Anele Yawa, secretary general of the Treatment Action Campaign in South Africa, said that in the coming years the TAC will focus on reducing new infections among marginalized groups such as young girls, sex workers and men who have sex with other men: “The number of people being infected has gone down from 8,000 to 5,000 a week, but this is not enough. More than 2,000 of those new infections are of young girls who sleep with older men.”
AIDS remains one of the leading causes of death in the world and is the top cause of death in Africa, according to the Institute for Health Metrics and Evaluation’s tracking data. While new HIV infections have declined since the 1990s, that decline has almost stopped. Numbers of new infections are far above the targets set by the United Nations.
Why does Africa still have such high rates of HIV/AIDS infection and death?
Over the past 20 years, the world has celebrated breakthroughs in HIV/AIDS prevention. Those include pre-exposure prophylaxis (PrEP), a pill that has been shown to reduce the risk of HIV infection when taken consistently; education and treatment programs; distribution of antiretrovirals (ARVs), medications that are used to slow the growth of the disease; and a massive global intervention against HIV/AIDS in Africa, which includes hundreds of billions of dollars spent on initiatives such as increasing treatment access in resource-poor countries.
So why does Africa still have such high rates of HIV infection and AIDS morbidity?
That’s the question Kim Yi Dionne tackles in her excellent new book, “Doomed Interventions: The Failure of Global Responses to AIDS in Africa.” Here’s her compelling argument: Yes, the global response to AIDS is one of the most heavily financed interventions aimed at improving the human condition ever seen. But interventions as they have been carried out to date are doomed — because it’s so hard to coordinate delivery when relying on so many actors.
She points to coordination problems at two levels. First, a policy is conceived at the highest levels of global institutions — but responsibility and implementation are delegated to faraway local agents. As a result, it’s incredibly challenging to coordinate that delivery across country borders, subnational units and various levels of various governments. Efficiency suffers while opportunities for corruption flourish.
Second, the intended recipients of these complex global interventions don’t agree that HIV/AIDS is the most important health concern to address. This may not surprise anyone familiar with ordinary citizens’ struggles in communities most affected by HIV/AIDS, where access to clean water, education, agricultural development and general health services ranks as a top priority. Dionne shows convincingly through survey data that citizens in Africa — even in the worst-affected countries — see AIDS as one of many problems they face, giving it relatively low priority on that list.
That’s a fairly sharp mismatch between what the global powers are identifying, analyzing and supplying, and what local agents want to do with resources they receive. As a result, it’s very difficult to coordinate the many actors in the global supply chain of AIDS intervention to achieve the singular result of reducing HIV transmission.
This HIV/AIDS case study reveals the dynamics in many such global efforts at humanitarian relief
In investigating AIDS interventionism, Dionne reveals the much broader challenges facing health and development interventions in poor countries. Many similar dynamics are at work when the international community tries to address famine or offer other types of humanitarian relief. Here we see why it’s so difficult to coordinate many countries across multiple levels of government to assess needs, deliver aid and measure impact. The local realities of these crises — health, environmental and otherwise — are disconnected from how the intervening powers perceive, assess and conceive of “fixes” to their challenges.
Beyond this important global takeaway, Dionne shows the nuanced, contextual, local factors that affect this broader phenomenon. Dionne examines social structures in rural Malawi — where 80 percent of that country’s population lives — and reveals the importance of village headmen among the many actors in the global HIV/AIDS crisis supply chain. Yes, combating HIV/AIDS does and must involve community health workers, local religious leaders and congregations, and community-based organizations. But as Dionne shows, village leaders are integral local agents, shaping priorities, directing resources and serving as a key link between citizens in the community and all the others.
Using rich qualitative subnational data, Dionne demonstrates that village headmen have taken on new roles in response to the AIDS epidemic, such as promoting HIV testing and identifying AIDS orphans to benefit from external donors’ relief programs. Critically, we learn that village leaders do accurately represent their villagers when they negotiate with outsiders bearing resources. This suggests that village headmen may be the most effective agents to partner with in undertaking large-scale projects to improve the human condition.
Through this insightful analysis and impressive multi-method approach, Dionne reveals new understandings about local communities’ priorities and about the agents most likely to help achieve them. The book shows the disconnect in the global supply chain but does not leave us without hope.
Rather, her framework should provide new perspectives and approaches for making such interventions work. Those would include identifying the policy priorities of both the international actors and their intended beneficiaries, building global chains not just of supply but of accountability, and treating local village leaders as key interlocutors.
This model study of an important public policy phenomenon suggests vast implications for complex, multilevel interventions of all kinds.
Correction: An earlier version of this post incorrectly stated that the Human Sciences Research Council was sponsored by the Southern African Development Community, rather than South Africa. We regret the error.
Rachel Beatty Riedl (@BeattyRiedl) is the director of the Program of African Studies, a fellow at the Institute for Policy Research and an associate professor of political science at Northwestern University, and the author of “Authoritarian Origins of Democratic Party Systems in Africa” (Cambridge University Press, 2014).