Paternalistic HIV/AIDS Policies in Africa
Despite shortcomings, the increased efforts of the global community to address the pandemic in Africa have been effective, as the percentage of people living with HIV/AIDS in sub-Saharan Africa has leveled off. Unfortunately, much of this effort was not undertaken until the turn of the last century, at which point the prevalence of HIV/AIDS in Africa was too vast to be ignored any longer. The result is a plateau in the prevalence of the disease consisting of a large population of infected individuals who now require costly treatment for the remainder of their lives.
If Africa is to continue to fight this epidemic it cannot be at the cost of economic growth. The two are inextricably linked and neither can be left out of the development equation. The best way for Africa to overcome the HIV/AIDS issue is for countries to be able to generate domestic revenue sources thorough trade and investment. Independent revenue will allow countries the freedom to manage the issue alone. Currently African countries are beholden to donors and lenders around the world. Forced to conform their economic policies to fit the requirements of international organizations and foreign governments, African nations have lost a piece of their sovereignty.
Africa is essentially working to combat HIV/AIDS with an allowance from paternalistic entities with restrictions that stipulate that the allowance may only be spent on goods produced by the parent. In most cases the allowance must also be repaid with interest. Africa must be given the opportunity to support itself. This would require adjustments to loan conditionalities, restructuring of trade agreements and more opportunity for grassroots organizations to access funding. Only after these issues are tackled will Africa be able to address the demands of both poverty and HIV/AIDS effectively.
The Roots of the Current Problem
In the 1980s, African economies were reeling from the imposition of structural adjustment programs (SAPs) mandated by the World Bank and International Monetary Fund (IMF). Forced to compete with cheaper foreign imports, the production of goods in Africa plummeted. As a result of trade rules imposed by the World Trade Organization (WTO), African nations lost revenue on their exports and domestic production was crowded out by cheap imports. The job loss associated with these policies contributed to a shortage of social services, including health services. Amid this economic crisis and reduction in spending on health services emerged HIV/AIDS. African governments already struggling to ensure basic human needs were overwhelmed by the spread of this disease. Unable to fund prevention and treatment, most African nations received HIV/AIDS relief money from foreign sources – unfortunately, these funds frequently came with restrictions. Instead of relying on foreign aid, the policies governing trade with Africa should be amended to enable these nations to garner revenue and address the problem independently. Instead of creating and fostering unhealthy relationships with “benefactor” countries, African nations should be empowered to govern themselves. The future of Africa hinges on many factors, but it is agreed that controlling HIV/AIDS is a factor of primary importance.
HIV/AIDS in Africa: the Basics
Sub-Saharan Africa is home to 67% of the world’s HIV/AIDS cases, but its total population is only 10-11% of the world population.[1] HIV/AIDS has 5 to 6% prevalence in sub-Saharan Africa, although in 9 countries over 10% of the adult population is infected. As of 2007, Swaziland’s prevalence was the highest, at nearly 26.1%. Although these statistics appear bleak, there is reason to believe that the epidemic is slowly coming under control. As the rate of new infections in this part of the world began to decline, the overall prevalence is stabilizing. To illustrate, the number of people living with HIV/AIDS rose by about 2.7 million people in the last decade, while the previous decade saw an increase of 13 million.[2] Despite these recent achievements, the early impact and painful costs of HIV/AIDS in Africa make this seem like Pyrrhic victory. While the overall percentage of the population living with HIV/AIDS has stabilized, it has stabilized at an unacceptably high level, with nearly 22.1 million people infected in sub-Saharan Africa alone.
Africa, especially sub-Saharan Africa, is now worse off economically and socially than it was before the HIV/AIDS epidemic struck. Countries that had previously been experiencing growth in the industrial and services sectors, such as Botswana, were devastated by HIV/AIDS and have seen declining rates of economic growth ever since.[3] The reasons for this decline in growth are mixed, though there is agreement among many that the structural adjustment policies (SAPs) of the World Bank are at least partially responsible.[4]
It is also important to note that just because people are surviving the HIV/AIDS storm does not imply that they are thriving. The high levels of mortality due to HIV/AIDS have created a generation of AIDS orphans in Africa, with an estimated 11 million children losing one or both patents to the disease.[5] Since these children often become the sole providers for themselves and any siblings, their opportunity for education is effectively eliminated. Forced to scramble to collect the most basic necessities like food, water and shelter, these children take on adult responsibilities without the benefit of a basic support system and minimal education. As these AIDS orphans reach adulthood and enter the workforce, the impact of this generation on the overall human capital of African nations remains to be seen.
