Sophie Harman

International development in transition

This is the pre-peer reviewed version of the following article: HARMAN, S. and WILLIAMS, D. (2014), International development in transition. International Affairs, 90: 925–941. doi: 10.1111/1468-2346.12148, which has been published in final form at http://dx.doi.org/10.1111/1468-2346.12148

Fighting HIV and AIDS: Reconfiguring the State?

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Ebola, gender and conspicuously invisible women in global health governance

10 billion goes to fight HIV and AIDS annually. This money has been accompanied by the introduction of quasi-governmental bodies, a mushrooming of civil society actors and high-level political commitments of states and international agencies. This article argues that the multiplicity of actors involved in the HIV and AIDS response has led to a re-modelling of the state in East Africa. Moreover, this re-modelling does not exist in isolation of wider trends within the global political economy, but is instead led by the World Bank as part of its wider governance reform agenda in which notions of sovereignty and partnership are challenged under the rubric of ownership. The article considers the role of the National AIDS Councils, the president, civil society and the Ministries of Health in Kenya, Tanzania and Uganda within the World Banks Multi-Country AIDS Program to explore this relationship.

The Dual Feminisation of HIV/AIDS

Abstract The international response to Ebola brings into stark contention the conspicuous invisibility of women and gender in global health governance. Developing feminist research on gender blindness, care and male bias, this article uses Ebola as a case to explore how global health rests on the conspicuous free labour of women in formal and informal care roles, yet renders women invisible in policy and practice. The article does so by demonstrating the conspicuous invisibility of women and gender in narratives on Ebola, emergency and long-term strategies to contain the disease, and in the health system strengthening plans of the World Health Organization and World Bank.

WHO must remain a strong global health leader post Ebola

The feminisation of HIV/AIDS commonly refers to the feminisation of the epidemic: women are disproportionately infected and affected by the disease. This paper argues that there is a dual feminisation of HIV/AIDS; that of the epidemic and that of its governance. Women are at the forefront of HIV/AIDS governance from the leadership of global programmes, directing national and district HIV/AIDS councils in-country, forming influential women and HIV/AIDS non-governmental organisations, and organising local communities. Yet this feminisation of governance has not led to better outcomes for the feminisation of the epidemic. This paper argues that this is because of the misapplication of gender mainstreaming and the politics of presence, the sidelining of gender expertise and institutional bias, and wider systematic issues with processes of HIV/AIDS governance that are exacerbated when addressing the concerns of women. La feminización del VIH/SIDA se refiere comúnmente a la feminización de la epidemia: las mujeres están infectadas y afectadas desproporcionadamente por la enfermedad. Este estudio sostiene que existe una doble feminización del VIH/SIDA; la de la epidemia y la de su control. Las mujeres están al frente del control del liderazgo de los programas globales del VIH/SIDA, dirigiendo concejos distritales e internos del país, formando a mujeres influyentes y organizaciones no gubernamentales del VIH/SIDA y organizando comunidades locales. Sin embargo, esta feminización del control no ha dado mejores resultados a la feminización de la epidemia. Este estudio sostiene que esto se debe al mal manejo de la integración de la perspectiva de género y a la política de la presencia, la marginación de la experiencia del género y el prejuicio institucional, y otros amplios asuntos sistemáticos con el control del VIH/SIDA, que se agravan cuando abordan los asuntos de las mujeres. 艾滋病问题的女性化指的是在传染方面的女性化：女性不成比例地被传染和受到该疾病影响。本文认为艾滋病问题存在双重的女性化：不仅是传染方面，还有治理方面。女性以全球性项目的领导地位处于艾滋病治理的最前沿，在国内她们指导国家的和地区的相关艾滋病委员会，组建有影响力的妇女和艾滋病非政府组织，并建立地方社团。然而治理的女性化并未对传染的女性化产生更好的结果。本文认为原因在于性别主流化的滥用和现存政治、性别专门知识的边缘化和制度偏见，以及艾滋病治理进程中解决妇女的关切时还在恶化的更为广泛的各种体系性问题。

