed with caution by the government, particularly if it does not appear to support its own Comprehensive Plan for responding to the pandemic. In answer to a series of interview questions regarding the relationship between the government and international donors, and possible patterns of donor dependence in South Africa, one United Nations representative explained: ‘The South African government sets the agenda. Things are done differently here in South Africa. If foreign donors don't like it, they can leave. A few have.’3
HIV/AIDS IN SOUTH AFRICA AND THE GOVERNMENT'S RESPONSE
UNAIDS estimates that approximately 5.5 million adults and children were living with HIV/AIDS in South Africa at the end of 2005, a figure that had risen from five million at the end of 2001 (UNAIDS Reference Kates and Lief2006a). The findings of a 2004 survey of national HIV and syphilis antenatal sero-prevalence indicated that HIV prevalence among pregnant women was 29.5 per cent, and suggested that as many as 6.7 million South Africans could be living with HIV/AIDS (Department of Health 2004).
The World Health Organization (WHO) and UNAIDS estimated that by the end of 2006 approximately 325,000 South Africans were receiving anti-retroviral treatment, which represented approximately one third of those in need of treatment (WHO/UNAIDS 2007). In February 2008, the government announced that the number of patients initiated on anti-retroviral treatment was 418,000. However, the pharmaceutical company Aspen Pharmacare, which makes most of the anti-retroviral drugs used in South Africa, estimates that only 340,000–350,000 were still on treatment in the public health system in February 2008 (others have died or stopped taking the drugs). It is estimated that a further 100,000 South Africans are on anti-retroviral treatment in the private health system (TAC 2008). Aspen Pharmacare has also calculated that no more than half of those who need treatment will be receiving it by mid-2009 (Kahn Reference Kahn2008).
When the African National Congress came to power in 1994, it was one of the first African governments to formulate a National AIDS Plan that emphasized prevention, comprehensiveness and a multi-sectoral and multi-stakeholder approach to the development and implementation of HIV/AIDS programmes. AIDS was declared a ‘Presidential Lead Project’ along with 20 other social priorities, giving it special status and early access to resources designated for reconstruction and development. The HIV/AIDS Directorate within the Department of Health was strengthened in order to drive the implementation process, and a National AIDS Programme Director was appointed.
The government launched the HIV/AIDS and STD Strategic Framework in 2000 (2000–5) which outlined a multi-sectoral approach to combating AIDS by incorporating national, provincial and local levels of government as well as other stakeholders outside the health sector. The four priority areas outlined in the plan are prevention; treatment, care and support; human and legal rights; and monitoring, research and surveillance. A Comprehensive Plan for the Management, Care and Treatment of HIV/AIDS was adopted in November 2003, and in 2007 a new HIV and AIDS and STI Strategic Plan for South Africa was unveiled which will guide government policy until 2011 (Department of Health 2006).
While the South African government has been strong on AIDS policy development, in practice the response to the pandemic has been slow and highly politicized, particularly in the area of treatment. The government's response to AIDS has been marred by patterns of technocratic, authoritarian and controlling political leadership through which it has sought to impose decisions rather than facilitating cooperation among people to realize society's goals (Johnson Reference Johnson2006). Inappropriate use of AIDS funding, endorsement of farcical and discredited AIDS drugs, and flirtation with AIDS denialists became defining features of the Mbeki administration's response to AIDS early on. Such blunders and shocking actions and positions did nothing to halt the spike in national HIV prevalence rates among antenatal clinic attendees from 2.2 per cent in 1992 to 26.5 per cent in 2002 (South African Government Reference Manuel2008; van der Vliet 2003).
