Between Self-Help and Dependence

Between Self-Help and Dependence: Donor Funding and the Fight against HIV/AIDS in
South Africa
Author(s): Krista Johnson
Source: Africa: Journal of the International African Institute , 2008, Vol. 78, No. 4
(2008), pp. 496-517
Published by: Cambridge University Press on behalf of the International African
Institute
Stable URL: https://www.jstor.org/stable/29734369
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Africa 78 (4), 2008 DOI: 10.3366/E0001972008000417
BETWEEN SELF-HELP AND DEPENDENCE:

DONOR FUNDING AND THE FIGHT AGAINST
HIV/AIDS IN SOUTH AFRICA
Krista Johnson
At a time when the AIDS pandemic has finally drawn the attention
of-and is increasingly being defined by-the international community,
the South African government has sought to develop a uniquely African
response. Indeed, the persistence of patterns of African dependence
on the West has been a key issue that has shaped the government's
response to AIDS. While many of its neighbours have seen their
health budgets dwarfed by foreign aid and their health policies in large
measure determined by donor organizations, South Africa has sought
to negotiate the tricky interface between self-help and dependence,
partnership and paternalism. This has led to a series of policy
positions and statements that sparked a furore of criticism and debate,
exacerbating the AIDS crisis. While the country's response to the
AIDS epidemic has been marred by controversy, confusion and policy
inaction, it is also true that South Africa now boasts the world's largest
public sector anti-retroviral treatment programme, one that is 90 per
cent funded by government resources, not donor funding (Tshabalala
Msimang2006).
South Africa provides an interesting and important case study
through which to examine the impact of international donor funding
in the fight against HIV/AIDS, and the changing relationship between
foreign donors and African governments in the light of the AIDS
pandemic. Since South Africa has the second highest population of
HIV-positive people in the world, waging a successful campaign against
HIV/AIDS is not only a priority for its government, but also high on
the agenda of the international donor community. However, tensions
between the government and the donors have a long history, fuelled
in part by Western donors' paternalism towards African countries and
in part by the South African government's determination to avoid the
trap of dependence at all costs and develop a response to the pandemic
that is affordable and sustainable using domestic resources. This article
examines donor funding for HIV/AIDS in the context of government
efforts to develop an African response to the pandemic not determined
nor primarily funded by foreign aid. It draws on primary data collected
in South Africa through interviews with donor representatives, non?
governmental organizations and government officials, as well as a
detailed review of key reports, literature and websites that provide
statistical data on the subject.
KRISTA JOHNSON is an Assistant Professor in the Department of African Studies at Howard

University. She has lived and studied in Southern Africa for over 7 years. Her most recent
work has focused on social policy making and AIDS in South Africa, the international political
economy of drug development, and donor funding for AIDS in Southern Africa.

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TREATING HIV/AIDS IN SOUTH AFRICA 497
A WAR CHEST FOR FIGHTING AIDS?
After two decades of neglect, battling the HIV/AIDS pandemic has

finally seized the attention of the international community. The Global
Fund to Fight AIDS, Tuberculosis and Malaria estimates that some
40 million people are infected with HIV, 70 per cent of whom live
in sub-Saharan Africa. To date, HIV/AIDS has killed more than 20
million people worldwide, with 3.1 million people dying of AIDS
related causes in 2004 alone.1 AIDS is already beginning to undo
many of the past human development advances. Life expectancy has
plummeted by more than 20 years in those countries heavily affected,2
and in sub-Saharan Africa it is estimated that per capita growth in
half of the countries is falling by 0.5-1.2 per cent each year as a
direct result of AIDS. Although AIDS is at the very heart of the
global development crisis, the fight against it has been considerably
under-financed by governments of the most heavily affected regions,
and by the international donor community. A 2001 study by Amir
Attaran and Jeffrey Sachs estimated that donor funding for AIDS
prevention and management programmes amounted to only US$170
million annually between 1996 and 1998, with about US$69 million
going to sub-Saharan Africa (Attaran and Sachs 2001). This latter
figure amounted to about US$3 per HIV-positive person. To put this
figure in perspective, American consumers spend US$8 billion per year
on cosmetics, and European cows on average receive subsidies of US$2
each per day.
In recent years, however, international donor aid for combat?
ing AIDS has been rising rapidly, primarily in the form of bilateral
development assistance and aid, as well as contributions to the
Global Fund. The World Bank also provides substantial funding for
HIV/AIDS, as does the private sector (foundations, corporations, inter?
national non-governmental organizations and individuals). Domestic
public health spending by many affected-country governments,
especially South Africa, has also grown tremendously, and households
and individuals within these countries often shoulder at least
some of the financial burden. Taken together, it is estimated that
resources made available from all of these funding streams rose from
approximately US$1.6 billion in 2001 to US$6.1 billion in 2004,
and US$8.9 billion in 2006 (Kates and Lief 2006; UNAIDS 2006b).
UNAIDS estimates that approximately US$10 billion is currently being
spent annually for all aspects of the global AIDS response. Despite
the increase in funding, official estimates suggest that there is still a
considerable financing gap that is likely to grow over time (Global
HIV Prevention Working Group 2007; Kates and Lief 2006; UNAIDS
2007).
The strong international response to HIV/AIDS can be seen
at the country level in some of the nine hardest-hit sub-Saharan
1 See (www.theglobalfund.org), accessed 12 May 2006.

