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Building dynamic democraticgovernance and HIV-resilient societies
Lee-Nah Hsu
Are we really doing all that we can to stop thespread of the human immunodeficiency virus(HIV) and the resulting acquired immunedeficiency syndrome (AIDS)? It would seemnot, judging from the speed with which thepandemic is gaining ground. Responses to HIVand AIDS – outside the domain of public healthinitiatives – still remain quite limited. Couldresponses to HIV and AIDS be improved? Theanswer is yes.Much of the researchand evaluation in the variousAIDS programmes ignorethe impact of developmenton HIV epidemics and, con-versely, the impact of AIDSon development. Little em-pirical research has been con-ductedtoassesstheimpactof infrastructural developmentprojects on the spread of HIVepidemics.Forexample,when a dam or road is beingconstructed in a remote,mountainous area of a devel-oping country, there is asudden influx of young andoften risk-taking male work-ers who will reside in the areafor an average of 3–5 years(seealsoGiang2004).Theruralresidentsinsuchareas are often poor, so their typical response tothis influx of salaried outsiders is a welcomingone. The presence of so many unattachedworkers will enable the villagers to sell foodand to provide lodging, entertainment, andother services. However, most of the villagershave no knowledge about HIV and AIDS oraccess to preventive measures against infection.Unfortunately, the unintended outcome of suchdevelopment projects can be the further spreadof HIV and AIDS. This does not mean thatinfrastructural development projects must bestopped, but it does mean that decision-makersrequiremoreinformationandcontextualknowl-edge before making choices on policies, pro-grammes, and resource allocations (du Guernyand Hsu 2002).No single checklistwill suffice: responding toHIV and AIDS is techni-cally complex and re-source-intensive (de Waal2003). However, one of thecritical elements that deci-sion-makers must consider,especially in anticipatingoutcomes and respondingeffectively and consistentlyto HIVand AIDS, involvesan elemental principle pro-moted by the United Na-tions: human rights.An elaboration of ourexample illustrates whythis is so important. Aspeople move into newareas, so do diseases. This phenomenon waswell demonstrated by the outbreak and rapidspread of the severe acute respiratory syndrome(SARS) in 2002–2003, and that of avianinfluenza in 2004–2005. (As this paper wasabout to go to press, the latter disease beganspreading among wild birds and poultry beyond
After serving as the Manager of theUNDP South-East Asia HIV and Devel-opment Programme from 1998 to 2004and as the Convener for the UnitedNations Regional Task Force on Mobilityand HIV Vulnerability Reduction from2000–2004, Lee-Nah Hsu taught at JohnsHopkins University. With a DSc fromHarvard University, her focus is to bridgethe gap between the development andAIDS sectors through multisectoral ac-tion research, linking contributions be-yond medicine alone to includeagriculture, construction, rural develop-ment and poverty reduction, aimed atbuilding HIV resilience and using researchfindings as the evidence-base for policyadvocacy, strategic planning and pro-grammatic actions.Email: zeehsu@hotmail.com.
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Asian countries into Europe.) Simi-larly, HIV does not respect national borders.However, unlike the regional response andglobal concern caused by the ‘‘bird flu’’, mostresponses to HIV and AIDS have been country-specific. As a result, large proportions of theactual transmission mechanisms and popula-tions are not addressed by such responses (duGuerny
etal 
.2003).Moreover,thefactthatHIVtransmission relates to human sexuality, sexualbehaviour, and drug dependence means that itstransmission is related to activities consideredtaboo in many societies or criminal in others.Consequently, decision-makers may be temptedto ignore these important HIV-related issues orthey may choose not to deal with them at all.