A consistent theme resonant amid much of the contestation and debate was the South African government's concern with affordability and sustainability in constructing an effective response to the epidemic. The government's relationship with AIDS civil society groups as well as foreign donors and international organizations has been largely framed within this technical discourse of affordability and sustainability. Nicoli Nattrass argues in her book The Moral Economy of AIDS in South Africa that:
By locating the AIDS policy discussions in a seemingly technical discourse of affordability and sustainability, the space for public deliberation over the appropriate size of a national treatment programme has been sharply curtailed. This has had the effect of stifling the formulation and expression of social values concerning how best to address the AIDS pandemic. (Nattrass Reference Nattrass2004)
In large measure, the emphasis on affordability and sustainability reflects an almost dogmatic insistence on establishing a response to AIDS that would not rely on donor funding. This was particularly apparent in the government's handling of the provision of anti-retroviral treatment, especially to prevent transmission from pregnant, HIV–positive women to their unborn children. Scientific trials in developed and developing countries have shown that treating pregnant women with a short course of anti-retrovirals could dramatically reduce the transmission of HIV from mother to child (Shisana and Zungu-Dirwayi Reference Shisana and Zungu-Dirwayi2003; Nattrass 2004). Yet the South African government initially raised the question of safety in explaining its stance on anti-retrovirals, and then argued that the government simply could not afford to provide anti-retrovirals through the public health sector. The government stuck to its unaffordability argument even though no real costing for such a programme was done until 2003.4
Once the price of AZT was slashed and nevirapine was offered free of charge to South Africa to use in the prevention of mother-to-child transmission, the government's position lost further credibility. A public outcry ensued, led largely by the Treatment Action Campaign (TAC) and its allies, which culminated in the landmark constitutional court case brought against the South African government over its obligation to provide anti-retroviral drugs to prevent mother-to-child transmission of HIV. On 5 July 2002 the court decided, in a unanimous decision, that the government had not met its constitutional obligation to uphold people's right of access to healthcare services, a landmark victory for South African AIDS activists that obliged government to provide ARVs to pregnant women and their babies.
In an interview with the author, former Director of the HIV/AIDS Directorate in the Department of Health Rose Smart explained the government's stance as emanating from a reluctance to start something that wasn't equity-based and sustainable, and that might necessitate a reliance on donor funding.Footnote 5 Sadik Kariem, Senior Medical Superintendent at Groote Schuur Hospital in Cape Town and member of the ANC Health Committee, also suggested in an interview with the author that the purported tendency within government towards denying the causal relationship between HIV and AIDS, widely reported in the South African and Western media, was fuelled in part by a refusal to become dependent on donor funding and other resources that would have to come from the West.
The explanation for denialism I believe is two-fold. One the one hand there was the economic argument and the concern that all the medicines and resources needed to run such a programme would have to come from the West, and that this would create a situation of economic dependency. There was concern that South Africa should not go the route of other African countries that had become so heavily dependent on the West. On the other hand the ANC's recent history in fighting a political and military war against an enemy, the apartheid government, who had used biological warfare as a strategy against the ANC also provided a ready audience within the ANC for such arguments and positions.6
The concern to develop a response that relies on African knowledge and resources instead of Western technology and knowledge also clearly underpins the South African government's promotion of indigenous and plant medicines as part of a comprehensive response to AIDS.
President Mbeki's quest for African solutions to the AIDS crisis also appears to be grounded in conceptions of race and his belief that responses to AIDS often reproduce racist and colonial discourses on Africans, medicine and disease. While some of these perceptions are not entirely unfounded,Footnote 7 a new and important body of literature on President Mbeki's and the South African government's response to AIDS provides us with a social history of racial inequality over the past century and its role in shaping the debates on AIDS (Fassin Reference Fassin2007). In his biography of President Mbeki, Mark Gevisser describes how the President's view of the disease was and still is shaped by an obsession with race, the legacy of colonialism and sexual shame, leaving many to conclude that Mbeki remains an AIDS dissident (Gevisser Reference Gevisser2007; McGreal 2007).
EARLY ENGAGEMENT WITH THE INTERNATIONAL COMMUNITY ON AIDS
The government's ambivalent relationship with foreign donors and international actors particularly over HIV/AIDS has a revealing history and has been shaped by its engagement with global forces since the days of apartheid. In an interview with the author, one donor representative surmised that the tepid relationship between the government and USAID/PEPFAR in part stems from US support for the apartheid regime.Footnote 8 More recently, the legal action brought against the South African government by the Pharmaceutical Manufacturers Association (PMA) over a 1997 amendment to the Medicines and Related Substances Control Act soured the government's attitude towards not only the big pharmaceutical companies but also the United States government.
