Journal Article

IDS Bulletin Vol. 39 Nos. 5

Politics and Policy Outcomes on Children Affected by HIV/AIDS in Africa

Published on 1 November 2008

Global agencies working for children affected by AIDS have recently reported some progress (UNAIDS 2008).

Year by year, more HIV-positive pregnant women receive medication to avoid infecting their unborn babies, increasing numbers of children in late stages of HIV infection receive antiretroviral treatment (ART), and a higher proportion of affected children enjoy some form of social protection and schooling. However, while all this is good news, countries still fail to provide basic services to the majority of orphans and vulnerable children (OVC) in the context of AIDS. Clearly, all stakeholders need to do more to protect children from the effects of AIDS. But how can this be done? A dominant discourse suggests that governance and politics can provide leverage to a more effective response.

Advice from global agencies on how countries should respond to AIDS is based on the central assumption that whatever the level of structural disadvantage and severity of the epidemic, countries can fight AIDS (more) effectively if they get the politics right. There have been repeated calls for better ‘leadership’. These recommendations have an institutional dimension that is summarised in the ‘Three Ones’: one HIV/AIDS action framework, one national AIDS coordinating authority, and one monitoring and evaluation system (UNAIDS 2004). However, these institutions and processes should also be based in and give effect to more normative politics of democracy; responses should mainstream human rights, and allow for participation and accountability (UNAIDS 2006a). While the institutional blueprint is meant to make governance more effective, the central motivation for the normative dimension is to ensure HIV-positive people of protection against discrimination and access to policymaking on AIDS. But the hypothesis that politics can make a difference is relevant also beyond the specifics of the AIDS response. More general theories of democracy and governance suggest that countries that are more democratic and countries that have better governance will respond more effectively to societal challenges, also in a development context (Halperin et al. 2005; Goetz and Jenkins 2004; Sen 1999; UNDP 2002).

This reasoning leads us to the central question for this research: are countries with better AIDS governance, with better governance generally and with higher quality democracy more effective in responding to the needs of children affected by AIDS?Or in a different formulation, are any elements of governance or democracy determinants of the effectiveness of such responses? If we can identify any such political factors we have contributed to the explanation of why some countries perform better in their responses to AIDS, but the results may also hold clues for more effective advocacy strategies.

Our research is guided by four contributions in the literature that seek to explain variations in country responses to AIDS through the same methodology that we will apply here, statistical analysis of data from a large number of countries. The research by Nicoli Nattrass (2006) seeks to explain variations in Highly Active Antiretroviral Therapy (HAART) coverage on the basis of data from 77 transitional and developing countries. She includes two political variables in a larger set of variables on economic, structural and regional effects. In terms of the political variables, her results show that quality of the electoral process has no impact but that established democracies have better coverage. Mary Kinney’s research (2007) tests the effect of foreign aid on ART coverage in sub-Saharan Africa. The research controls for the political variables identified by Nattrass, but it also includes data on the quality of governance and levels of democracy. With regard to politics, the research shows that better governance is a determinant of higher ART coverage.

The research by Evan Lieberman (2007) tests whether the coverage of ART across 85 developing countries is determined in part by countries’ degree of ethnic fractionalisation, a factor that is assumed to reflect the degree to which the provision of public goods is hampered by the politics of neopatrimonialism. In terms of political factors, he finds that both ethnic fractionalisation and government effectiveness determine ART. The research by Jacob Bor (2007), finally, argues an explanation for the quality of governments’ responses to AIDS, as measured by the ‘political support’ score in the AIDS Program Effort Index with data on 53 developing countries (POLICY Project 2003). In terms of political factors, he concludes that electoral accountability has a statistically significant negative effect on the quality of the response, suggesting that competitive democratic elections are a disincentive for a strong government action. Instead of elections, he finds that the level of press freedom has a positive effect.

These four different analyses reach somewhat different results because they use different data to capture abstract political concepts and because they include different countries in their analyses. Despite these differences, it is clear that political variables are relevant and sometimes central to the explanatory argument. Compared to the four analyses above, our research here is more explorative. Instead of generating a ‘best model’ explanation for a particular outcome – a model that may or may not include a political variable – we will test the relevance of a number of political variables for explaining a number of different policy outcomes, as will become clear in the section below. Our research is based on data from 42 of the 44 countries in sub-Saharan Africa (excluding only Liberia and Equatorial Guinea), the sub-continent which is worst affected by the global AIDS pandemic and where the needs of children affected by AIDS present governments with particular challenges.

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This article comes from the IDS Bulletin 39.5 (2008) Politics and Policy Outcomes on Children Affected by HIV/AIDS in Africa

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Strand, P., Kinney, M. and Mattes, R. (2008) Politics and Policy Outcomes on Children Affected by HIV/AIDS in Africa. IDS Bulletin 39(5): 80-87

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Per Strand
Mary Kinney
Robert Mattes


Robert Mattes

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Institute of Development Studies


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