Humanrightscanserveasthebasis for HIV prevention
However, if decision-makers give primacy tohuman rights, the needs of all people will beconsidered and all people’s rights respected; andas such, the principles of human rights will bepertinent for HIV prevention.As previously described, development pro-cesses are not neutral with respect to HIV andAIDS. ‘‘Development’’ does not mean reducingthe chances of HIV spreading. Forms of devel-opment that are not people-oriented or thatsacrificehumandevelopmentforeconomicgainsactually increase people’s vulnerability to HIV,particularly poor people’s, and may even ex-acerbate HIV epidemics. Development pro-grammes have stimulated the unprecedentedmovement of people and goods both domes-tically and internationally. The majority of suchmovement involves people seeking alternativesand opportunities to improve their livelihood orto escape chronic deprivation, sudden economicdownturns, or natural disasters (Skeldon 2000).As people move away from their homes andculture,theyhave lessaccesstosupportivesocialnetworks and may be exposed to differentialtreatment and new temptations. Many of themdo not have expectations of staying in the placesto which they have moved. All these circum-stances increase the vulnerability of people onthe move and of the people living in areas inwhich the migrants have set up temporaryresidence. Thus, it is necessary to build thecapability of these people to integrate and toprotect their social values, their health, and theirwell-being. Building people’s resilience is anessential task in the efforts to stem the spread of HIV and AIDS.Two interrelated strategies are important inthis regard: protection and empowerment. Pro-tection shields people from dangers or protectsthem from HIV infection. In the context of HIVand AIDS, empowerment means creating anenabling environment in which people can enterinto public dialogue and obtain the necessaryinformation, and have the means and choices tomake decisions about their lives and to protectthemselves from HIV and AIDS. Both of thesestrategies are elements of human security, anddemocratic governance can act as a guarantor of thatsecurity,
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whichisitselfabasichumanright.While the notion of governance comprisesthe complex principles, mechanisms, processes,systems, institutions, and practices throughwhich citizens and groups articulate their inter-ests, mediate their differences and exercise theirlegal rights and obligations, democratic govern-ance principles take these attributes to a higherplain. Democratic governance is participatory,transparent and accountable, and it is effectivein making the best use of resources. It is equi-table and it promotes the rule of law (UNDP1999). Three key players are involved in goodgovernance: the state, civil society, and the pri-vate sector. The state uses the afore-mentionedmechanisms to pursue its legislative, politicaland economic goals just as civil society and theprivate sector use them to foster their interests.The state works through parliament, ministriesand departments, and legal institutions; civilsociety and the private sector through NGOs,business councils and the like. Underlying theprinciples of democratic governance is a com-mitment to human rights.While ‘‘perfect governance’’ remains anideal, a quick review of the global situationindicatesthat thecountries that haveattained anadvanced level of human development and havedeveloped an effective democratic governanceprocess are associated with lower HIV preva-lence (du Guerny
et al 
. 2002b).Both scattergrams in Fig. 1 show a correla-tion at the global level between the HumanDevelopment Index (HDI) and the Gender-
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related Development Index (GDI), and HIVprevalence among countries. It appears that lowlevels of gender equity and low levels of humandevelopment achievement have some associa-tion with high HIV prevalence, with a fewnotable exceptions, as shown in Fig. 1. There areseveral countries where the GDI and HDI arelow, and HIV prevalence is also low. Based onthe data available, these are key outlier coun-tries. Empirically, one finds that gender inequi-tiesinthelevelsofschoolenrolmentandincome,for example, create the type of social inequitythat contributes to the vulnerability of femalesto HIV infection (see also Gordon
et al 
. 2000).However, while the available data do notdemonstrate any causal relationship, policy-makers and programme planners need to under-stand why HIV infection has been so rapid insomecountries,buthasincreasedmoreslowlyorhas remained at lower levels in other countries.They need to see that HIV/AIDS requiresresponses much broader than health alone.Unless the social conditions that facilitate thespreadof HIVandAIDScanbeimpacted,itwillnot be possible to slow down its transmission.Just as perfect democratic governance doesnot exist anywhere in the world, perfect resourcedistribution, even in so-called developed coun-tries, does not exist. Nevertheless, the way inwhich inequity in resource distribution plays outin the presence of HIV is reflected in the gaps ineconomic development between countries.Along the continuum from the poorest to therichest countries, the poor exert their efforts intrying to access resources and income; the richuse their income and resources to gain powerand influence,
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thereby enabling them to in-crease and safeguard their wealth.By contrast, the democratic governanceprocess addresses the issue of income andresource distribution. Thus, it deals with thebackground to HIV vulnerabilities that rangefrom puttingpeople incircumstances where theyare exposed to infection, to pushing individualsto take risks that they would not have takenunder normal circumstances, had the environ-ment been more favourable to their livelihood(United Nations 2003).Just as there are some common elements inwhat constitutes democratic governance, simi-larly, an analysis of the mechanisms for buildingHIV resilience reveals a number of commonelements, as seen in the following country casestudies. It is worth examining these before consi-dering the general application of the principlesthey demonstrate.
The case of Brazil
In the early 1990s, the Brazilian Governmentrecognized the threat posed by HIV and AIDSand devised a national AIDS strategy.
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Thatcomprehensive strategy called for the provisionof free medication, initiation of a major mass-media campaign through prime-time televisionto disseminate HIV-preventive messages, andthe distribution of condoms free of charge to sexworkers.
Figure
1. Correlations between the Human Development Index, Gender-related Development Index and HIVprevalence.
Source
: Graphics prepared by Lee Nah Hsu and Vincent Fung. Data taken from
UNAIDS Global HIV/AIDS Trend Report, 2002
and
UNDP Human Development Report, 2003 and Human Development Index, 2001
.
Building dynamic democratic governance and HIV-resilient societies
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