The PMA court case provides a blatant example of powerful Western and transnational interests directly influencing the South African state's ability to conduct socio-economic policy making, cheapen vitally needed medicines and address the racial and class imbalances in healthcare inherited from the past. The government saw its efforts to transform the racially divided and highly unequal healthcare system inherited in 1994 as being thwarted by big Pharma, who claimed that the Act was unconstitutional and violated its property rights. Internationally, the PMA's affiliates launched a smear campaign against the government, alleging that its actions threatened the international patent regime and were contrary to its obligations as a member of the World Trade Organization (WTO). The pharmaceutical industry's case found resonance especially among key US government officials, leading to South Africa being placed on the United States Trade Representatives Watch List (Heywood Reference Heywood2001).
The amendment to the Medicines Act did not strictly pertain to HIV/AIDS, but was geared more broadly towards tackling distortions in the healthcare system and making medicines more affordable through generic substitution of off-patent medicines, the use of parallel importation and compulsory licensing.Footnote 9 At the time when the PMA instituted proceedings against the South African government, no one in the international community raised the possibility of providing affordable anti-retrovirals to HIV-positive people in Africa, and no African government considered the provision of anti-retrovirals through the public sector a viable or sustainable response to the AIDS pandemic.
The PMA court case became a pivotal arena in the fight against HIV/AIDS when national and international AIDS activists launched a campaign against the pharmaceutical industry and focused attention on the prohibitive costs of anti-retroviral drugs. This highly organized and visible global AIDS activist community – it included groups such as ACT UP, the Consumer Project on Technology, and Médecins Sans Frontières as well as the South African Treatment Action Campaign (TAC) – spurred international public awareness especially around the issue of access to treatment. These transnational AIDS activist networks were successful not only in forcing the PMA to drop their case in 2001, but also in increasing the attention paid by international donors to the AIDS pandemic (Johnson Reference Johnson2006).
Pressure was brought to bear on Western donor governments and multilateral institutions who up until this point had shown relative indifference towards the global AIDS pandemic, and had decided that any money they did provide would be better spent on AIDS prevention or the treatment of other diseases or opportunistic infections. United States organizations such as the Centers for Disease Control (CDC) and the US Agency for International Development (USAID) calculated that opening the door for AIDS treatment in Africa would create a limitless demand on scarce resources. Jeffrey Harris of the CDC said in an interview, ‘We were afraid that if we opened the door on treatment at all, then all of our money would be drawn away. You get into paying for commodities that have to be supplied, supplied, supplied, to the end of time’ (Gellman Reference Gellman2000).
By the time the PMA dropped the case in 2001, the international climate had changed: treatment even for those in developing countries was now seen as a possibility. In June of that year the United Nations General Assembly Special Session on AIDS was held, during which the leaders of the G8 countries committed themselves to channelling more resources into the fight against AIDS, signalling their intention through the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria. More recently, member states at the June 2006 United Nations General Assembly high-level meeting on HIV/AIDS agreed to work towards the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010 (WHO/UNAIDS 2007).
The international community was finally beginning to mobilize significant resources to fight the AIDS pandemic, especially in Africa, the hardest-hit region. In familiar fashion, however, the advanced industrialized countries were all too willing to play the role of ‘missionary’ and step in to ‘save’ Africa. They proposed solutions for Africa that promote aid, hand-outs and Western knowledge and technology instead of removing the structural barriers, such as unfavourable international trade laws, that contribute to inhibiting African countries from ‘saving’ themselves. But this approach reasserts global power imbalances and thus helps to explain much of the anger felt by African leaders struggling to avoid the pitfalls of African dependency and Western paternalism.
No African leader has been more outspoken than South African President Thabo Mbeki in trying to shape the paradigm through which the AIDS pandemic in Africa is viewed and the discourse used to define the problem as well as the solution. Some of President Mbeki's actions and statements sparked a furore of criticism and debate as he attempted to redefine AIDS in Africa as a disease of poverty. The controversy and indeed outrage began when President Mbeki convened a presidential AIDS panel to shed light on the causes of AIDS. The panel comprised scientists who believe in the causal link between HIV and AIDS as well as those who do not. There was uproar, especially in the mainstream and Western media, as critics accused President Mbeki of questioning whether HIV causes AIDS and championing discredited scientists.
