Results in HIV/AIDS interventions: Considerations on the need for a vertical approach in an horizontal world, and vice versa

Aids day
During Aids-day, the blogs proved that the debate between the believers in a vertical approach and the believers in a geographical approach rages on. I did not write on it before, because it is an issue with ramifications in all directions, and wonderful opportunities for tangents and meandering digressions. Most thinking is black and white: HIV/AIDS needs advocacy and a vertical approach otherwise it does not get the priority it deserves, or all development must be locally generated, and advocates should stay out.
I will try to be brief and as provocative as I can to highlight the need for a more instinctive and competitive approach on this divisive issue.
Conferences
I was working in the HIV/AIDS sector in South Africa, before Mbeki got internet-shavvy, and before the Global Fund For AIDS, TB and Malaria existed. It was a very frustrating experience. The South African government was hailed as one of the few Sub-Saharan governments with a decent policy, but rates of HIV-positive cases kept going up. Donors and the government were subsidizing mostly advocacy and awareness programs, and the responsible officials were often found in international conferences. In short, everything was politically correct, and nothing worked. Until GFATM was created. They had exotic ideas such as “evidence based” interventions. Things were falling into place when the price for drugs dropped too. Alternative reading: until Brazil and MSF got their way and cheap drugs.

Lesson 1: If there is an internationally recognized crisis, focused forceful global action can be useful.
Lesson 2: “Evidence based” interventions might have a bigger chance for success than doing whatever seems right when you are at it.
Lesson 3: Advocates can make a difference. Sometimes for the better.

Reform
Since the UN was created, there have been calls for reform, but here I am talking about 2004, with a donor drive for more streamlining amongst agencies. Smaller agencies should be integrated in the bigger ones. This would lead to more efficiency, as we all know that big bureaucracies, thanks to economies of scale, are more efficient than nimble organisations fighting for their survival. One of the agencies under fire was UNIFEM, The organisation that “provides financial and technical assistance to innovative programmes and strategies that promote women’s human rights, political participation and economic security.” It should have been merged with UNDP. One of the delegates of the G77 berated: all UN-agencies have been created because there was a good reason. So good a reason, that all MS in unanimity decided to create this organisation. Are you really sure that the situation of women has changed to such a degree that we don need this organisation any more?

Indeed only 6 years later, the same donors managed to create a bigger UN-women organisation, that should strengthen the original mandate of UNIFEM, and bring it to a larger scale.

Lesson 4: never thrust a donor (or anyone) that is sure about the next silver bullet
Lesson 5: Sometimes, if something is very important, you need to create a special tasks force to make it happen.
Lesson 6: Development fads come in tides, tides rolling in and out, a new tide rolling in…

Localizing
In the early years when I was working on HIV/AIDS in South Africa, it was amazing how many of the “good practices” were just copy paste from the interventions that were used in the HIV/AIDS communities on the West Coast. A group threatened by exclusion dominated by homosexuality and intravenous drug use, while in Africa victims were often heterosexual middle class. It was only when results were required that the programs got adapted.

Lesson 7: local actors seeking locally adapted solutions based on global knowledge works better than local solutions transplanted to a different ecosystem. Without good knowledge to start with, chances are good nothing will happen at all.
Lesson 8: never thrust donors or iNGOs that they are open for local input. If they think they have a silver bullet, they will push it, claiming it is localised.

Conclusions:

Lesson 9: global institutions should offer global knowledge and try to adapt catalytic operations to local circumstances. Acceptance and rolling out should be up to the local owners of the problem (if they find it is a problem).
Lesson 10: vertical and localized horizontal programs must coexist, and fight for attention. Having a dynamic of competition, where global, vertical programs must prove their mettle, and local horizontal programs are constantly challenged is a good thing.

Lesson 11: as a donor, you invest your money best where it delivers the most. Depending of the situation and the “maturity” of the issue, this can be a global vertical program, or a local operation, or anything in between. You should have thematic and geographical programmes with different goals competing for resources and attention.

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