The Emergence of Globalization and HIV/AIDS in Africa
Isolating the individual impacts of HIV/AIDS and globalization in Africa is difficult. These two developments emerged around the same time, both gaining strength and momentum towards the end of the 20th century. Globalization enabled the increase in trade between Africa and the rest of the world, although the conditions forced upon African trade agreements by development organizations such as the World Bank and International Monetary Fund caused most African nations to lose their share of the domestic market.[6] This loss reduced the purchasing power of individuals and limited the number of jobs available. With the increase in foreign investment and concentration of wealth in cities, rural populations were drawn to urban centers in the hopes of securing more profitable opportunities.
Concurrent to the emergence of globalization, HIV/AIDS appeared and began to spread rapidly across the continent, due to a combination of urbanization and lack of reliable public health information. The spread of this disease created a desperate need for resources. Expensive HIV/AIDS drugs were now in high demand, putting further strain on resources needed to provide food and water to poor populations. Some countries, such as Botswana, initially chose to focus efforts on prevention, which was less expensive. This was not a socially equitable or desirable solution, and exemplifies the extremely difficult choices governments had to make in determining where to allocate their limited resources.
Economic Development Policies in Africa
IMF and World Bank policies
As mentioned previously, the IMF and World Bank have been the two of the primary sources of funds entering Africa for the past 30 years. These international organizations were developed in the years following World War II and were designed to maintain the stability of the world economy and assist in the rebuilding of Europe. The mission of both organizations has expanded since their creation, and they now provide loans to developing nations with the intent of building stronger economies and encouraging development.
However, the effectiveness of IMF and World Bank loans have routinely been called into question. Both organizations have received criticism regarding the policies they force upon countries accepting loans. These policies, called Structural Adjustment Programs, were mandated across the board for countries receiving funds, without consideration to the individual nation’s specific economic situations. SAPs contained up to 67 requirements which focused on currency devaluation, reductions in government spending, trade liberalization, tax increases and privatization. SAPs essentially opened African markets to cheap imports while devaluing and restricting exports.
The result in sub-Saharan Africa was particularly detrimental. While the short term effects of cheap imports from the United States, Asia, and Europe flooding African markets reduced prices of consumer goods, the long term impact was higher unemployment. Unable to compete with cheaper imports African industries folded. A similar case is true with respect to African exports. While open trade policies mandated by IMF allowed Africa to sell more goods overseas. This policy also eliminated Africa’s ability to set a price for these goods and limited the taxes that could be collected on export sales, signaling the loss of an important source of revenue for African nations.
Along with policies mandated by the World Trade Organization (discussed below) the ultimate impact of IMF and World Bank loans on Africa was to decrease revenue from exports, increase unemployment, decrease government spending on health and anti-poverty programs and encourage corruption. Another problem was the emphasis the IMF and World Bank placed on speedy loan repayment. This stipulation significantly depleted the funding available for social programming, including HIV/AIDS prevention and treatment. As recently as 2008, African countries continued to spend up to five times as much on debt repayment as on health care.[7] In fact, it has been proposed that the only groups to truly benefit from loan programs in Africa are the wealthy nations responsible for their implementation.
With cheaper African exports, new African markets to flood with cheap imports and the opportunity to exploit Africa’s natural resources through transnational investment, wealthy countries had much to gain by the implementation of SAPs. The organizational structure of the IMF and World Bank did little to counteract this progression. Largely driven by the wealthiest nations, loan condition policies were adopted by vote, where the highest contributing countries are given more total votes to cast. The US controls 17% of the vote in the World Bank, while the G7 collectively control 45%. These numbers are significant in contrast to African representation, where the 48 sub-Saharan countries together control only 9% of the vote.[8] These facts collectively reflect a genuine conflict of interest within the IMF and World Bank: wealthy countries were mandating policies in poor countries to help themselves and private industry, under the guise of international development.