2 See {www.undp.org/popin/popdiv/hivmtg/aidsrep.pdf), accessed 12 May 2006.

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498 TREATING HIV/AIDS IN SOUTH AFRICA
African countries. For example, during 2000-4, the average level of

external funding increased significantly in Lesotho (1,100 per cent),
Swaziland (951 per cent), Tanzania (394 per cent), and Zambia
(698 per cent) (Lewis 2005). For some low-income countries in the
most heavily affected regions, such huge sums of aid are effectively
replacing government health budgets. A 2003 comparative analysis
of the financing of HIV/AIDS programmes in Southern Africa, for
example, revealed that over 80 per cent of total HIV/AIDS spending
in Mozambique, Lesotho and Swaziland came from external bilateral
and multilateral donors (Martin 2003).
Dramatic increases have occurred in HIV/AIDS donor financing,
while many Southern African government public health budgets have
changed little and in some cases (for example Mozambique and
Zambia) have actually declined (Lewis 2005). In Uganda and Zambia,
for example, AIDS funds exceeded all public health spending by
almost 185 per cent. This imbalance raises serious questions about
how countries can accommodate and wisely allocate new resources for
HIV/AIDS given the limited or declining public health capacity.
The implications of the growth of HIV/AIDS donor funding are
likely to be far-reaching. For example, concerns have been raised as
to whether such huge inflows of aid might undermine macroeconomic
stability or fiscal management. It is also uncertain whether these
countries can effectively utilize these resources given the institutional
capacity and governance problems that often plague their healthcare
systems. The volatility and unpredictability of funding is a further
concern. The improvement of HIV/AIDS services will require an
expansion of the civil service. But such expansion will not be sustainable
through government budgets in many low-income countries once donor
funding dries up. Furthermore, the reliance on imported anti-retro viral
drugs for AIDS patients cannot be sustained with government resources
in many Southern African countries. Given that AIDS patients are
dependent on continued therapy for survival, interruptions in anti
retroviral treatment caused by funding gaps could lead to increased
mortality rates (Compernolle 2007).
Historically foreign aid as a percentage of government revenue in
South Africa has been very small. In 1998, donor support accounted
for 0.2 per cent of government revenue, and today it remains less
than 1 per cent. External sources of health financing in 1998 likewise
contributed less than 1 per cent of revenue for the public health sector,
and their share remains very low today. But foreign aid for HIV/AIDS is
significant. Of all recipient countries, South Africa, behind Uganda and
the Democratic Republic of Congo, received the third largest allocation
of aid for HIV/AIDS from OECD countries in 2004 (OECD/UNAIDS
2004). In 2002/3 it is estimated that donor funding comprised 40 per
cent of allocations for HIV/AIDS in South Africa, totalling just over
US$53 million (Ndlovu 2006b). While the total sum donated had
nearly tripled by 2004 (OECD/UNAIDS 2004), unlike in neighbouring
countries, donor funding as a percentage of allocations has remained
steady or even declined, as the South African government has increased

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its budget allocations for HIV/AIDS exponentially as well (Tshabalala

Msimang2006).
Furthermore, the government has been very strategic in accepting
and utilizing foreign aid. In general, donor assistance has been
viewed with caution by the government, particularly if it does not
appear to support its own Comprehensive Plan for responding to the
pandemic. In answer to a series of interview questions regarding the
relationship between the government and international donors, and
possible patterns of donor dependence in South Africa, one United
Nations representative explained: 'The South African government sets
the agenda. Things are done differently here in South Africa. If foreign
donors don't like it, they can leave. A few have.'3
HIV/AIDS IN SOUTH AFRICA AND THE GOVERNMENT'S RESPONSE
UNAIDS estimates that approximately 5.5 million adults and children

were living with HIV/AIDS in South Africa at the end of 2005, a figure
that had risen from five million at the end of 2001 (UNAIDS 2006a).
The findings of a 2004 survey of national HIV and syphilis antenatal
sero-prevalence indicated that HIV prevalence among pregnant
women was 29.5 per cent, and suggested that as many as 6.7 million
South Africans could be living with HIV/AIDS (Department of Health
2004).
The World Health Organization (WHO) and UNAIDS estimated
that by the end of 2006 approximately 325,000 South Africans were
receiving anti-retroviral treatment, which represented approximately
one third of those in need of treatment (WHO/UNAIDS 2007).
In February 2008, the government announced that the number of
patients initiated on anti-retroviral treatment was 418,000. However,
the pharmaceutical company Aspen Pharmacare, which makes most
of the anti-retroviral drugs used in South Africa, estimates that only
340,000-350,000 were still on treatment in the public health system
in February 2008 (others have died or stopped taking the drugs). It is
estimated that a further 100,000 South Africans are on anti-retroviral
treatment in the private health system (TAC 2008). Aspen Pharmacare
has also calculated that no more than half of those who need treatment
will be receiving it by mid-2009 (Kahn 2008).
When the African National Congress came to power in 1994, it
was one of the first African governments to formulate a National
AIDS Plan that emphasized prevention, comprehensiveness and a
multi-sectoral and multi-stakeholder approach to the development
and implementation of HIV/AIDS programmes. AIDS was declared
a 'Presidential Lead Project' along with 20 other social priorities,
giving it special status and early access to resources designated for
reconstruction and development. The HIV/AIDS Directorate within
3Interview with UNICEF representative, 8 June 2006.

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the Department of Health was strengthened in order to drive the

implementation process, and a National AIDS Programme Director
was appointed.
The government launched the HIV/AIDS and STD Strategic
Framework in 2000 (2000-5) which outlined a multi-sectoral approach
to combating AIDS by incorporating national, provincial and local
levels of government as well as other stakeholders outside the health
sector. The four priority areas outlined in the plan are prevention;
treatment, care and support; human and legal rights; and monitoring,
research and surveillance. A Comprehensive Plan for the Management,
Care and Treatment of HIV/AIDS was adopted in November 2003,
and in 2007 a new HIV and AIDS and STI Strategic Plan for South
Africa was unveiled which will guide government policy until 2011
(Department of Health 2006).
While the South African government has been strong on AIDS
policy development, in practice the response to the pandemic has
been slow and highly politicized, particularly in the area of treatment.
The government's response to AIDS has been marred by patterns of
technocratic, authoritarian and controlling political leadership through
which it has sought to impose decisions rather than facilitating
cooperation among people to realize society's goals (Johnson 2006).
Inappropriate use of AIDS funding, endorsement of farcical and
discredited AIDS drugs, and flirtation with AIDS denialists became
defining features of the Mbeki administration's response to AIDS early
on. Such blunders and shocking actions and positions did nothing to
halt the spike in national HIV prevalence rates among antenatal clinic
attendees from 2.2 per cent in 1992 to 26.5 per cent in 2002 (South
African Government 2008; van der Vliet 2003).
A consistent theme resonant amid much of the contestation and
debate was the South African government's concern with affordability
and sustainability in constructing an effective response to the epidemic.
The government's relationship with AIDS civil society groups as well as
foreign donors and international organizations has been largely framed
within this technical discourse of affordability and sustainability. Nicoli
Nattrass argues in her book The Moral Economy of AIDS in South Africa
that:
By locating the AIDS policy discussions in a seemingly technical discourse

