Institutions and Identities:Institutions and Identities:Explaining Government Responses to Explaining Government Responses to HIV/AIDS in Brazil and South AfricaHIV/AIDS in Brazil and South Africa

Varun GauriVarun Gauri

DECRGDECRG

Evan LiebermanEvan Lieberman

Princeton UniversityPrinceton University

Motivation for Research on HIV/AIDSMotivation for Research on HIV/AIDS

Total: 34 – 46 million>90 percent in developing countries

2.5-3.5 million died in 2003 alone

Western Europe520 000 – 680 000

North Africa & Middle East

470 000 – 730 000

Sub-Saharan Africa25.0 – 28.2 million

Eastern Europe & Central Asia1.2 – 1.8 million

South & South-East Asia

4.6 – 8.2 million

Australia & New Zealand

12 000 – 18 000

North America790 000 – 1.2 million

Caribbean350 000 – 590 000

Latin America1.3 – 1.9 million

East Asia & Pacific700 000 – 1.3 million

Adults and children estimated to be living with HIV/AIDS as of end 2003Adults and children estimated to be living with HIV/AIDS as of end 2003

Source: UNAIDS (2003)

33

Life expectancy in Life expectancy in Brazil and South AfricaBrazil and South Africa

68.6

66.2

54.8

46.5

62.9

49.2

30

35

40

45

50

55

60

65

70

75

19

60

19

63

19

66

19

69

19

72

19

75

19

78

19

81

19

84

19

87

19

90

19

93

19

96

19

99

20

02

Brazil

SouthAfrica

Source: World Bank, World Development Indicators (2004)*Adult HIV Prevalence estimates, UNAIDS epidemiological factsheets (2004)

(HIV+ : 0.7%)*

(HIV+ : 21.5%)*

44

Theoretical relevance for political Theoretical relevance for political economy of developmenteconomy of development

Politics of development (Sen, Przeworski Politics of development (Sen, Przeworski et. al., Haggard & Kaufman)et. al., Haggard & Kaufman)Origins of state capacity (Tilly, Levi, Origins of state capacity (Tilly, Levi, Migdal, Evans)Migdal, Evans)Politics of public policy making, especially Politics of public policy making, especially social policy (Steinmo and Thelen, Bates social policy (Steinmo and Thelen, Bates & Krueger, Van de Walle, Grindle)& Krueger, Van de Walle, Grindle)Very limited published political science Very limited published political science research on HIV/AIDSresearch on HIV/AIDS

55

The PuzzleThe Puzzle: : Might have expected similar Might have expected similar

government responses…government responses…

Life-threatening pandemic has touched virtually every corner of the Life-threatening pandemic has touched virtually every corner of the globeglobeNarrow time frame (1982-present)Narrow time frame (1982-present)General agreement about scientific and policy best practice General agreement about scientific and policy best practice (“Geneva Consensus”)(“Geneva Consensus”)Wide dissemination of informationWide dissemination of information

… … But we observe wide variation.But we observe wide variation.

66

AIDS Response RegimeAIDS Response Regime

Total national government effort to curb Total national government effort to curb the AIDS epidemicthe AIDS epidemic

As distinct from NGO, sub-national As distinct from NGO, sub-national government, international responsesgovernment, international responses

Aggressiveness (speed, scope)Aggressiveness (speed, scope)– Bureaucratic developmentBureaucratic development– Prevention policies, as implementedPrevention policies, as implemented– Treatment of PLWHA, as implementedTreatment of PLWHA, as implemented

77

Case Selection Strategy:Case Selection Strategy:Brazil and South AfricaBrazil and South Africa

Author familiarityAuthor familiarityControl for level of developmentControl for level of developmentControl forControl for similar epidemic onset similar epidemic onset– Somewhat earlier in Brazil (1982 vs 1985)Somewhat earlier in Brazil (1982 vs 1985)– Initially prevalent among gay men in urban centersInitially prevalent among gay men in urban centers– But fear of major generalized epidemic in both But fear of major generalized epidemic in both

countries by 1991countries by 1991

Initially select cases with high variation on the Initially select cases with high variation on the dependent variable (expenditure and reputation)dependent variable (expenditure and reputation)

88

Expenditures on HIV/AIDSExpenditures on HIV/AIDS

National Program Expenditures on HIV/AIDS

0102030405060708090

100

1987

1989

1991

1993

1995

1997

1999

2001

Mil

lio

ns

of

US

Do

llar

s, 2

002

South Africa

Brazil

99

Expenditures on ARVsExpenditures on ARVs

Expenditures on ARVs

050

100150200250300350400

1997

1998

1999

2000

2001

2002

2003

2004

Year

US

Do

llar

s, m

illi

on

s

Brazil

South Africa

1010

Table 1: Aggressiveness of Government Responses to HIV/AIDS (1982-2004) South Africa Brazil Policy Areas Much more

aggressive More

aggressive

About same

More aggressive

Much more aggressive

Bureaucratic Development Timing and authority of national program

X

Level of historical expenditures

X

Scope and timing of research and surveillance

X

Scope of NGO partnerships

X

Prevention Timing of blood safety

X

Scope of testing

X

Scope of condom distribution and use

X

Timing of programs to prevent mother to child transmission

X

Timing and scope of programs targeted at local risk groups

X

Treatment of PLHAs Timing of monotherapy

X

Timing and scope of triple therapy

X

Scope of laboratory system

X

Timing and scope of human rights legislation

X

Overall: Bureaucratic Development

X

Overall: Prevention X Overall: Treatment of PLHAs X

1111

Model of AIDS Policy Making:Model of AIDS Policy Making:Preliminary Assertions (Constants)Preliminary Assertions (Constants)