In more recent years, the IMF has responded to criticism of its blanket SAPs by creating additional tools to replace the SAP: the Poverty Reduction Strategy Paper (PRSP) and Policy Support Instrument (PSI). These tools are designed to give countries more control over how they maintain stable economies in order to leverage more value from their IMF and World Bank loans. These proposals, while developed in-country, must still meet the approval of the lending organizations. As such, they have been less pivotal in practice than in design. More recently the IMF agreed, under pressure from the G8, to allow debt forgiveness to the most impoverished nations. Of course, for a country to qualify for debt forgiveness they must agree to adopt further economic stipulations developed by the IMF, deepening the problem of control.
World Trade Organization policies
The World Trade Organization played an important role in developing the rules governing trade in African economies at the end of the 20th century. This organization, which regulates international trade and negotiates tariffs, was active in bringing African economies into the world market. Much like IMF and World Bank policies, initial WTO policies were criticized for benefitting wealthier countries which could afford to heavily subsidize domestic production. For African countries without the resources to protect domestic industries, WTO tariff policy signaled increases in export tariffs that were exacerbated by an influx of cheap international goods.
The WTO allowed free exports on raw materials, but imposed heavy tariffs on processed or manufactured goods. These policies served to discourage precisely the kind of young industrial development from which Africa could benefit. As such emphasis shifted away from light domestic manufacturing towards foreign direct investment.
Beginning in the early 2000s, the WTO began to lift some of the heavier trade restrictions on African countries. Through the Everything but Arms initiative, Economic Partnership Agreements, and the African Growth and Opportunity act, most countries in Africa obtained duty free/quota free market access in the US and the EU. While this policy was beneficial, barriers to trade, such as rule of origin, non-tariff barriers, and Aid for Trade issues still exist in Africa today.[9]
The WTO’s most significant role in HIV/AIDS policy in Africa relates to the issue of drug availability. Until the turn of the last century, the WTO supported demands from developed nations and large drug companies to prevent the sale of generic drugs in countries where antiretroviral drugs had been patented. These countries did not have the resources to purchase non-generic drugs at market price (up to $10,000 annually per capita)[10] yet were forbidden from importing generics or producing drugs domestically to compete with patented imports. This decision played a major role in influencing the early African HIV/AIDS policies that effectively ignored infected populations because they could not afford the high cost of treatment. This approach is surely linked to the subsequent explosion of HIV/AIDS prevalence across the continent.
More recently the WTO has allowed these countries to introduce much cheaper generic drugs to compete with patented brands.[11] The outcome has been a significant reduction in the price of antiretroviral therapy, down to about $100 annually per capita.[12] While this is a clear victory for African nations fighting HIV/AIDS, other harmful WTO policies are still in place. Although there had been debate emphasizing development as the new primary WTO initiative, the recent economic downturn has caused a shift towards protectionist trade policies.[13] These policies, like earlier ones, continue to hurt Africa’s ability to obtain much-needed revenue from trade.
Additional Foreign Involvement in Africa
Transnational Corporations and Foreign Investment
While the HIV/AIDS epidemic is one of the most important battles Africa currently faces, there are many other social and economic needs that compete for the same limited resources. Governments must often make the difficult decision between providing basic infrastructure, sanitation or health services. More often than not in sub-Saharan Africa these governments become dependent on the “goodwill” of foreign organizations and investors operating within their borders to fund social programs. This is especially true in countries with a wealth of natural resources, many of which exist in sub-Saharan Africa. The “paradox of plenty”[14] creates weak, unstable, corrupt governments dependant on the export of natural resources. These nations, which are supported by export revenues and do not collect taxes, are less accountable to their populations. As such, they tend to pursue policies that are economically appealing on the macro level, with less regard to the economic and social wellbeing of their populations. This leads to the enrichment of a nation without parallel increases in societal wellbeing.
Lacking the infrastructure, technology and money to extract and process natural resources domestically, African countries often contract with foreign corporations. These corporations eagerly mine minerals and drill for oil at very low cost to the company but with high costs to the local population. The resources are then exported for processing and sale on the world market for great profit to the extraction company. The “goodwill” aid administered by these corporations can be removed or reduced at the discretion of the corporation. The social benefits packages, such as schools, sewage treatment, and limited health care are often promoted as altruism; however the more direct purpose is to pacify the exploited population in the region. Governments become dependent on these services of which they are too weak or poor to provide. The limited benefits therefore become linked to foreign investment and come and go with the creation and dissolution of contracts. This conditionality weakens the sovereignty of these nations by keeping the nation in a constant state of desperation and dependence.