of affordability and sustainability, the space for public deliberation over
the appropriate size of a national treatment programme has been sharply
curtailed. This has had the effect of stifling the formulation and expression of
social values concerning how best to address the AIDS pandemic. (Nattrass
2004)
In large measure, the emphasis on affordability and sustainability

reflects an almost dogmatic insistence on establishing a response to
AIDS that would not rely on donor funding. This was particularly
apparent in the government's handling of the provision of anti
retroviral treatment, especially to prevent transmission from pregnant,
HIV-positive women to their unborn children. Scientific trials in

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developed and developing countries have shown that treating pregnant

women with a short course of anti-retrovirals could dramatically reduce
the transmission of HIV from mother to child (Shisana and Zungu
Dirwayi 2003; Nattrass 2004). Yet the South African government
initially raised the question of safety in explaining its stance on anti
retrovirals, and then argued that the government simply could not
afford to provide anti-retrovirals through the public health sector. The
government stuck to its unaffordability argument even though no real
costing for such a programme was done until 2003.4
Once the price of AZT was slashed and nevirapine was offered
free of charge to South Africa to use in the prevention of mother-to
child transmission, the government's position lost further credibility. A
public outcry ensued, led largely by the Treatment Action Campaign
(TAC) and its allies, which culminated in the landmark constitutional
court case brought against the South African government over its
obligation to provide anti-retroviral drugs to prevent mother-to-child
transmission of HIV. On 5 July 2002 the court decided, in a unanimous
decision, that the government had not met its constitutional obligation
to uphold people's right of access to healthcare services, a landmark
victory for South African AIDS activists that obliged government to
provide ARVs to pregnant women and their babies.
In an interview with the author, former Director of the HIV/AID S
Directorate in the Department of Health Rose Smart explained
the government's stance as emanating from a reluctance to start
something that wasn't equity-based and sustainable, and that might
necessitate a reliance on donor funding.5 Sadik Kariem, Senior Medical
Superintendent at Gro?te Schuur Hospital in Cape Town and member
of the ANC Health Committee, also suggested in an interview with the
author that the purported tendency within government towards denying
the causal relationship between HIV and AIDS, widely reported in the
South African and Western media, was fuelled in part by a refusal to
become dependent on donor funding and other resources that would
have to come from the West.
The explanation for denialism I believe is two-fold. One the one hand there
was the economic argument and the concern that all the medicines and
resources needed to run such a programme would have to come from the
West, and that this would create a situation of economic dependency. There
was concern that South Africa should not go the route of other African
countries that had become so heavily dependent on the West. On the other
hand the ANC's recent history in fighting a political and military war against
an enemy, the apartheid government, who had used biological warfare as a
strategy against the ANC also provided a ready audience within the ANC
for such arguments and positions.6
The concern to develop a response that relies on African knowledge and

resources instead of Western technology and knowledge also clearly
4 Interview with Ria Schoeman, March 2004.

5Telephone interview with Rose Smart, April 2004.
6Interview with Sadik Kariem, April 2004.

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underpins the South African government's promotion of indigenous

and plant medicines as part of a comprehensive response to AIDS.
President Mbeki's quest for African solutions to the AIDS crisis
also appears to be grounded in conceptions of race and his belief that
responses to AIDS often reproduce racist and colonial discourses on
Africans, medicine and disease. While some of these perceptions are
not entirely unfounded,7 a new and important body of literature on
President Mbeki's and the South African government's response to
AIDS provides us with a social history of racial inequality over the past
century and its role in shaping the debates on AIDS (Fassin 2007).
In his biography of President Mbeki, Mark Gevisser describes how the
President's view of the disease was and still is shaped by an obsession
with race, the legacy of colonialism and sexual shame, leaving many
to conclude that Mbeki remains an AIDS dissident (Gevisser 2007;
McGreal 2007).
EARLY ENGAGEMENT WITH THE INTERNATIONAL COMMUNITY ON AIDS
The government's ambivalent relationship with foreign donors and

international actors particularly over HIV/AIDS has a revealing history
and has been shaped by its engagement with global forces since the days
of apartheid. In an interview with the author, one donor representative
surmised that the tepid relationship between the government and
USAID/PEPFAR in part stems from US support for the apartheid
regime.8 More recently, the legal action brought against the South
African government by the Pharmaceutical Manufacturers Association
(PMA) over a 1997 amendment to the Medicines and Related
Substances Control Act soured the government's attitude towards not
only the big pharmaceutical companies but also the United States
government.
The PMA court case provides a blatant example of powerful Western
and transnational interests directly influencing the South African
state's ability to conduct socio-economic policy making, cheapen vitally
needed medicines and address the racial and class imbalances in
healthcare inherited from the past. The government saw its efforts to
transform the racially divided and highly unequal healthcare system
inherited in 1994 as being thwarted by big Pharma, who claimed
that the Act was unconstitutional and violated its property rights.
Internationally, the PMA's affiliates launched a smear campaign against
the government, alleging that its actions threatened the international
patent regime and were contrary to its obligations as a member of
the World Trade Organization (WTO). The pharmaceutical industry's
case found resonance especially among key US government officials,
7 There have been actual instances of racism in the history of AIDS science. Some early
theories on the origins of AIDS in Africa relied on fairly flimsy evidence as well as on insulting
and culturally inaccurate speculation about African sexuality. (See Mandisa Mbali 2002.)
8Interview with PEPFAR/USAID, 12 June 2006.

