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

1. Institutions and Identities:Explaining Government Responses to HIV/AIDS in Brazil and South Africa Varun Gauri DECRG Evan Lieberman Princeton University

2. Motivation for Research on HIV/AIDS Adults and children estimated to be living with HIV/AIDS as of end 2003 Eastern Europe & Central Asia 1.2 – 1.8 million Western Europe 520 000 – 680 000 North America 790 000 – 1.2 million East Asia & Pacific 700 000 – 1.3 million North Africa & Middle East 470 000 – 730 000 Caribbean 350 000 – 590 000 South & South-East Asia 4.6 – 8.2 million Sub-Saharan Africa 25.0 – 28.2 million Latin America 1.3 – 1.9 million Australia & New Zealand 12 000 – 18 000 Total: 34 – 46 million >90 percent in developing countries 2.5-3.5 million died in 2003 alone Source: UNAIDS (2003)

3. Life expectancy in Brazil and South Africa (HIV+ : 0.7%)* (HIV+ : 21.5%)* Source: World Bank, World Development Indicators (2004) *Adult HIV Prevalence estimates, UNAIDS epidemiological factsheets (2004)

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

5. The Puzzle: Might have expected similar government responses… • Life-threatening pandemic has touched virtually every corner of the globe • Narrow time frame (1982-present) • General agreement about scientific and policy best practice (“Geneva Consensus”) • Wide dissemination of information … But we observe wide variation.

6. AIDS Response Regime • Total national government effort to curb the AIDS epidemic • As distinct from NGO, sub-national government, international responses • Aggressiveness (speed, scope) • Bureaucratic development • Prevention policies, as implemented • Treatment of PLWHA, as implemented

7. Case Selection Strategy:Brazil and South Africa • Author familiarity • Control for level of development • Control for similar epidemic onset • Somewhat earlier in Brazil (1982 vs 1985) • Initially prevalent among gay men in urban centers • But fear of major generalized epidemic in both countries by 1991 • Initially select cases with high variation on the dependent variable (expenditure and reputation)

8. Expenditures on HIV/AIDS

9. Expenditures on ARVs

11. Model of AIDS Policy Making:Preliminary Assertions (Constants) • Inherently undesirable agenda item for national government leaders/ policy makers • Internal and external stigma • Sex, sexuality, drug use • “Silent” epidemic • Implies asking citizens to do things they would rather not do • Policy response increasingly aggressive when political influence of proponents supersedes that of policy opponents • Proponents: International organizations; HIV+ individuals; health care professionals; activists/NGO’s • Opponents: Competing interests; moral conservatives • Political arena mediates influence of such groups such that resources or extent of problem provide limited predictive power

12. Decentralization of decision-making autonomy provides policy “surface area” for policy entrepreneurs in low priority policy area Early sub-national adoption highlights threat, provides template for action, leading to faster response at national level Minimum of centralized state capacity necessary, but contra Nathanson, increasingly centralized state does not always lead to faster, more expansive response Explaining cross-country variation:I) Political institutions

13. Comparing political institutions

14. The impact of institutions on AIDS politics and policy • Decentralized Brazilian institutions facilitate rapid response • Federal government initially resisted response • Early and aggressive Estado and municipo responses in Southeast: testing, education, ARV, treatment, counseling • Central government follows, facing mounting pressure • Centralized South African institutions inhibit true policy autonomy, stifling action • Entrepreneurial municipalities and provinces are branded renegades (e.g. Global Fund debacle w/ KwaZulu-Natal) • ANC rank and file dares not challenge NEC (e.g. Durban municipality on Nevirapine for MTCT)

15. Hypothesized impact of institutions Rapid Brazil Predicted speed of AIDS policy response by central government (ceteris paribus) So. Africa Slow/none Consolidated state? Local policy autonomy No High Yes High Yes Medium Yes Low Yes None Centralization/concentration of political authority

16. Explaining cross-country variation: II) National Political community • National Political Community= state-sponsored definition of nation • Strength of NPC rooted in sum of attachments to and tolerance towards fellow citizens • Negatively related to group-based intolerance of citizens • Government AIDS response depends on domestic political support, which hinges on perceived risk of infection • Perceived risk= f (“actual” risk; information, interpretation) • In weak NPCs/divided societies, politically salient divides create space for mis-information, discounting of threat: • Risk of infection depends on intimate contact with HIV+ individuals • In divided societies, such contact is presumed to be within groups • Risk assigned to “them” • Risk discounted as conspiracy by “them” • Marginalized group leaders distance group from disease [Cohen 1998] • Result: less overall demand from society, and lowered perceived threat from government (and vice versa)

17. Measuring National Political CommunityWorld Values Survey (1980, 90, 95-7 waves): Who would you not like to have as a neighbor?Percent mentioning “Someone of a different race” NB: Higher values indicate weaker National Political Community

18. Measuring National Political CommunityWorld Values Survey (1995-7): Who would you not like to have as a neighbor?Percent mentioning “homosexuals” NB: Higher values indicate weaker National Political Community

19. Self-reported inter-racial marriage Source: Telles 1994, analysis of Brazil 1991, South Africa 1996 census data NB: Higher values indicate stronger National Political Community

20. The Impact of NPC on AIDS Politics, Policy • South Africa • All HIV/AIDS statistics, even blood, reported along racial lines • Racial discourse • Blacks: White, gay disease; plot (AIDS =“Afrikaner Invention to Deprive us of Sex”) • Whites: Black/ African disease; terrorists • Civil society disunity: TAC/NAPWA race conflict • Result: Only 13% of South Africans said AIDS should be priority for government (2002) • Brazil • Virtually no race-based HIV/AIDS statistics reported • Almost no discussion of race in context of HIV/AIDS • Promotion of solidariédade strategy (“Whitening” public health legacy) • Possible for gay groups to organize, demand action • Result: wide popular support for and pride in AIDS resposta

21. Hypothesized impact of National Political Community High Brazil Predicted aggressiveness of AIDS policy response by central government (ceteris paribus) So. Africa Low/none Low/divided society High Tolerance for other groups in NPC/Mixing

22. Rival hypotheses: Weak/no evidence • Political regime type/ civil society (Sen) • International linkages/influence • State capacity, especially in health • Executive leadership (‘the Mbeki hypothesis’) • Tautology? Cannot measure leadership in terms of action on AIDS • By any standard, better general “leadership” in South Africa as compared with Brazil • Wouldn’t have had similar effect in more decentralized polity (e.g., Brazil)