The discussion of what causes AIDS was part of President Mbeki's broader efforts to redefine AIDS in Africa as a disease of poverty, and to find specific and targeted responses to what he terms a uniquely African pandemic at a time when AIDS in Africa was increasingly being defined by donor governments and organizations in the West. Responding to international pressure and condemnation, President Mbeki wrote a letter to various heads of state, outlining the case for a uniquely African reading of the pandemic:
Whereas in the West HIV-AIDS is said to be largely homosexually transmitted, it is reported that in Africa, including our country, it is transmitted heterosexually. Accordingly, as Africans, we have to deal with this uniquely African catastrophe …. It is obvious that whatever lessons we have to and may draw from the West about the grave issue of HIV-AIDS, a simple superimposition of Western experience on African reality would be absurd and illogical. (Mbeki Reference Mbeki2000)
President Mbeki's linking of poverty with AIDS has political implications domestically and globally, and requires us to engage with underlying socio-economic conditions and interventions rather than simply behavioural ones. What was lost in all the controversy and criticism were the political implications of linking poverty and AIDS. If AIDS is redefined as a disease of poverty, then the socio-economic conditions in which one lives become as relevant a factor as sexual practices and behaviour in understanding the spread of AIDS and in proposing an effective response to it. Such a perspective flies in the face of the ABC approach (Abstinence, Be faithful, otherwise use a Condom), the behavioural intervention most heavily promoted to reduce HIV transmission in sub-Saharan Africa (Hodgson Reference Hodgson2005). However, President Mbeki's flirtation with so-called AIDS dissidents and discredited scientists, and the inaction on the part of his government, in the end obscured and undermined this valid perspective and the political nature of the pandemic.
FUNDING THE FIGHT
Despite the government's commitment, along with other African governments, to allocate at least 15 per cent of the national budget to the health sector, only 12.4 per cent of South Africa's 2008 national budget is allocated to health (Mukotsanjera Reference Mukotsanjera2008).Footnote 10 This does represent an increase from previous years, with HIV/AIDS allocations in particular increasing dramatically during the past six years. The AIDS Budget Unit at the Institute for Democracy in South Africa (IDASA) reported that total government HIV/AIDS allocations increased from under R250 million in 2000/1 to over R3.5 billion in 2006/7 (Hickey Reference Hickey2003).Footnote 11 In his recent 2008/9 budget speech to Parliament, South African Finance Minister Trevor Manuel said that annual expenditures for HIV/AIDS across government departments will top R6.5 billion by 2010/11 (Manuel Reference Manuel2008). As a share of the total health budget, HIV/AIDS allocations have increased from 13 per cent in 2004/5 to 18 per cent in 2006/7. As a share of total government expenditure, HIV/AIDS allocations constitute less than 1 per cent, with R5.66 billion allocated for HIV/AIDS in the 2008/9 budget (Mukotsanjera Reference Mukotsanjera2008).12
The increased budget allocations for HIV/AIDS have translated into a strengthened response from the South African government, particularly in the area of treatment. The National Treasury reports that ‘the treatment component of the comprehensive HIV and AIDS plan has been expanded to 192 sites in all 53 health districts and in more than 170 local municipalities, compared to only 139 accredited facilities in 2004/5’ (National Treasury 2006). In addition, the government's National Strategic Plan for 2007–11 has as its primary aims the reduction of new HIV infections by 50 per cent by 2011 and expanded access to appropriate treatment, care and support to 80 per cent of all HIV-positive people and their families by the same date (South African Government 2008). However, AIDS organizations such as the Treatment Action Campaign have argued that the government is likely to fall short of these targets as the budgetary allocations, while laudable, will cover only 52 per cent of the estimated 1.7 million people who will need anti-retroviral treatment in 2011 (TAC 2008).