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leading to South Africa being placed on the United States Trade

Representatives Watch List (Heywood 2001).
The amendment to the Medicines Act did not strictly pertain to
HIV/AIDS, but was geared more broadly towards tackling distortions
in the healthcare system and making medicines more affordable
through generic substitution of off-patent medicines, the use of parallel
importation and compulsory licensing.9 At the time when the PMA
instituted proceedings against the South African government, no one
in the international community raised the possibility of providing
affordable anti-retrovirals to HIV-positive people in Africa, and no
African government considered the provision of anti-retrovirals through
the public sector a viable or sustainable response to the AIDS
pandemic.
The PMA court case became a pivotal arena in the fight against
HIV/AIDS when national and international AIDS activists launched
a campaign against the pharmaceutical industry and focused attention
on the prohibitive costs of anti-retroviral drugs. This highly organized
and visible global AIDS activist community - it included groups such as
ACT UP, the Consumer Project on Technology, and M?decins Sans
Fronti?res as well as the South African Treatment Action Campaign
(TAC) - spurred international public awareness especially around
the issue of access to treatment. These transnational AIDS activist
networks were successful not only in forcing the PMA to drop their
case in 2001, but also in increasing the attention paid by international
donors to the AIDS pandemic (Johnson 2006).
Pressure was brought to bear on Western donor governments and
multilateral institutions who up until this point had shown relative
indifference towards the global AIDS pandemic, and had decided that
any money they did provide would be better spent on AIDS prevention
or the treatment of other diseases or opportunistic infections. United
States organizations such as the Centers for Disease Control (CDC)
and the US Agency for International Development (USAID) calculated
that opening the door for AIDS treatment in Africa would create a
limitless demand on scarce resources. Jeffrey Harris of the CDC said in
an interview, 'We were afraid that if we opened the door on treatment
at all, then all of our money would be drawn away. You get into paying
for commodities that have to be supplied, supplied, supplied, to the end
of time' (Gellman 2000).
By the time the PMA dropped the case in 2001, the international
climate had changed: treatment even for those in developing countries
was now seen as a possibility. In June of that year the United Nations
General Assembly Special Session on AIDS was held, during which
the leaders of the G8 countries committed themselves to channelling
more resources into the fight against AIDS, signalling their intention
9 Parallel importation is the importing of a brand-name medicine under patent from a

country where the patentee sells it at a lower price than in the local market. Compulsory
licensing refers to the overriding of certain patent rights by the licensing of a competitor to
produce and market a medicine that is still under patent (Heywood 2001: 6).

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through the creation of the Global Fund to Fight AIDS, Tuberculosis

and Malaria. More recently, member states at the June 2006 United
Nations General Assembly high-level meeting on HIV/AIDS agreed to
work towards the goal of universal access to comprehensive prevention
programmes, treatment, care and support by 2010 (WHO/UNAIDS
2007).
The international community was finally beginning to mobilize
significant resources to fight the AIDS pandemic, especially in Africa,
the hardest-hit region. In familiar fashion, however, the advanced
industrialized countries were all too willing to play the role of
'missionary' and step in to 'save' Africa. They proposed solutions
for Africa that promote aid, hand-outs and Western knowledge
and technology instead of removing the structural barriers, such as
unfavourable international trade laws, that contribute to inhibiting
African countries from 'saving' themselves. But this approach reasserts
global power imbalances and thus helps to explain much of the
anger felt by African leaders struggling to avoid the pitfalls of African
dependency and Western paternalism.
No African leader has been more outspoken than South African
President Thabo Mbeki in trying to shape the paradigm through which
the AIDS pandemic in Africa is viewed and the discourse used to define
the problem as well as the solution. Some of President Mbeki's actions
and statements sparked a furore of criticism and debate as he attempted
to redefine AIDS in Africa as a disease of poverty. The controversy and
indeed outrage began when President Mbeki convened a presidential
AIDS panel to shed light on the causes of AIDS. The panel comprised
scientists who believe in the causal link between HIV and AIDS as well
as those who do not. There was uproar, especially in the mainstream
and Western media, as critics accused President Mbeki of questioning
whether HIV causes AIDS and championing discredited scientists.
The discussion of what causes AIDS was part of President Mbeki's
broader efforts to redefine AIDS in Africa as a disease of poverty, and to
find specific and targeted responses to what he terms a uniquely African
pandemic at a time when AIDS in Africa was increasingly being defined
by donor governments and organizations in the West. Responding to
international pressure and condemnation, President Mbeki wrote a
letter to various heads of state, outlining the case for a uniquely African
reading of the pandemic:
Whereas in the West HIV-AIDS is said to be largely homosexually

transmitted, it is reported that in Africa, including our country, it is
transmitted heterosexually. Accordingly, as Africans, we have to deal with
this uniquely African catastrophe_It is obvious that whatever lessons we
have to and may draw from the West about the grave issue of HIV-AIDS,
a simple superimposition of Western experience on African reality would be
absurd and illogical. (Mbeki 2000)
President Mbeki's linking of poverty with AIDS has political

implications domestically and globally, and requires us to engage

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with underlying socio-economic conditions and interventions rather

than simply behavioural ones. What was lost in all the controversy
and criticism were the political implications of linking poverty and
AIDS. If AIDS is redefined as a disease of poverty, then the socio
economic conditions in which one lives become as relevant a factor
as sexual practices and behaviour in understanding the spread of
AIDS and in proposing an effective response to it. Such a perspective
flies in the face of the ABC approach (Abstinence, Be faithful,
otherwise use a Condom), the behavioural intervention most heavily
promoted to reduce HIV transmission in sub-Saharan Africa (Hodgson
2005). However, President Mbeki's flirtation with so-called AIDS
dissidents and discredited scientists, and the inaction on the part of his
government, in the end obscured and undermined this valid perspective
and the political nature of the pandemic.
FUNDING THE FIGHT
Despite the government's commitment, along with other African

