Louisiana Lush

How policy transfer can improve the integration of HIV prevention services into primary health care in sub-Saharan Africa.

Policies to improve public health in low-income countries are often devised internationally by development agencies and academics. In theory, they are then incorporated into national policy and implemented. But work by the London School of Hygiene and Tropical Medicine suggests the process is rarely so simple. The notion of policy transfer highlights the way policy-makers draw lessons from elsewhere and apply them in particular contexts. Recent research has focused on integrating the treatment and prevention of HIV and sexually transmitted diseases (STDs) with primary health care.

For many years, people with STDs were suspected to be at higher risk of HIV infection. But in the mid-1990s a trial showed that HIV transmission could be slowed by 40 per cent in areas where STDs were treated at primary health-care level (although this is frequently not available in low-income countries). The trial led international health policy-makers, based in the World Health Organisation and other aid agencies, to promote the idea that STD services should be integrated into primary health care. This was especially appropriate for places such as sub-Saharan Africa, where a large proportion of the population is at risk of HIV infection and many suffer common STDs.

This step was seen as a relatively simple and potentially effective intervention. In sub-Saharan Africa, though, enthusiasm for this was tempered by limited political, financial, managerial and technical resources, hindering implementation. Lack of political interest was linked to a relatively coercive relationship between national policy-makers and the aid agencies that fund much of the health care in Africa. When governments did not support the reforms, donors imposed their priorities and distributed aid accordingly. Governments went along with donor policies to get much-needed funds, but implementation was weak and service delivery did not improve.

We studied similar issues in South Africa, including how national agendas were set and formulated into policy and what happened during implementation in the Northern Province, one of the poorest parts of South Africa. Since it was relatively isolated from international discourse until the early 1990s, South Africa developed its own policies for integrating services. These reflected many of the concerns and interests of the international community, but were generated from within, rather than imposed from outside.

Policy development took place at a time of radical political and economic change, as the apartheid regime gave way to a democratically elected government, which created opportunities for introducing new policies. But rapid reform meant national policy-makers failed to take account of impediments to implementation at sub-national levels or of constraints on service delivery. Political changes also led to more autonomy for provinces, so it was difficult for national policy-makers to implement policies. In the end, STD services suffered.

We concluded that any framework for understanding how and why international policies do not always turn out as expected needs to incorporate the notion of policy transfer. It should also consider analysis of how issues get on to agendas and how policies are formulated and implemented. Where international agendas are not reflected in national policy, they are less likely to be fully absorbed or implemented. Even where policies are transferred between national and sub-national levels, problems remain with generating resources for implementation.

Louisiana Lush is lecturer in health and population policy, centre for population studies, department of epidemiology and population health, London School of Hygiene and Tropical Medicine.

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