Donor funding for HIV/AIDS has also been increasing in South Africa in recent years, although not as rapidly as public sector funding. Key sources of donor funding for HIV/AIDS in South Africa include bilateral and multilateral aid to the government as well as direct funding to non-governmental organizations from foreign governments and international aid agencies. According to the South African Department of Health, the United States government provides the largest amount of donor funds for HIV/AIDS programes, amounting to US$126.4 million (R866 million) from 2001–6, and increasing significantly to US$584 million allocated for 2008 (PEPFAR 2008a). At the end of September 2007, South Africa had already received over US$88 million for AIDS and tuberculosis from the Global Fund, the second largest source of donor funds.Footnote 13 Other major donors include the European Union (R344 million for 2000–7), the United Kingdom Department for International Development (DfID) (R493,047,864 for 2001–7), Australia's AUSAID (R263,850,000 for 2000–8) and Canada's CIDA (R121 million for 2003–8) (Ndlovu Reference Ndlovu2005).
The national Department of Health has developed a database referred to as a ‘donor matrix’ to monitor financial commitments for HIV/AIDS in South Africa. The donor matrix is aimed at monitoring funding for health services by listing donor commitments, disbursements, objectives, activities and implementing bodies. But it is not regularly updated and reflects committed amounts rather than actual disbursements (Kelly et al. 2005). There are also challenges of ‘annualizing’ amounts that have been committed over multiple years. The national Department of Health also initiated a donor coordinating forum in which all bilateral and multilateral donors were to be represented. According to Guthrie and Hickey,
The purpose of the forum was to allow the Department of Health to interact with donors on a single platform, ensuring that they all had access to the same information at the same time. The chief directorate (for HIV/AIDS and TB, within the Department of Health) hopes to also use the forum as a conduit for provinces to indicate their donor funding needs and to emphasize how donors could assist with ensuring local delivery, through programmes such as home-based care and VCT (voluntary counselling and testing). (Guthrie and Hickey 2004)
Spending of committed government funds has been a significant problem in the past and remains so in some provinces. Spending of bilateral donor funds for HIV/AIDS is reported to be slower than the spending of government funds, with large amounts having to be refunded to donors (Ndlovu Reference Ndlovu2005). This is because donor funding is usually earmarked for very specific purposes and objectives. Typically such funds come with strict conditions to be satisfied when spending the money. According to Ndlovu, ‘Although earmarked funding is beneficial in ensuring that new and critical projects are funded, donor funds may hinder or clash with national government priorities, leading to decreased flexibility for implementers when spending on vital local priorities.’ In addition, spending of donor funds is hindered by weak provincial health systems and insufficient capacity of the government to commit the money to augmenting key programmes. In recognition of this, several donors, the European Union and the United Nations in particular, have targeted capacity building within the public health sector.14
In fact, by some accounts within government and the donor community, absorptive capacity rather than availability of resources is increasingly becoming the key funding issue in South Africa.Footnote 15 Provincial governments in South Africa, which are responsible for most of the HIV/AIDS spending, are faced with the challenge of increasing spending at programme level. There is a strong need to invest in the development of governmental and non-governmental systems to ensure that resources are utilized effectively and efficiently.
WHO CALLS THE SHOTS?
Through the President's Emergency Plan for AIDS Relief (PEPFAR), the United States is the largest foreign donor to HIV/AIDS activities in South Africa, one of fifteen focus countries that are the main beneficiaries of PEPFAR funding. In 2008 PEPFAR will provide just over US$584 million for HIV/AIDS programmes in South Africa (PEPFAR 2008a). PEPFAR works with approximately 300 non-governmental partners in South Africa, through which it supports the provision of anti-retroviral treatment, prevention and care programmes. No PEPFAR money is given directly to the government. However, the United States Agency for International Development (USAID), the principal US government agency administering PEPFAR, does partner with a number of national and provincial South African government departments, including the Department of Health, the Department of Defence and the Department of Correctional Services, in the provision of HIV/AIDS programmes. PEPFAR's prime partners, and the prime recipients of PEPFAR funding, are largely northern non-governmental organizations and US government institutions such as the Centers for Disease Control as well as mainly faith-based local community organizations who in turn administer HIV/AIDS programmes in South Africa (PEPFAR 2008a).