governments, to allocate at least 15 per cent of the national budget
to the health sector, only 12.4 per cent of South Africa's 2008
national budget is allocated to health (Mukotsanjera 2008).10 This
does represent an increase from previous years, with HIV/AIDS
allocations in particular increasing dramatically during the past six
years. The AIDS Budget Unit at the Institute for Democracy in South
Africa (IDASA) reported that total government HIV/AIDS allocations
increased from under R250 million in 2000/1 to over R3.5 billion
in 2006/7 (Hickey 2003).n In his recent 2008/9 budget speech to
Parliament, South African Finance Minister Trevor Manuel said that
annual expenditures for HIV/AIDS across government departments
will top R6.5 billion by 2010/11 (Manuel 2008). As a share of the
total health budget, HIV/AIDS allocations have increased from 13
per cent in 2004/5 to 18 per cent in 2006/7. As a share of total
government expenditure, HIV/AIDS allocations constitute less than
1 per cent, with R5.66 billion allocated for HIV/AIDS in the 2008/9
budget (Mukotsanjera 2008).12
The increased budget allocations for HIV/AIDS have translated
into a strengthened response from the South African government,
particularly in the area of treatment. The National Treasury reports that
'the treatment component of the comprehensive HIV and AIDS plan
has been expanded to 192 sites in all 53 health districts and in more
than 170 local municipalities, compared to only 139 accredited facilities
10 In 2001 African leaders met in Abuja, Nigeria and declared AIDS a state of emergency
on the continent. They pledged to set a target of allocating at least 15 per cent of annual
budgets to the improvement of the health sector.
11 These figures are in South African Rand.
12 In 2005/6 HIV/AIDS allocations constituted just over 0.5 per cent of total government
expenditure.

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in 2004/5' (National Treasury 2006). In addition, the government's

National Strategic Plan for 2007-11 has as its primary aims the
reduction of new HIV infections by 50 per cent by 2011 and expanded
access to appropriate treatment, care and support to 80 per cent of
all HIV-positive people and their families by the same date (South
African Government 2008). However, AIDS organizations such as the
Treatment Action Campaign have argued that the government is likely
to fall short of these targets as the budgetary allocations, while laudable,
will cover only 52 per cent of the estimated 1.7 million people who will
need anti-retroviral treatment in 2011 (TAC 2008).
Donor funding for HIV/AIDS has also been increasing in South
Africa in recent years, although not as rapidly as public sector funding.
Key sources of donor funding for HIV/AIDS in South Africa include
bilateral and multilateral aid to the government as well as direct funding
to non-governmental organizations from foreign governments and
international aid agencies. According to the South African Department
of Health, the United States government provides the largest amount
of donor funds for HIV/AIDS programes, amounting to US$126.4
million (R866 million) from 2001-6, and increasing significantly to
US$584 million allocated for 2008 (PEPFAR 2008a). At the end of
September 2007, South Africa had already received over US$88 million
for AIDS and tuberculosis from the Global Fund, the second largest
source of donor funds.13 Other major donors include the European
Union (R344 million for 2000-7), the United Kingdom Department
for International Development (DfID) (R493,047,864 for 2001-7),
Australia's AUSAID (R263,850,000 for 2000-8) and Canada's CIDA
(R121 million for 2003-8) (Ndlovu 2005).
The national Department of Health has developed a database
referred to as a 'donor matrix' to monitor financial commitments
for HIV/AIDS in South Africa. The donor matrix is aimed at
monitoring funding for health services by listing donor commitments,
disbursements, objectives, activities and implementing bodies. But it
is not regularly updated and reflects committed amounts rather than
actual disbursements (Kelly et al. 2005). There are also challenges
of 'annualizing' amounts that have been committed over multiple
years. The national Department of Health also initiated a donor
coordinating forum in which all bilateral and multilateral donors were
to be represented. According to Guthrie and Hickey,
The purpose of the forum was to allow the Department of Health to interact
with donors on a single platform, ensuring that they all had access to the
same information at the same time. The chief directorate (for HIV/AIDS
and TB, within the Department of Health) hopes to also use the forum
as a conduit for provinces to indicate their donor funding needs and to
emphasize how donors could assist with ensuring local delivery, through
programmes such as home-based care and VCT (voluntary counselling and
testing). (Guthrie and Hickey 2004)
13 See (http://www.theglobalfund.org/en), accessed 13 November 2007.

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Spending of committed government funds has been a significant

problem in the past and remains so in some provinces. Spending of
bilateral donor funds for HIV/AIDS is reported to be slower than
the spending of government funds, with large amounts having to be
refunded to donors (Ndlovu 2005). This is because donor funding is
usually earmarked for very specific purposes and objectives. Typically
such funds come with strict conditions to be satisfied when spending
the money. According to Ndlovu, 'Although earmarked funding is
beneficial in ensuring that new and critical projects are funded, donor
funds may hinder or clash with national government priorities, leading
to decreased flexibility for implementers when spending on vital local
priorities.' In addition, spending of donor funds is hindered by weak
provincial health systems and insufficient capacity of the government
to commit the money to augmenting key programmes. In recognition
of this, several donors, the European Union and the United Nations
in particular, have targeted capacity building within the public health
sector.14
In fact, by some accounts within government and the donor
community, absorptive capacity rather than availability of resources
is increasingly becoming the key funding issue in South Africa.15
Provincial governments in South Africa, which are responsible for most
of the HIV/AIDS spending, are faced with the challenge of increasing
spending at programme level. There is a strong need to invest in the
development of governmental and non-governmental systems to ensure
that resources are utilized effectively and efficiently.
WHO CALLS THE SHOTS?
Through the President's Emergency Plan for AIDS Relief (PEPFAR),

