By Evan Lieberman
Associate Professor, Department of Politics, Princeton University

People in South Africa overwhelmingly believe that addressing HIV/AIDS is firstly the responsibility of national government, in contrast with the current governance arrangements that put provincial government as the lead for governing health matters. Although foreign donors and civil society play very large roles in governing infectious disease, less than 20 percent of Eastern Cape residents identified them as appropriate authorities in a nationally representative 2009 omnibus survey of South African adults. This highlights a serious disconnect between citizen expectations and reality in terms of who governs infectious disease, which dampens citizen abilities to hold the appropriate authorities accountable.

So who should be responsible for governing the threat of infectious diseases such as HIV/AIDS, tuberculosis, and malaria? As the “old” paradigm of strong centralized state public health programs was found to be outmoded, a new set of governance models emerged in its wake, all involving greater devolution of authority and more horizontally organized reporting structures. In particular, a few appealing terms have buzzed about during the past three decades of the global AIDS crisis, including “multisectoral,” “synergistic,” “partnership,” “mutual accountability,” and “coordination.” Who could argue with any of these?

The problem, from a policy implementation standpoint, is that these are actually goals in themselves, not levers that can simply be pulled at will to successfully reduce the transmission of diseases, to treat those who are infected, and/or to provide support to those who need it.

Telling a bunch of disparate and often rival interests to just cooperate or to act in a synergistic manner is like taking a bunch of kids to a candy store and telling them to select the healthiest snacks, especially those without excess sugar. It might happen, but it’s not likely without strong incentives and enforceable sanctions.

Too many contemporary best practice recommendations concerning the structure of governance for better global public health seem to rest on politically naïve assumptions. Those who suggest “cooperation” or “coordination” as a strategy rather than as an objective seem to take for granted that the various health-relevant actors and stakeholders in a society will not only prioritize health-related goals, but will consistently do so in a manner that is concerned with the general welfare, and not with their own interests as politicians seeking re-election or as organizations looking for additional resources. While there are many committed civil servants, NGO leaders, and activists who act selflessly each and every day, such patterns are more exceptional than the norm.

In my recently published research on the governance of infectious disease in South Africa (Social Science & Medicine, September 2011) I detail some of the pathologies of an approach that devolves authority to multiple, overlapping actors in a structure recognizable as polycentric governance. I present a case study from South Africa to examine how governance structure affects accountability and performance. The analysis is based on interviews with municipal councilors, hospital and clinic administrators, non-government service providers, political party leaders, academics and journalists, religious leaders, traditional leaders and healers, large businesses, and public law advocates. In addition, we administered a survey to local councilors, and I commissioned a question about perceived governance responsibilities for HIV/AIDS on the aforementioned 2009 omnibus survey of South African adults.

Comments made during the interviews indicate some of the challenges of polycentric governance. While some health programs are organized and administered at the municipality level, funding often comes from the provincial or national arenas, making it difficult for the municipality to hire long-term employees or maintain programs. Although non-governmental organizations provide valuable funding and new projects, they also add to the complexity of the system owing to their fragile resource needs. NGO representatives complained about time wasted on reports and paperwork to comply with PEPFAR and other donors.

Polycentrism may also lead to the unnecessary provision of duplicate services or competition among actors who are carrying out similar programs. For example, in some areas we found two types of local clinics, some run by the municipality, and others managed by the province through the district health system. This resulted in some duplication of services as well as conflict over funding disparities. Provincial clinics were generally better resourced, while municipalities, with very limited tax bases, depend on the provinces for funding.

Many would argue that with a crisis as acute as the AIDS epidemic in South Africa, more actors working to provide resources and solve problems would lead to better outcomes. However, this does not necessarily appear to be the case. Polycentric governance without a clear hierarchy or system for enforcing commitments can lead to duplicate services or gaps that are left unfilled, not to mention confusion and frustration.

This research raises more questions than provides answers. It does not identify the optimal governance structure for the South African case, let alone a general model that might work elsewhere. But it does suggest the need to take much more seriously the question of how to govern, and to distinguish desirable goals from concrete strategies. More systematic reflection and research is needed concerning how to incentivize political leaders at various levels of government, and the range of non-government organizations and service providers to do a better job of prioritizing and coordinating critical disease-related services.

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