Despite being the largest HIV/AIDS foreign donor in South Africa, the United States has a more marginalized and tepid relationship with the government than other major donors. This probably has to do with the fact that the South African government doesn't directly receive any PEPFAR funding, in contrast to some of the other major donors such as the European Union and the Global Fund to Fight AIDS, TB and Malaria that provide funding directly to the South African National Treasury, giving the South African government more control over the coordination and disbursement of the funds. In addition, from the South African government's perspective, the United States government has made little effort to consult or liaise with it regarding the implementation of PEPFAR. South African Health Minister, Manto Tshabalala-Msimang, said that South Africa was surprised to be identified as a key beneficiary when the plan was announced in 2003. She complained at the opening of a 2006 conference on PEPFAR in Durban that PEPFAR in South Africa ‘started off on a wrong foot. We were not consulted.’ She went on to demand a greater say over the way PEPFAR funding is spent in the country, arguing that giving the money directly to local programmes created a coordination problem (Cullinan Reference Cullinan2006).
This is a common theme that emerges in many of the South African government's pronouncements on foreign aid. Speaking of the World Health Organization's 3×5 Initiative in 2005 – just before the end of a campaign that fell short of its target by about 1.8 million anti-retroviral treatment recipients – the Health Minister complained that ‘nobody had asked South Africa what they thought of the proposal; instead it was imposed from Geneva’ (Hodgson Reference Hodgson2006). Implicit in a number of government policy developments and statements is frustration at Western paternalism and the fact that African governments, the targeted recipients of such programmes, are rarely consulted.
The South African government's wary response to the PEPFAR programme can also be attributed to what many see as the politicization of US foreign aid under President George W. Bush's administration, tying aid less to the ethical imperatives of alleviating poverty and more to the administration's short-term political and military objectives (Engler Reference Engler2006). Under the initial leadership of Randall Tobias, former CEO of pharmaceutical giant Eli Lilly and Company, PEPFAR was criticized by many civil society groups for pushing a politically loaded, abstinence-based response to AIDS prevention in Africa (Hodgson Reference Hodgson2006).
Changes in the objectives and administration of US foreign aid are part of a broader project of ‘transformational diplomacy’ initiated by Secretary of State Condoleezza Rice.Footnote 16 Under this plan, USAID has been relocated inside the State Department, Randall Tobias has been appointed as the new administrator of USAID and new Director of Foreign Assistance, and foreign aid dollars are now apportioned on a country basis rather than according to issue areas such as child health or infectious diseases. Such changes have left many concerned that the restructuring of US foreign assistance programmes is tying aid money to US strategic interests in a far more overt manner. Institutionally, too, the US decision to channel the bulk of its resources through PEPFAR and circumvent the Global Fund has undermined the principle of multilateral governance and cooperation on global health issues. In turn, the Global Fund has had problems attracting enough money and then getting donor countries to honour their commitments, again contributing to the weakening and vulnerability of such hybrid modes of governance.
While there is probably no love lost between the South African government and the United States government, each seems to tolerate the other out of necessity. The US$584.5 million provided through PEPFAR goes a long way to assisting the South African government in meeting the objectives of its Comprehensive Plan, particularly in the area of capacity building. It is therefore in its interest to cooperate with PEPFAR and its partners in many areas. Similarly, the South Africa programme plays a particularly pivotal role in PEPFAR's success as it accounts for nearly a quarter of PEPFAR's global treatment targets, even though South Africa on average receives only 10 per cent of the annual PEPFAR budget.Footnote 17 Of the two million HIV-positive people PEPFAR has targeted to treat by the 2008 financial year, 500,000 are expected to be in South Africa, by far the country with the largest treatment targets (PEPFAR 2008a, 2008b).
Interestingly, one of the areas in which the South African government has consciously decided not to relinquish control has been in the procurement of anti-retroviral medicines. One of the stipulations of the PEPFAR programme is that funds can only be used to procure anti-retroviral drugs approved by the US Food and Drug Administration (FDA). Until very recently, this meant that PEPFAR funds could only be used to purchase brand-name drugs primarily from US and European pharmaceutical companies at considerably higher prices than their generic counterparts available from Thailand, Brazil, India and even South Africa. The South African government has largely circumvented this stipulation by insisting on procuring the vast majority of anti-retroviral drugs distributed in South Africa. Thus, while PEPFAR boasts that as of September 2007 over 329,000 South Africans have begun anti-retroviral treatment with US government support, PEPFAR in fact procures drugs for only about 20 per cent of these patients (PEPFAR 2008b).Footnote 18 Thus while PEPFAR will spend US$265 million in 2008 to support anti-retroviral treatment, the majority of this (US$222 million) will be spent on services and technical assistance rather than the purchase of drugs (PEPFAR 2008a).
