Institutionalising an Emergency Response: HIV/AIDS and Governance in Uganda and Senegal

- excerpted from the Introduction

While the implications of the AIDS crisis are devastating, some countries in Africa have made progress fighting the pandemic. This report examines how governance in Uganda and Senegal may have contributed to progress in fighting HIV/AIDS. I suggest that the role of central government has been crucial to successes achieved thus far in the fight against HIV/AIDS. Most controversially, I make a distinction between the development of a multisectoral approach to the epidemic as a key to success, and the template of multisectoral organisation that has been promoted by UNAIDS, the Global Fund and the World Bank, which I argue is extremely problematic. I also suggest that the successful move away from purely biomedical approaches to disease that has been so important in the international HIV/AIDS campaign, risks going too far toward the opposite extreme, losing sight of the crucial role that the medical profession and the health sector must play. I present a typology of the main activities that governments need to engage in to confront the epidemic, demonstrating that most involve both 'bio-medical/technical' and 'social, economic and political' dimensions. Hopefully, this report can also serve to educate governance experts about HIV/AIDS connecting the physiological and epidemiological features of the crisis with the political and social concerns of those who work in the governance field...

Uganda and Senegal have been chosen as case studies based on the widely recognised success they have achieved so far in confronting the HIV/AIDS epidemic. Uganda, one of the earliest and hardest hit by the virus appears to have brought it under control. Senegal is one of the few countries in Africa where HIV prevalence has been maintained at below 2%. In this report I examine what contribution different approaches to governance in these two countries may have made to the fight against very different experiences of the epidemic. If similar governance initiatives contributed to progress in two different experiences of the epidemic, we can identify some meaningful lessons.

The study is based on two brief field visits to Kampala and Dakar, meetings and interviews conducted with over 50 people working in government, NGOs, the academy and international agencies in the two countries, and documentation collected in country and from my base in the UK...

The key findings of the report:

• Central leadership is crucial to making progress...
• Central leadership is necessary to developing multisectoral involvement...
• Central leadership needs to set the tone for public debate...
• The organisational template imposed by the World Bank and the Global Fund needs to be applied more flexibly than it has been to date...
• In pursuing a multisectoral approach it is crucial not to lose sight of the biomedical core that needs to play a special role in fighting the virus...
• Prevention activities dealing with behavioural change need to be analysed in terms of those that address individual behaviour and those that address the behaviour of groups...
• New 'development' projects and strategies need to be evaluated for their potential impact on public health, particularly in relation to the AIDS crisis...
• Getting the balance right between control and participation/rights...
• Controversial legislation needs to be considered in the interests of public health...
• Specific legislative and non-legislative measures improving the status of women...
• Decentralisation and privatisation measures within the health service need to be reconsidered in light of HIV/AIDS...
• A theoretical possibility exists for the AIDS crisis to justify the expansion of the fiscal basis of the state and national governments and donors need to consider new local and national taxation reforms...