the United States is the largest foreign donor to HIV/AIDS activities
in South Africa, one of fifteen focus countries that are the main
beneficiaries of PEPFAR funding. In 2008 PEPFAR will provide just
over US$584 million for HIV/AIDS programmes in South Africa
(PEPFAR 2008a). PEPFAR works with approximately 300 non?
governmental partners in South Africa, through which it supports the
provision of anti-retroviral treatment, prevention and care programmes.
No PEPFAR money is given directly to the government. However,
the United States Agency for International Development (USAID), the
principal US government agency administering PEPFAR, does partner
with a number of national and provincial South African government
departments, including the Department of Health, the Department of
Defence and the Department of Correctional Services, in the provision
of HIV/AIDS programmes. PEPFAR's prime partners, and the prime
recipients of PEPFAR funding, are largely northern non-governmental
14 Interview with UNICEF, 9 June 2006; Interview with Department of Health, 8 June
2006.
15 Interview with UNICEF, 9 June 2006; Interview with Department of Health, 8 June
2006.

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organizations and US government institutions such as the Centers

for Disease Control as well as mainly faith-based local community
organizations who in turn administer HIV/AIDS programmes in South
Africa (PEPFAR 2008a).
Despite being the largest HIV/AIDS foreign donor in South Africa,
the United States has a more marginalized and tepid relationship with
the government than other major donors. This probably has to do with
the fact that the South African government doesn't directly receive
any PEPFAR funding, in contrast to some of the other major donors
such as the European Union and the Global Fund to Fight AIDS,
TB and Malaria that provide funding directly to the South African
National Treasury, giving the South African government more control
over the coordination and disbursement of the funds. In addition,
from the South African government's perspective, the United States
government has made little effort to consult or liaise with it regarding
the implementation of PEPFAR. South African Health Minister,
Manto Tshabalala-Msimang, said that South Africa was surprised to be
identified as a key beneficiary when the plan was announced in 2003.
She complained at the opening of a 2006 conference on PEPFAR in
Durban that PEPFAR in South Africa 'started off on a wrong foot. We
were not consulted.' She went on to demand a greater say over the way
PEPFAR funding is spent in the country, arguing that giving the money
directly to local programmes created a coordination problem (Cullinan
2006).
This is a common theme that emerges in many of the South African
government's pronouncements on foreign aid. Speaking of the World
Health Organization's 3x5 Initiative in 2005 - just before the end of a
campaign that fell short of its target by about 1.8 million anti-retro viral
treatment recipients - the Health Minister complained that 'nobody
had asked South Africa what they thought of the proposal; instead
it was imposed from Geneva' (Hodgson 2006). Implicit in a number
of government policy developments and statements is frustration
at Western paternalism and the fact that African governments, the
targeted recipients of such programmes, are rarely consulted.
The South African government's wary response to the PEPFAR
programme can also be attributed to what many see as the politicization
of US foreign aid under President George W. Bush's administration,
tying aid less to the ethical imperatives of alleviating poverty and
more to the administration's short-term political and military objectives
(Engler 2006). Under the initial leadership of Randall Tobias, former
CEO of pharmaceutical giant Eli Lilly and Company, PEPFAR was
criticized by many civil society groups for pushing a politically loaded,
abstinence-based response to AIDS prevention in Africa (Hodgson
2006).
Changes in the objectives and administration of US foreign aid are
part of a broader project of 'transformational diplomacy' initiated by
Secretary of State Condoleezza Rice.16 Under this plan, USAID has
16 See Secretary of State website, (http://www.state.gOv/r/pa/prs/ps/2006/59339.htm).

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been relocated inside the State Department, Randall Tobias has been
appointed as the new administrator of USAID and new Director of
Foreign Assistance, and foreign aid dollars are now apportioned on a
country basis rather than according to issue areas such as child health
or infectious diseases. Such changes have left many concerned that the
restructuring of US foreign assistance programmes is tying aid money
to US strategic interests in a far more overt manner. Institutionally, too,
the US decision to channel the bulk of its resources through PEPFAR
and circumvent the Global Fund has undermined the principle of
multilateral governance and cooperation on global health issues. In
turn, the Global Fund has had problems attracting enough money
and then getting donor countries to honour their commitments, again
contributing to the weakening and vulnerability of such hybrid modes
of governance.
While there is probably no love lost between the South African
government and the United States government, each seems to tolerate
the other out of necessity. The US$584.5 million provided through
PEPFAR goes a long way to assisting the South African government
in meeting the objectives of its Comprehensive Plan, particularly in the
area of capacity building. It is therefore in its interest to cooperate with
PEPFAR and its partners in many areas. Similarly, the South Africa
programme plays a particularly pivotal role in PEPFAR's success as it
accounts for nearly a quarter of PEPFAR's global treatment targets,
even though South Africa on average receives only 10 per cent of the
annual PEPFAR budget.17 Of the two million HIV-positive people
PEPFAR has targeted to treat by the 2008 financial year, 500,000
are expected to be in South Africa, by far the country with the largest
treatment targets (PEPFAR 2008a, 2008b).
Interestingly, one of the areas in which the South African government
has consciously decided not to relinquish control has been in the
procurement of anti-retroviral medicines. One of the stipulations
of the PEPFAR programme is that funds can only be used to
procure anti-retroviral drugs approved by the US Food and Drug
Administration (FDA). Until very recently, this meant that PEPFAR
funds could only be used to purchase brand-name drugs primarily
from US and European pharmaceutical companies at considerably
higher prices than their generic counterparts available from Thailand,
Brazil, India and even South Africa. The South African government
has largely circumvented this stipulation by insisting on procuring the
vast majority of anti-retroviral drugs distributed in South Africa. Thus,
while PEPFAR boasts that as of September 2007 over 329,000 South
Africans have begun anti-retroviral treatment with US government
support, PEPFAR in fact procures drugs for only about 20 per cent
of these patients (PEPFAR 2008b).18 Thus while PEPFAR will spend
US$265 million in 2008 to support anti-retroviral treatment, the
17 Interview with PEPFAR/USAID, 12 June 2006.