The South African government's relationship with the Global Fund to fight AIDS, Tuberculosis and Malaria has also at times been less than amicable. This is somewhat surprising given the multilateral, bottom-up approach to donor funding the Global Fund was intended to embody, which differs significantly from PEPFAR's bilateral, top-down approach. However, despite its being a multilateral, public–private partnership, only 3 per cent of all contributions to the Global Fund come from non-state actors, while the wealthy G8 countries alone finance two thirds of the Global Fund. In fact, what makes the Global Fund unique among actors in the global health field is not so much its resource base as its hybrid governance structure that gives recipient countries and civil society actors a say in decision-making processes (Bartsch and Kohlmorgen 2007).
In this case, too, it appears that the allocation of Global Fund money to South Africa was a strategic accommodation that suited both the Global Fund and the South African government. From the Global Fund's perspective, it is hardly feasible to have a credible global AIDS programme that does not include the country with the largest number of HIV-positive people (exceeded perhaps only by India). Similarly, for the South African government to refuse Global Fund money would not only look bad, given the severity of its AIDS epidemic, but would also provide ammunition to critics who claim the South African government has been dragging its feet, almost to the point of inflicting a form of genocide on its own people (Lewis Reference Lewis2007).
The latest figures from the Global Fund's progress report show that six grants have been approved to South Africa, totalling just over US$205 million. As of 16 April 2008 a total of US$116,500,964 had already been disbursed to South Africa (Global Fund 2008). It wasn't until 2003 that South Africa signed a long-delayed funding deal with the Global Fund after nearly two years of wrangling over how aid to the country would be distributed. There was also disagreement over when Global Fund money could be used to buy anti-retroviral drugs, which the government only approved for use in the public sector in November 2003. It insisted that all funds should first come to the National Treasury, after which the national government would disburse funds to specific programmes and provinces (Quinn Reference Quinn2006). This became a particular sticking point regarding funds awarded to KwaZulu-Natal Province (US$26,741,529) in Round 1 and the Western Cape Province (US$15,521,457) in Round 3. Global Funding was also awarded to LoveLife and Soul City, two public/private partnership programmes, in support of social and behavioural change initiatives, particularly among adolescents.
In 2004 a new dispute broke out between the South African government and the Global Fund when Richard Feachem, head of the Fund, accused the government of delaying disbursements of millions of dollars in HIV/AIDS assistance. Feachem told the South African media: ‘It's intolerable that the money gets stuck in Pretoria and if Pretoria can't move it for any reason, we will simply withdraw it and establish direct relationships with the people actually doing the work’ (Quinn Reference Quinn2006). South African health officials said the state was abiding by the terms of the agreement and passing along all money received to recipient groups and non-governmental organizations (NGOs). Even President Mbeki felt compelled to respond to what he argued were simply false allegations. Interestingly, he argued that this situation again highlighted the global power imbalances and reinforced the position of structural subservience in which developing countries often find themselves.
In his comments, Professor Feachem referred to the Global Fund grants voted for South Africa as ‘our money’, to emphasize the relationship between a benefactor and a recipient of benefaction. In the comments he has since denied, he emphasized the power of the benefactor to do in our country as it pleases, and our helplessness to do anything in this regard, because of our poverty. It is true that we are poor and need the support of people of goodwill. It is however also true that we would betray those who sacrificed for our liberation, and corrupt our freedom, if we succumbed to the expectation of some of those more richly endowed than ourselves, that our poverty should condemn us to perpetual subservience. This we will not do. (Mbeki Reference Guthrie and Hickey2004)
The difficult relationship that has developed between the South African government and the Global Fund has some speculating that South Africa is unlikely to receive significant sums of money from the Fund in subsequent funding rounds.Footnote 19 Most accounts suggest that the Western Cape Province and the KwaZulu-Natal Province did good work with the Global Fund money they received. However, in comparison the national government has nothing more than an average track record in distributing and effectively and efficiently utilizing their Global Fund allocations.
