The international policy response to AIDS in Africa (1986-1996): Empirical bases, theoretical tools

Two goals guide this chapter. First, it aims to demonstrate how public action was constructed at the international level and then at the State level to respond to the spread of AIDS in Africa, and how such action was received. Second, it addresses the epistemological question of which anthropological and political science tools can best contribute to the analysis of the fight against AIDS in Africa. This goal is achieved by creating a theoretical framework which is outlined in the second part of the chapter.

The 2000s signalled a turning point in the response to the major pandemics that had emerged during the previous quarter-century. By 2009, global financing for the three major pandemic diseases, AIDS, tuberculosis, and malaria reached USS15.5 billion, half of which came from bilateral and multilateral aid. In this context, the AIDS response carried substantial weight, which led to a better awareness of the other two pandemics. Between the early 1980s, when the first cases of AIDS appeared, and the end of the 1990s, the AIDS pandemic had indisputably become one of the deadliest diseases ever to spread within such a short time period. Globally, sub-Saharan Africa has paid the heaviest price of all world regions, claiming 70% of the cases worldwide, or 25.8 million out of some 36.9 million (UNAIDS, 2015).

Any presentation of the straggle against AIDS must take into account the disease’s uneven development across Africa. I do so by beginning with the major thrust of the international response, namely its major benchmarks and directives, from the founding of the World Health Organization (WHO) Global Programme on AIDS (GPA) in 1986 up to the creation of the Joint UN Programme on HIV/ AIDS (UNAIDS) in 1996. The chapter opens with a comparison of the contributions and limitations of each programme through the prism of the African experience and its contribution to public policy analysis (Table 1.1).

The gradual construction of a theoretical framework to describe and analyse the international response to AIDS in Africa

Jones’s sequential grid: between black box and blind spot in public policy analysis

Sequence analysis of public policy implementation occupies a central place in the political sociology of public action (Hassenteufel, 2005, 2011). Research centred

Table 1.1 Seroprevalence rates (in %) of HIV/AIDS in the 15-49 age group, for selected African countries, 2016.

Source: World Factbook, CIA: www.cia.gov/library/publications/resources/the-world-factbook/ Note: For each country in the table, file specific estimates are: Swaziland (27.2%), Botswana (21.9%), South Africa (18.9%), Namibia (13.8%), Zimbabwe (13.5%), Zambia (12.4%), Mozambique (12.3%), Malawi (9.2%), Kenya (5.4%), Cameroon (3.8%), Côte d’Ivoire (2.7%), Senegal (0.6%), Niger (0.5%), Mauritania (0.5%).

on public policies promulgated or influenced by international organisations, such as comparative studies of different “States in action”, falls into the domain of transnational policy analysis. Public policy in which the State theoretically plays a regulatory role tends to fall under the rubric of "public action”, because of the highly diverse actors and multiple centres of power (polyarchies) that guide such policy.

Books influenced by social anthropology, like Marc-Eric Gruenais’s Organiser la lutte contre le sida en Afrique [Organising the Fight Against AIDS in Africa] (Gruénais et al., 1999), do not explicitly reference the notions and concepts of Public Policy Analysis (PPA). This is why, elsewhere, I proposed to bridge PPA and social anthropology Eboko, 2005a). Given the richness and diversity of the paradigms and subject matter of each discipline, my intention has not been to critique their shortcomings at the risk of setting up an epistemological stand-off between the two. After all, researchers and research teams who find themselves at the interface of different disciplines often try to work with the paradigms of each. In the field of transnational policy, Andy Smith has attempted to join International Relations (IR) and PPA in the European context Smith, 2013). In his case and mine, the challenge is to find analytic frameworks that not only allow the researcher to understand a given situation, but are also replicable (or not) in similar situations and allow for the generation of falsifiable hypotheses. In other words, such frameworks should be able to contribute to advancing scientific and critical thinking in one or several fields.

Within this logic, the process of implementing transnational public policies in the fight against AIDS in African States, first described in one of Gruénais’s comparative studies (Gruénais et al., 1999), can be illuminated through sequence analysis. Although the approach to policy by examining its sequences is usually attributed to Charles Jones, the most cited and critiqued author in this, it actually dates back to Harold Lasswell in the mid-1950s (Hassenteufel, 2011) and was mostly used by Laswell’s students. Among them, Garry Brewer (1974) stands out for having proposed six successive sequences: ( 1) the definition of the problem; (2) the ranking of problems in terms of preference; (3) the selection of a solution; (4) the implementation of "the solution”; (5) the evaluation; (6) the actualisation of the policy (Hassenteufel, 2011, p. 30). In their comparative study of AIDS public policy in vertical health programs, Gruénais and his team touched on four of Brewer’s six sequences. The team also addressed other conventional ideas developed in Public Policy Analysis. Their studies of Cameroon (Central Africa), Côte d’Ivoire and Senegal (West Africa), and Kenya (East Africa) identify three successive entry-points - processes, institutions, and actors - and draw on anthropology, sociology, political science, and history. Their multidisciplinary approach would undoubtedly have sounded familiar to the tenants of the “31” model (“ideas”, “institutions”, and “interests”) in PPA (Palier and Surel, 2005).

Following in the footsteps of this collective approach and drawing on my dual training (my doctoral thesis was co-directed by a political scientist and by an anthropologist), I have situated my own objectives, research projects, and analyses within Public Policy Analysis. I began by drawing on the classic "Grenoble School” of political science connected to Bnmo Jobert and Pierre Muller (Grawitz and Leca, 1985; Jobert and Muller, 1987). To study public policy in the domain of AIDS, I identified the following stages: the emergence of the problem; the construction of solutions according to the guidelines of the WHO Global Programme on AIDS (GPA); standardised implementation and the achievement of transnational policies within a differentiated dynamic (Eboko, 1999c). As a member of the French Institute for Research on Development (Institut de Recherche pour le Développement (IRD)), I was able to expand this theoretical and empirical reflection within a comparative perspective. To do so, I chose to confront PPA with the "political cultures” perspective (Cefa'i, 2001), apprehended through a dynamic approach (Eboko, 2005a, 2005b, 2005c). After the lowering of drug prices accelerated access to combination antiretrovirals (ARV), I turned to the institutionalisation of the straggle against AIDS in Africa, almost 20 years after the epidemic had first been acknowledged (Eboko, 2004).