Governing Health Risk by Buying Behaviour

The 2014 Ebola outbreak in west Africa has demonstrated again the urgent need for strong leadership and coordination in responding to global health challenges. As members of the global health scholarly community, we call upon all WHO Member States to recommit themselves to strengthening global outbreak alert and response by sustainably investing in the WHO, its departments, and personnel. As members of the WHO secretariat have admitted, mistakes were made in how the organisation initially responded to the 2014 Ebola outbreak. Ahead of the 68th World Health Assembly in May, 2015, the temptation will be to point fingers and use the extreme case of Ebola to justify further erosion of the WHO. The temptation might also be to divert voluntary contributions to other institutions. We firmly believe that any such measures must be approached with extreme care. In international forums, a proposal is being discussed to establish a new “first responder” UN agency, which will provide emergency operational assistance in humanitarian crises by rapidly deploying trained personnel, equipment, and supplies. While an enhanced rapid response would be beneficial, a new agency would be subject to the same vagaries of institutional funding and Member State interests in delivering its mandate. Even more importantly, these are functions that the WHO already fulfils via the Global Outbreak Alert and Response Network (GOARN), which maintains a roster of experts that can be deployed to assist in humanitarian disasters. The resources to create an entirely new agency would therefore be better served by strengthening the WHOs emergency response division rather than duplicating existing functions. Resources could also be more effectively used to help Member States implement the International Health Regulations (2005) via health system strengthening. An independent investigation of the WHOs handling of the 2014 Ebola outbreak is both appropriate and warranted. The investigation should focus on the structural and procedural elements of institutional practice, consider how recent funding cuts affected the WHOs ability to respond, and identify pathways to sustainable funding of the institution. The WHO can provide global health leadership that is technically informed and representative. The organisation remains a fundamental element of global health governance, and provides an indispensable service as the lead technical agency in global health. While mistakes have been made, rather than engage in the further dismantling of the WHO we call on all Member States and the international community to give the organisation the resources it needs to serve its members and the populations they represent.

Understanding global health and development partnerships: Perspectives from African and global health system professionals

This article considers the role of conditional cash transfers as a mechanism of governing health risk by buying behaviour change in sexual practice. Conditional cash transfers have come to be identified as a potential solution to the problem of HIV prevention, and as such look likely to be applied throughout countries with high prevalence rates in sub-Saharan Africa. The article considers the implications of two pilot studies in Tanzania and Malawi for governing the risk of HIV infection. It outlines the problem of behaviour change and individual rationality, the potential of conditional cash transfers as a relatively inexpensive programme with high outcomes, and some of the limitations and implications of these initiatives for individual bodies, rationality and global health governance. The article makes the argument that conditional cash transfers should be met with caution and that governing health risk by buying behaviour represents the intersection of bio-political control with neo-liberal forms of economic incentive through financial gain. The balancing of long-term health needs with short-term financial gain induces will to change behaviour, the problem being the sustainability of such change in the absence of financial gain and the long-term consequences of constructing behaviour.

15 years of ‘War on AIDS’: what impact has the global HIV/AIDS response had on the political economy of Africa?

Partnership is a key idea in current debates about global health and development assistance, yet little is known about what partnership means to those who are responsible for operationalising it or how it is experienced in practice. This is particularly the case in the context of African health systems. This paper explores how health professionals working in global health hubs and the health systems of South Africa, Tanzania and Zambia understand and experience partnership. Drawing on semi-structured interviews with 101 professionals based in each country, Washington DC and Geneva between October 2012 and June 2013, the paper makes four key arguments. First, partnership has a legitimating function in global health policy processes for international development institutions, government agencies and civil society organisations alike. Second, the practice of partnership generates idiosyncratic and complicated relationships that health professionals have to manage and navigate, often informally. Third, partnership is shaped by historical legacies, critical events, and independent consultants. Fourth, despite being an accepted part of global health policy, there is little shared understanding of what good partnership is meant to include or resemble in practice. Knowing more about the specific socio-cultural and political dynamics of partnership in different health system contexts is critical to equip health professionals with the skills to build the informal relations that are essential to effective partnership engagement.

Beyond trips: Why the wto‘s Doha Round is unhealthy

This is an Accepted Manuscript of an article published by Taylor & Francis in Review of African Political Economy on 21st August 2015, available online: http://wwww.tandfonline.com/10.1080/03056244.2015.1064370.

Bottlenecks and benevolence: how the World Bank is helping communities to ‘cope’ with HIV/AIDS

Abstract The current round of World Trade Organization (wto) negotiations—the Doha Round—has significant implications for global health which have received insufficient attention from the global health community. All too often the health implications of global trade agreements are examined only after their conclusion, and are concerned only with intellectual property rights. This paper seeks to move beyond this narrow focus and elucidate the wider health implications of the Doha Round. It explores the negative effect of the Round on state capacity to provide and regulate health services in low-income countries, and the impact it will have on livelihoods among the poor and their ability to access health services. Overall the paper makes the case for greater engagement from the health community with the wto and the Doha Round negotiations beyond the customary focus on intellectual property rights.