Inherently undesirable agenda item for national government leaders/ Inherently undesirable agenda item for national government leaders/ policy makerspolicy makers– Internal and external stigmaInternal and external stigma– Sex, sexuality, drug useSex, sexuality, drug use– ““Silent” epidemicSilent” epidemic– Implies asking citizens to do things they would rather not doImplies asking citizens to do things they would rather not do

Policy response increasingly aggressive when political influence of Policy response increasingly aggressive when political influence of proponents supersedes that of policy opponentsproponents supersedes that of policy opponents– ProponentsProponents: International organizations; HIV+ individuals; health care : International organizations; HIV+ individuals; health care

professionals; activists/NGO’sprofessionals; activists/NGO’s– OpponentsOpponents: Competing interests; moral conservatives: Competing interests; moral conservatives

Political arena mediates influence of such groups such that Political arena mediates influence of such groups such that resources or extent of problem provide limited predictive powerresources or extent of problem provide limited predictive power

1212

Explaining cross-country variation:Explaining cross-country variation:I) Political institutionsI) Political institutions

Decentralization of decision-making autonomy provides Decentralization of decision-making autonomy provides policy “surface area” for policy entrepreneurs in low policy “surface area” for policy entrepreneurs in low priority policy areapriority policy area

Early sub-national adoption highlights threat, provides Early sub-national adoption highlights threat, provides template for action, leading to template for action, leading to faster faster response at national response at national levellevel

Minimum of centralized state capacity necessary, but Minimum of centralized state capacity necessary, but contra Nathanson, increasingly centralized state does contra Nathanson, increasingly centralized state does not always lead to faster, more expansive responsenot always lead to faster, more expansive response

1313

Comparing political institutionsComparing political institutions

Brazil:Brazil:

Decentralized/ High Decentralized/ High Policy AutonomyPolicy Autonomy

South Africa:South Africa:

Centralized/ Low Policy Centralized/ Low Policy AutonomyAutonomy

Federal constitutionFederal constitution

(federal tradition)(federal tradition)

YesYes

(Strong/long)(Strong/long)

YesYes

(Weak/new)(Weak/new)

Taxation powers of Taxation powers of sub-national sub-national governmentsgovernments

ExtensiveExtensive MinimalMinimal

Election of provincial Election of provincial (estado) (estado) leadersleaders

DirectDirect Indirect (ultimately, Indirect (ultimately, choice of party leaders)choice of party leaders)

Party systemParty system Fragmented; no majority Fragmented; no majority party; regional power party; regional power basesbases

Single-party dominant: Single-party dominant: ANC controls 66% of ANC controls 66% of parliament; 7/9 provincesparliament; 7/9 provinces

1414

The impact of institutions on AIDS The impact of institutions on AIDS politics and policypolitics and policy

Decentralized Brazilian institutions facilitate rapid Decentralized Brazilian institutions facilitate rapid responseresponse– Federal government initially resisted responseFederal government initially resisted response– Early and aggressive Early and aggressive EstadoEstado and and municipo municipo responses in responses in

Southeast: testing, education, ARV, treatment, counselingSoutheast: testing, education, ARV, treatment, counseling– Central government Central government follows, follows, facing mounting pressurefacing mounting pressure

Centralized South African institutions inhibit true Centralized South African institutions inhibit true policy autonomy, stifling actionpolicy autonomy, stifling action– Entrepreneurial municipalities and provinces are branded renegades Entrepreneurial municipalities and provinces are branded renegades

(e.g. Global Fund debacle w/ KwaZulu-Natal)(e.g. Global Fund debacle w/ KwaZulu-Natal)– ANC rank and file dares not challenge NEC (e.g. Durban municipality on ANC rank and file dares not challenge NEC (e.g. Durban municipality on

Nevirapine for MTCT)Nevirapine for MTCT)

1515

Hypothesized impact of institutionsHypothesized impact of institutions

Centralization/concentration of political authority

NoHigh

Predicted speed of AIDS policy response by central government(ceteris paribus)

Slow/none

RapidBrazil

So. Africa

Consolidated state?Local policy autonomy

YesHigh

YesMedium

YesLow

YesNone

1616

Explaining cross-country variation:Explaining cross-country variation: II) National Political communityII) National Political community