The South African government's fear of falling into the trap of dependence shapes its relationship even with smaller donors with whom the relationship appears more amicable. This is particularly so with regard to the procurement of drugs, an area where the government insists on maintaining control. This applies not only to anti-retroviral drugs but to all vaccines distributed in the country. For example, the South African government provides free health care, including vaccinations, for all children under six years of age. A UNICEF representative explained that the government procures and distributes all vaccines for children in the country, even though it would be more cost-effective to allow UNICEF to provide the vaccines or even to purchase the vaccines from UNICEF as is the case in most developing countries.20
More recently, the South African government's relationship with UNICEF soured when news sources reported that a senior UNICEF official, Ann Veneman, during a recent four-day visit to South Africa, said that the country is neglecting the more than 100,000 children born HIV–positive each year (Reuters Reference Quinn2007). This prompted considerable anger on the part of senior government and ANC officials. The ANC leadership in its online newsletter Umrabulo questioned UNICEF as a ‘reliable partner’ and argued that Veneman's remarks fed into the dishonest propaganda on the government and its handling of the AIDS crisis.
Given our reality, characterized in part by a determined effort to impose on us certain views about HIV and AIDS, despite our comprehensive National Strategy, and the concrete actions we have and are taking to implement this strategy, Veneman should have known that her highly tendentious remarks would inevitably be used by some for purposes she did not intend. (ANC 2007)
Health Minister Manto Tshabalala-Msimang used the occasion of World AIDS Day to refute the reporting of Veneman's visit to South Africa. In an article in Umrabulo, she noted that according to UNICEF's own report card South Africa was one of 17 countries that were on track to meeting the United Nations 2010 target in the provision of anti-retroviral treatment for prevention of mother-to-child transmission of HIV.
The UNICEF report card also states that South Africa and Kenya were the only two of the countries with the high burden of HIV that were reaching 40 per cent of HIV positive mothers in need of anti-retrovirals for PMTCT by 2006. This figure has since risen to between 50–60 per cent for South Africa in 2007. (Tshabala-Msimang 2007)
Where the South African government has sought strong partnerships with donors is in the area of institutional capacity building. A good example of this is the European Union Partnerships for the Delivery of Primary Health Care including an HIV/AIDS programme. This is a six-year programme housed within the national Department of Health and funded by the EU. With a budget of five million pounds, its aim is to strengthen the delivery of district primary health care services, especially those addressing HIV/AIDS, by supporting the development of partnerships between government and non-governmental organizations (Department of Health 2005). According to the National Programme Manager, the aim is for the government to continue funding the programme once the EU money is finished.21
CONCLUSION
The South African government has developed its own home-grown approach to donor funding, one that seeks to use donor funding strategically to support domestic initiatives and priorities instead of allowing the development agenda to be imposed on it from outside. Because the government has invested so much of its own resources in recent years in combating AIDS, it is in a much stronger position to work as an equal partner with donors to achieve mutually recognized goals. It has been able to avoid the trap of dependency while implementing a response to AIDS that is both affordable and sustainable.
But the South African government's response to AIDS has also drawn understandable criticism. The overwhelming focus on developing an African solution to the AIDS crisis, and the highly politicized nature of the government's response that has been shaped largely by its engagement with global actors, led to critical years of policy inaction and confusion. That South Africa now boasts the world's largest public sector anti-retroviral treatment programme funded almost entirely by domestic resources is overshadowed by the fact that there still remain nearly 600,000 South Africans in need of treatment who aren't getting it.
For the donor community staff, working in South Africa is anything but ‘business as usual’. They quickly learn to accept that it is the South African government who is calling the shots. As one donor representative put it, pressuring the South African government is ineffective. ‘The more pressure you apply, the more resistance from the government you will receive.’Footnote 22 Donors are also well aware that while their contribution to the fight against AIDS in South Africa is important and significant, the government's response to the pandemic is not reliant on donor funding. Despite a somewhat rocky history, it is to be hoped that an equal and constructive partnership can prevail, in which the South African government and donor organizations prioritize the needs of those affected by HIV/AIDS.