18 Interview with PEPFAR/USAID, 12 June 2006.

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majority of this (US$222 million) will be spent on services and technical

assistance rather than the purchase of drugs (PEPFAR 2008a).
The South African government's relationship with the Global Fund
to fight AIDS, Tuberculosis and Malaria has also at times been less
than amicable. This is somewhat surprising given the multilateral,
bottom-up approach to donor funding the Global Fund was intended to
embody, which differs significantly from PEPFAR's bilateral, top-down
approach. However, despite its being a multilateral, public-private
partnership, only 3 per cent of all contributions to the Global Fund
come from non-state actors, while the wealthy G8 countries alone
finance two thirds of the Global Fund. In fact, what makes the Global
Fund unique among actors in the global health field is not so much
its resource base as its hybrid governance structure that gives recipient
countries and civil society actors a say in decision-making processes
(Bartsch and Kohlmorgen 2007).
In this case, too, it appears that the allocation of Global Fund money
to South Africa was a strategic accommodation that suited both the
Global Fund and the South African government. From the Global
Fund's perspective, it is hardly feasible to have a credible global AIDS
programme that does not include the country with the largest number
of HIV-positive people (exceeded perhaps only by India). Similarly, for
the South African government to refuse Global Fund money would not
only look bad, given the severity of its AIDS epidemic, but would also
provide ammunition to critics who claim the South African government
has been dragging its feet, almost to the point of inflicting a form of
genocide on its own people (Lewis 2007).
The latest figures from the Global Fund's progress report show
that six grants have been approved to South Africa, totalling just over
US$205 million. As of 16 April 2008 a total of US$116,500,964 had
already been disbursed to South Africa (Global Fund 2008). It wasn't
until 2003 that South Africa signed a long-delayed funding deal with
the Global Fund after nearly two years of wrangling over how aid to the
country would be distributed. There was also disagreement over when
Global Fund money could be used to buy anti-retroviral drugs, which
the government only approved for use in the public sector in November
2003. It insisted that all funds should first come to the National
Treasury, after which the national government would disburse funds
to specific programmes and provinces (Quinn 2006). This became a
particular sticking point regarding funds awarded to KwaZulu-Natal
Province (US$26,741,529) in Round 1 and the Western Cape Province
(US$15,521,457) in Round 3. Global Funding was also awarded to
LoveLife and Soul City, two public/private partnership programmes, in
support of social and behavioural change initiatives, particularly among
adolescents.
In 2004 a new dispute broke out between the South African
government and the Global Fund when Richard Feachem, head of the
Fund, accused the government of delaying disbursements of millions
of dollars in HIV/AIDS assistance. Feachem told the South African

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media: 'It's intolerable that the money gets stuck in Pretoria and if
Pretoria can't move it for any reason, we will simply withdraw it and
establish direct relationships with the people actually doing the work'
(Quinn 2006). South African health officials said the state was abiding
by the terms of the agreement and passing along all money received to
recipient groups and non-governmental organizations (NGOs). Even
President Mbeki felt compelled to respond to what he argued were
simply false allegations. Interestingly, he argued that this situation again
highlighted the global power imbalances and reinforced the position
of structural subservience in which developing countries often find
themselves.
In his comments, Professor Feachem referred to the Global Fund grants

voted for South Africa as 'our money', to emphasize the relationship
between a benefactor and a recipient of benefaction. In the comments he
has since denied, he emphasized the power of the benefactor to do in our
country as it pleases, and our helplessness to do anything in this regard,
because of our poverty. It is true that we are poor and need the support of
people of goodwill. It is however also true that we would betray those who
sacrificed for our liberation, and corrupt our freedom, if we succumbed to
the expectation of some of those more richly endowed than ourselves, that
our poverty should condemn us to perpetual subservience. This we will not
do. (Mbeki 2004)
The difficult relationship that has developed between the South

African government and the Global Fund has some speculating that
South Africa is unlikely to receive significant sums of money from
the Fund in subsequent funding rounds.19 Most accounts suggest
that the Western Cape Province and the KwaZulu-Natal Province did
good work with the Global Fund money they received. However, in
comparison the national government has nothing more than an average
track record in distributing and effectively and efficiently utilizing their
Global Fund allocations.
The South African government's fear of falling into the trap of
dependence shapes its relationship even with smaller donors with whom
the relationship appears more amicable. This is particularly so with
regard to the procurement of drugs, an area where the government
insists on maintaining control. This applies not only to anti-retroviral
drugs but to all vaccines distributed in the country. For example,
the South African government provides free health care, including
vaccinations, for all children under six years of age. A UNICEF
representative explained that the government procures and distributes
all vaccines for children in the country, even though it would be more
cost-effective to allow UNICEF to provide the vaccines or even to
purchase the vaccines from UNICEF as is the case in most developing
countries.20
19Interview with UNICEF Representative, 9 June 2006.

20Interview with UNICEF Representative, 9 June 2006.