Foreign Governments
Africa receives substantial assistance from foreign governments for the creation and promotion of anti- HIV/AIDS programs. Various funds around the world have been developed to supply regions or specific countries with drugs, supplies, and in some cases personnel to combat the spread of HIV/AIDS. The largest contributing donor of this type is the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), which supplied $5.8 billion in HIV/AIDS relief between 1997 and 2007. However, PEPFAR imposes limits and regulations stipulating what can and cannot be purchased with donated funds. Typically, these regulations require that the funds only be used to purchase drugs approved by the U.S. F.D.A and have U.S. origin.[15] This eliminates spending funds on less expensive generic drug imports or locally produced drugs. It also ensures that the money will eventually support the major pharmaceutical companies in the United States, effectively serving as a subsidy to already wealthy drug companies with diminished benefit to recipient countries.
The World Bank
While the World Bank is now a major provider of funding for HIV/AIDS initiatives in Africa, this was not always the case. Between 1990 and 1998 the World Bank enacted only two dedicated loans for the prevention and treatment of HIV/AIDS in sub-Saharan African nations.[16] By the World Bank’s own admission, they seriously underestimated the full weight the impact of HIV/AIDS would have on the economies of these countries, and as such chose not to address the issue in its early stages.[17] Recently the World Bank has increased the number of dedicated loans in this focus area, and has encouraged countries applying for loans to fully flesh out plans of action with respect to HIV/AIDS control in their loan application paperwork, specifically in their PRSPs.[18] Between 1997 and 2007 total World Bank funding commitments rose from just over $100,000 to $1.7 billion.
While the additional funding provided to sub-Saharan African nations is encouraging, the standard conditions inherent to World Bank loans discussed earlier remain a drawback.
Non-Government Organizations
Small and large non-government organizations also provide funding and support for HIV/AIDS programs in Africa. The most outstanding member of this community is the Global Fund, which since its founding in 2002 has committed over $3 billion to HIV/AIDS relief. These funds, donated by government and private sources, are disbursed in the form of grants, which do not have to be repaid. Like the World Bank and direct donations from foreign countries, this organization requires that recipient countries meet certain benchmarks and milestones in their use of grant money; however, these conditions are far less restrictive and have less to do with overall national economic policy than assurance of program transparency.
This organization is known for its innovative fundraising strategies (RED, Idol Gives Back) and is the second largest funder of HIV/AIDS treatment and prevention programs worldwide, after PEPFAR. Recently the Global Fund introduced its Debt2Health initiative. This creative program encouraged creditors to forgive a portion of the borrowing country’s debt with the stipulation that the borrower put the balance of the forgiven debt towards health initiatives.[19] Another policy working in the Global Fund’s favor is the emphasis they put on accountability. They do not plan or implement programs, but instead encourage partnerships between private, government and civic organizations within applicant countries to develop innovative programs that use evidence based practices specific to the country in question. Although the Global Fund has faced problems due to its hands-off style of oversight, it continues to be a major source of resources for sub-Saharan African countries.
Morality in a Globalized World
Comprehensive examination of the issues of HIV/AIDS and economic hardship in Africa forces a question of morality that does not exist in other areas globalization. Questions such as whether it moral for international organizations to extract profits from weak nations or whether it moral for these organizations to interfere at all in questions of public health in Africa arise. Unlike withholding other goods and services, the limitations placed on Africa’s ability to purchase antiretroviral drugs have a direct impact on human life. As a global society we must decide if organizations like PEPFAR and the WTO should be given the power to dictate purchasing options in situations such as these.
Policy makers have struggled to create policy that is both equitable and ethical in Africa. Many organizations are now attempting to re-align their goals to account for the full and pervasive impact of HIV/AIDS in the continent. Increasingly, HIV/AIDS is no longer perceived as a public health issue in isolation from the rest of countries’ policies, but rather a factor that is inextricably linked to the prosperity of the continent. This is a positive step and although there is still a long way to go before success can be claimed, it seems that the global community is beginning to hold itself accountable for previous oversights in Africa.