Far from being primarily driven by scientific evidence, decisions about spending priorities for HIV prevention programmes emerge from an imperfect, politicised process, Moritz Hunsmann argues in an article published online ahead of print in Social Science and Medicine.
Drawing on observations of Tanzanian national policy meetings and interviews with policy makers, he says that cost, political constituencies, the vertical nature of the response to AIDS, the expected timeline of interventions’ political returns, and the perceived feasibility of different approaches all influence the formulation of HIV prevention policies.
The researcher was particularly interested in why policies which aim to change individuals’ sexual behaviour tend to be supported, whereas policies to change ‘structural factors’ are rarely implemented. Structural interventions try to address the broader legal, political and socio-economic contexts in which individuals make behavioural decisions.
The research was conducted in Tanzania in 2007 to 2009, a period of relative plenty in terms of international aid. In-depth interviews were conducted with 92 HIV prevention policy makers, including representatives from government agencies, bilateral and multilateral donor agencies, international and Tanzanian non-governmental organizations, researchers and consultants.
In addition, the researcher observed eight national-level policy discussions, including Prevention Technical Working Group meetings, donor-government policy reviews and a Global Fund stakeholder meeting.
Tanzania is heavily dependent on international aid, primarily via PEPFAR and the Global Fund. Therefore one limitation of the study is that it examined decision making processes taking place at the national level, rather than within the international institutions.
The researcher identified five key aspects of the decision making processes which go some way to explain the barriers to implementation of structural HIV prevention approaches.
Structural interventions were assumed to have a low cost-effectiveness in terms of HIV prevention. However, while interviewees paid lip-service to the value of considering cost-effectiveness, it was never explicitly discussed at any of the meetings that he observed. In interviews, it was not cited as being an important issue in the debate over prevention priorities. One donor agency official commented:
“Nobody worried about cost-effectiveness in the formulation of the Prevention Strategy, partly because we are put under enormous pressure to get something done and to get it done quickly.”
When the research was conducted, donor funding was abundant. According to the study, there was limited pressure to keep costs down or to prioritise interventions which had the greatest impact in relation to the money spent.
As different HIV prevention organisations working in Tanzania specialised in different aspects of HIV prevention, any shift in prevention priorities would have led to funds being taken away from some organisations and given to others. This could have put the continuing existence of some organisations into question.
The research found that the policy arenas where prevention priorities are discussed were composed of the very players who implemented or funded the policies decided upon. One official recalled a Global Fund preparatory meeting:
“It was horrible! Everybody was there... and everyone was pushing for their intervention or domain of speciality… without even having a broader vision of the proposal as a whole or of HIV policy as a coherent ensemble.”
While there were political constituencies for keeping current HIV prevention priorities unchanged, there wasn’t a well-organised constituency for structural interventions.
The anticipated time span before an intervention showed an effect was a major concern. Convinced that the indirect effect of structural interventions on HIV ruled out the possibility of a rapid impact, many interviewees considered them as long-term responses to be implemented once other interventions had been effectively scaled-up. (In Tanzania, basic interventions for the prevention of mother to child transmission or to provide voluntary counselling and testing are far from universally available).
Interviewees suggested that in an environment in which government officials seek re-election and donors have short funding cycles, there was a short-term pressure to be seen to have done something. Mass-media campaigns are highly visible whereas structural interventions may not be.
The vast majority of the money for HIV work came through disease-specific programmes, such as PEPFAR and the Global Fund. The money spent on HIV was roughly equivalent to the total spent on all other health issues combined.
In this fragmented funding and policy environment, policy makers tended to only take into account the effect of an intervention on HIV. The benefits that structural interventions could have for a wide range of other health and social issues were not valued and policy makers were not encouraged to work towards cross-sectional goals.
Structural interventions were understood to be deeply political and discouragingly complex. Asked about nutritional interventions, one donor said:
“The issue of nutrition is linked with issues of food production, food prices, agricultural policy. It’s so complicated!”
Whereas some structural interventions may be limited to altering specific aspects of a social environment, policy makers tended to see them as requiring total change. They were equated with poverty eradication.
“HIV money can’t solve the continent’s development challenges! And these are very long processes: decreasing poverty, changing gender norms, improving the level of nutrition status. We’ll never be able to do that!”
Mortitz Hunsmann notes that political scientists and economic theorists have previously shown that in other domains of policy making, decisions are rarely made in a linear way, by rationally evaluating costs and benefits. In fact, policies and priorities are usually developed as time goes on, in response to particular circumstances.
He questions an apolitical vision of evidence-based health policy. “Bold calls for science to guide HIV prevention policies will arguably continue to have limited impact if voiced in a political vacuum that abstracts from what we know about real-world policy processes,” he says.
Hunsmann M. Limits to evidence-based health policymaking: Policy hurdles to structural HIV prevention in Tanzania. Social Science & Medicine, doi:10.1016/j.socscimed.2012.01.023. 2012.