National Political Community= state-sponsored definition of nationNational Political Community= state-sponsored definition of nation– Strength of NPC rooted in sum of attachments to and tolerance Strength of NPC rooted in sum of attachments to and tolerance

towards fellow citizenstowards fellow citizens– Negatively related to group-based intolerance of citizensNegatively related to group-based intolerance of citizens

Government AIDS response depends on domestic political support, Government AIDS response depends on domestic political support, which hinges on perceived risk of infectionwhich hinges on perceived risk of infectionPerceived risk= f (“actual” risk; information, interpretation)Perceived risk= f (“actual” risk; information, interpretation)In weak NPCs/divided societies, politically salient divides create In weak NPCs/divided societies, politically salient divides create space for mis-information, discounting of threat:space for mis-information, discounting of threat:– Risk of infection depends on Risk of infection depends on intimateintimate contact with HIV+ individuals contact with HIV+ individuals– In divided societies, such contact is presumed to be In divided societies, such contact is presumed to be within within groupsgroups– Risk assigned to “them” Risk assigned to “them” – Risk discounted as conspiracy by “them”Risk discounted as conspiracy by “them”– Marginalized group leaders distance group from disease [Cohen 1998]Marginalized group leaders distance group from disease [Cohen 1998]– Result: less overall demand from society, and lowered perceived threat Result: less overall demand from society, and lowered perceived threat

from government (and vice versa)from government (and vice versa)

1717

Measuring National Political CommunityMeasuring National Political CommunityWorld Values Survey (1980, 90, 95-7 waves): World Values Survey (1980, 90, 95-7 waves):

Who would you Who would you not not like to have as a neighbor?like to have as a neighbor? Percent mentioning “Someone of a different race”Percent mentioning “Someone of a different race”

0

5

10

15

20

25

30

Brazil 1990 Brazil 1995-7 South Africa1981

South Africa1995-7

NB: Higher values indicate weaker National Political Community

1818

Measuring National Political CommunityMeasuring National Political CommunityWorld Values Survey (1995-7): World Values Survey (1995-7):

Who would you Who would you not not like to have as a neighbor?like to have as a neighbor? Percent mentioning “homosexuals”Percent mentioning “homosexuals”

49

16

0

10

20

30

40

50

60

Brazilians South Africans

NB: Higher values indicate weaker National Political Community

1919

Self-reported inter-racial marriageSelf-reported inter-racial marriage

0%

5%

10%

15%

20%

25%

Brazil South Africa

Source: Telles 1994, analysis of Brazil 1991, South Africa 1996 census dataNB: Higher values indicate stronger National Political Community

2020

The Impact of NPC on AIDS The Impact of NPC on AIDS Politics, PolicyPolitics, Policy

South AfricaSouth Africa– All HIV/AIDS statistics, even blood, reported along racial linesAll HIV/AIDS statistics, even blood, reported along racial lines– Racial discourseRacial discourse

Blacks: White, gay disease; plot (AIDS =“Blacks: White, gay disease; plot (AIDS =“AAfrikaner frikaner IInvention to nvention to DDeprive us of eprive us of SSex”)ex”)Whites: Black/ African disease; terroristsWhites: Black/ African disease; terrorists

– Civil society disunity: TAC/NAPWA race conflictCivil society disunity: TAC/NAPWA race conflict– Result: Only 13% of South Africans said AIDS should be priority for Result: Only 13% of South Africans said AIDS should be priority for

government (2002)government (2002)

BrazilBrazil– Virtually no race-based HIV/AIDS statistics reportedVirtually no race-based HIV/AIDS statistics reported– Almost no discussion of race in context of HIV/AIDSAlmost no discussion of race in context of HIV/AIDS– Promotion of Promotion of solidarisolidariéédade dade strategy (“Whitening” public health legacy)strategy (“Whitening” public health legacy)– Possible for gay groups to organize, demand actionPossible for gay groups to organize, demand action– Result: wide popular support for and pride in AIDS Result: wide popular support for and pride in AIDS respostaresposta

2121

Hypothesized impact of National Hypothesized impact of National Political CommunityPolitical Community

Tolerance for other groups in NPC/Mixing

Low/divided society High

Predicted aggressiveness of AIDS policy response by central government(ceteris paribus)

Low/none

High

Brazil

So. Africa

2222

Rival hypotheses: Weak/no evidenceRival hypotheses: Weak/no evidence

Political regime type/ civil society (Sen)Political regime type/ civil society (Sen)International linkages/influenceInternational linkages/influenceState capacity, especially in healthState capacity, especially in healthExecutive leadership (‘the Mbeki hypothesis’)Executive leadership (‘the Mbeki hypothesis’)– Tautology? Cannot measure leadership in terms of Tautology? Cannot measure leadership in terms of

action on AIDSaction on AIDS– By any standard, better general “leadership” in South By any standard, better general “leadership” in South

Africa as compared with BrazilAfrica as compared with Brazil– Wouldn’t have had similar effect in more Wouldn’t have had similar effect in more

decentralized polity (e.g., Brazil)decentralized polity (e.g., Brazil)