Healthy Dialogues: August 2011
August 23, 2011
The Healthy Dialogues blog strives to create a dynamic space for conversations about current topics in health. We pick experts, from both inside and outside CSIS, to provide a range of views on a single topic. We hope that by stringing our experts’ responses together, an interesting and complex picture of the topic will be created. An integral component of this blog is you! If you have a topic you'd like us to address in the future, tell us. If you have a question you'd like us to answer next, ask it. We want to hear what's on your mind.
This month's blog is dedicated to reflections on the recent trip the Global Health Policy Center (GLPC) took to South Africa. A delegation from GHPC traveled to South Africa in August, 2011 to look at the major efforts underway to renew the United States’ bilateral relationship with South Africa, with a particular focus on creating sustainable partnerships in health and other areas of U.S. foreign assistance. The delegation looked specifically at: The U.S.-South Africa Strategic Dialogue; South Africa's shift toward greater country ownership in the health sphere; and turning the tide on the HIV epidemic.
We are excited to have two experts from our South Africa delegation answer questions for this month's blog. Writers include:
Ambassador William Bellamy (ret.), Director, Africa Center for Strategic Studies, National Defense University
Peter Lamptey, President of Public Health Programs, Family Health International
Question: In light of fiscal uncertainty in the U.S., at what level do you think the United States should continue engaging emerging economies like South Africa?
It will be difficult to re-balance and right-size assistance programs in Africa without cuts to PEPFAR and other health initiatives. In much of Africa, there is a great disparity between our generous spending on health programs and our spending on everything else, so much so that there are limited savings to be had outside PEPFAR.
PEPFAR has been a popular, bipartisan program. Who can argue with its well calibrated mix of prevention, treatment and care, and its well documented successes? Still, it is not in the US interest to allow foreign assistance to Africa to be so completely dominated by one category of spending. The Administration should propose substantial reductions in PEPFAR in places, such as South Africa, where the will and capacity exist to assume responsibility for at least some programs. We should concentrate the largest part of PEPFAR spending in the future on nations still struggling to develop this capacity.
The US should actively and aggressively engage emerging economies like South for a variety of reasons:
- Ensure the successful transition of US funding to a sustainable national government responsibility and support
- Be able to demonstrate success stories in foreign assistance in terms of developmental effectiveness as well as being able to “graduate” such countries from further dependence
- Learn from lessons in emerging economies such as South Africa to guide US developmental assistance in the future
- Promote South Africa as regional and continental economic and development leaders that will lead to more South to South assistance and reduce dependence on the US.
- Promote the role of South Africa as a regional leader to support conflict resolution and the development of democratic institutions
Question: After being on the ground in the South Africa and hearing various U.S./South African perspectives on a range of issues, what do you think is a plausible next step the United States can take to move South Africa’s health agenda forward?
As the U.S. winds down direct involvement in HIV-AIDS prevention, treatment and care, the shortfall of skills in South Africa’s health sector becomes a more critical issue. Training more doctors, nurses and technicians in South Africa is not the answer. Once trained, they are as likely to emigrate as to remain behind.
This is a global problem. Part of the solution is surely enlargement of the global pool of skilled health care professionals. This means the US and other advanced countries need to invest more in training their own health care personnel, and rely less on recruiting in the developing world. A shift in U.S. domestic policy to help reverse the world-wide brain drain by creating more homegrown jobs ought to garner bipartisan Congressional support. It would be welcomed in the developing world as well. It could be a centerpiece of the gradual transition away from PEPFAR.
The US has already taken some important steps in creating a new U.S.-South Africa Partnership Framework (2011-2017) that promotes a new way of doing business that ensures PEPFAR support based on the South African government's priorities. The framework is based on a new relationship that encourages consultation, coordination, shared responsibility, joint planning and implementation. It also ensures:
- Greater country ownership, decision making and prioritization in the health area
- U.S. support is complimentary and not duplicative
- Eventual transition of funding responsibility to the South African government
The next steps would include:
- Improved communication and coordination of the Partnership framework at the provincial and district levels to ensure that more effective implementation
- Further discussion, clarification and agreement on the role of civil society in the funding transition
- How South Africa would build adequate local capacity to support and manage a scaled up treatment program, a more effective prevention program and support research and innovation
Question: What do you consider the most important takeaway for this trip to South Africa?
Americans underestimate how historical grievances from the apartheid era, combined with an often intense aversion to current US policies, shape negative South African views of the U.S. Even though many ordinary South Africans do not share this animus, anti-Americanism is routine among key elites -- at many levels of the South African government, throughout the ruling ANC, and within academic and activist communities.
It would be a mistake therefore to assume that our huge PEPFAR investment in South Africa will generate corresponding levels of goodwill or official gratitude. Health care professionals and others directly involved in the fight against HIV-AIDS appeciate the enormity of America’s contribution. But relatively few outside this community notice or comment. Ironically, this contrast between American generosity and South African indifference may provide one of the best storylines of the PEPFAR program. It demonstrates that our primary purpose is to save lives, not win public approval or curry official favor.
Discussions with key policy experts and leaders of local institutions in South Africa revealed very diverse opinions on the history and state of US-South Africa relations. I witnessed the following perspectives:
- A complex but favorable relations based on mutual interests - such the important and critical South African leadership role in Africa and the much-needed PEPFAR support for South African HIV/AIDS research and programs
- A relatively warm but often rocky relationship based on mutual respect but constantly tested by the widely different policies of the two governments on issues such as Zimbabwe, Ivory Coast and Libya. A question often asked is “what does the US want from South Africa?"
- Relatively poor relationship based on major political and policy differences as a result of several historical events (US role during apartheid, classification of ANC as a terrorist organization until recently); historically poor relationships between US and South Afrcian political leadership, and perceived inconsistencies and double standards of US foreign policies. And equally critical of US foreign policies e.g. “US foreign policies too militaristic”, “US lacks a moral compass on foreign policy”, “US foreign policy entirely driven by US self- interest”
The need for improvement in the relationship between the South African government and U.S. government that would include:
- Improved and transparent communication between policy makers of the two countries based on mutual interests and the critical role of South Africa as an emerging economy and in regional and third world politics
- Open discussion and recognition of the historical and the clarification of both the policies and the current differences
- Acknowledgement and appreciation by South Africa of US/PEPFAR support. This should make it easier to “sell” the benefits of foreign assistance to a more critical US Congress.