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More recently, the South African government's relationship with

UNICEF soured when news sources reported that a senior UNICEF
official, Ann Veneman, during a recent four-day visit to South Africa,
said that the country is neglecting the more than 100,000 children born
HIV-positive each year (Reuters 2007). This prompted considerable
anger on the part of senior government and ANC officials. The ANC
leadership in its online newsletter Umrabulo questioned UNICEF as
a 'reliable partner' and argued that Veneman's remarks fed into the
dishonest propaganda on the government and its handling of the AIDS
crisis.
Given our reality, characterized in part by a determined effort to impose on

us certain views about HIV and AIDS, despite our comprehensive National
Strategy, and the concrete actions we have and are taking to implement this
strategy, Veneman should have known that her highly tendentious remarks
would inevitably be used by some for purposes she did not intend. (ANC
2007)
Health Minister Manto Tshabalala-Msimang used the occasion of

World AIDS Day to refute the reporting of Veneman's visit to
South Africa. In an article in Umrabulo, she noted that according to
UNICEF's own report card South Africa was one of 17 countries
that were on track to meeting the United Nations 2010 target in the
provision of anti-retroviral treatment for prevention of mother-to-child
transmission of HIV.
The UNICEF report card also states that South Africa and Kenya were the
only two of the countries with the high burden of HIV that were reaching 40
per cent of HIV positive mothers in need of anti-retrovirals for PMTCT by
2006. This figure has since risen to between 50-60 per cent for South Africa
in 2007. (Tshabala-Msimang 2007)
Where the South African government has sought strong partnerships

with donors is in the area of institutional capacity building. A good
example of this is the European Union Partnerships for the Delivery
of Primary Health Care including an HIV/AIDS programme. This
is a six-year programme housed within the national Department
of Health and funded by the EU. With a budget of five million
pounds, its aim is to strengthen the delivery of district primary
health care services, especially those addressing HIV/AIDS, by
supporting the development of partnerships between government
and non-governmental organizations (Department of Health 2005).
According to the National Programme Manager, the aim is for the
government to continue funding the programme once the EU money is
finished.21
2 interview with PDPHCP Manager, South African National Government, 8 June

2006.

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CONCLUSION
The South African government has developed its own home-grown

approach to donor funding, one that seeks to use donor funding
strategically to support domestic initiatives and priorities instead
of allowing the development agenda to be imposed on it from
outside. Because the government has invested so much of its own
resources in recent years in combating AIDS, it is in a much stronger
position to work as an equal partner with donors to achieve mutually
recognized goals. It has been able to avoid the trap of dependency
while implementing a response to AIDS that is both affordable and
sustainable.
But the South African government's response to AIDS has
also drawn understandable criticism. The overwhelming focus on
developing an African solution to the AIDS crisis, and the highly
politicized nature of the government's response that has been shaped
largely by its engagement with global actors, led to critical years
of policy inaction and confusion. That South Africa now boasts
the world's largest public sector anti-retroviral treatment programme
funded almost entirely by domestic resources is overshadowed by the
fact that there still remain nearly 600,000 South Africans in need of
treatment who aren't getting it.
For the donor community staff, working in South Africa is anything
but 'business as usual'. They quickly learn to accept that it is the
South African government who is calling the shots. As one donor
representative put it, pressuring the South African government is
ineffective. 'The more pressure you apply, the more resistance from
the government you will receive.'22 Donors are also well aware that
while their contribution to the fight against AIDS in South Africa is
important and significant, the government's response to the pandemic
is not reliant on donor funding. Despite a somewhat rocky history, it is
to be hoped that an equal and constructive partnership can prevail, in
which the South African government and donor organizations prioritize
the needs of those affected by HIV/AIDS.
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ABSTRACT
This article examines funding for HIV/AIDS in South Africa, and the
relationship between foreign donors and the South African government.
The recognition of the AIDS pandemic as an epochal crisis has led to a
proliferation of international and donor organizations now directly involved
in the governance, tracking and management of the pandemic in many African
countries. In many ways, the heavy donor hand that is increasingly defining
the pandemic and the global response to it feeds into a new imperialist logic
that subordinates pan-African agendas, masks broader issues of access central
to the fight against the pandemic, and strengthens traditional relationships of

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dependence between wealthy Western nations and poorer African nations. The
South African government's relationship with foreign donors, however, has
been shaped by its efforts to develop an African response to the pandemic
not determined nor primarily funded by foreign aid. This article highlights the
positive and negative implications of the sometimes contentious relationship
between the South African government and foreign donors, as well as the
Africa-centred, self-help agenda it pursues, highlighting the opportunities as
well as challenges for African governments to define the global response to the
pandemic.
R?SUM?
Cet article examine le financement de la lutte contre le VIH/SIDA en Afrique
du Sud, et la relation entre les bailleurs de fonds ?trangers et le gouvernement
sud-africain. La reconnaissance de la pand?mie du SIDA en tant que crise
?poquale a conduit ? une prolif?ration d'organisations internationales et
bailleurs de fonds aujourd'hui directement impliqu?s dans la gouvernance,
le suivi et la gestion de la pand?mie dans de nombreux pays africains.
? plusieurs ?gards, le poids des bailleurs de fonds qui d?finit de plus en
plus la pand?mie et la r?ponse globale qui lui est donn?e s'inscrit dans une
nouvelle logique imp?rialiste qui subordonne les programmes panafricains,
masque des questions plus larges d'acc?s qui sont au centre de la lutte contre
la pand?mie, et renforce les relations traditionnelles de d?pendance entre
les nations occidentales riches et les nations africaines pauvres. Cependant,
la relation qu'entretient le gouvernement sud-africain avec les bailleurs de
fonds ?trangers a ?t? fa?onn?e par ses efforts d'?laborer une r?ponse africaine
? la pand?mie qui ne soit pas d?termin?e ni essentiellement financ?e par
l'aide ?trang?re. Cet article met en lumi?re les implications positives et
n?gatives de la relation parfois difficile entre le gouvernement sud-africain et les
bailleurs de fonds ?trangers, ainsi que les objectifs d'entraide ax?s sur l'Afrique
qu'il poursuit, en soulignant les opportunit?s et les d?fis qui se posent aux
gouvernements africains pour d?finir la r?ponse globale ? la pand?mie.

137.158.158.62 on Fri, 30 Apr 2021 08:11:29 UTC

Between Self-Help and Dependence

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Between Self-Help and Dependence

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Between Self-Help and Dependence: Donor Funding and the Fight against HIV/AIDS in

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