What Zambia Teaches Us About International AIDS Policy
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Earlier this month, Population Action International (PAI) and the Sexuality Information and Education Council of the United States (SIECUS) teamed up to conduct a joint policy research trip to Zambia. Zambia is one of the 15 focus countries prioritized to receive global U.S. HIV/AIDS assistance. Zambia was also one of the first countries where PAI documented, in 2003, the destructive impact of the Global Gag Rule (also known as the Mexico City policy) on family planning and reproductive health care services.
Other criteria, however, also made Zambia an ideal country through which to answer many questions about the effects of U.S. policy and funding. Long before PEPFAR's arrival, a conservative religious environment defined Zambian society, within which the promotion of abstinence and marriage were already strong currents in everyday life.
First, what would the effect be after four years of the U.S. putting nearly $577 million into the country under policies that disproportionately emphasize these strategies over a more comprehensive HIV- prevention approach that included condom education and distribution?
Second, how are PEPFAR policies interpreted and implemented in this environment? And have they exacerbated the dire sexual and reproductive health and rights situation in Zambia, where rural family planning and reproductive health outreach collapsed after the country's leading SRHR provider refused the terms of the Global Gag Rule?
Third, has U.S. assistance harmonized with other donors and what has the Zambian government's role been in the midst of this? And finally, and perhaps most importantly, what are the needs of the health care workers on the ground and the Zambian people themselves in attempting to stem the generalized HIV epidemic in the country?
Having returned from the research trip to Zambia, PAI and SIECUS will be answering these key questions over the next several weeks and reporting on our findings and educating Members of Congress and their staff about how U.S. policy and assistance really plays out in the field. We'll also be collaborating with and supporting Zambian NGO colleagues to increase SRHR advocacy with their own policymakers.
Immediately, however, we wanted to share some disturbing observations from our research interviews that both advocates and lawmakers should consider long and hard during Congressional recess and in preparation for floor consideration of PEPFAR reauthorization in a few weeks.
1) By all appearances, reproductive health seems to have vanished from Zambia both conceptually and as a health service. At the policy level, there is no official framework for SRHR. At the program level, sexual and reproductive health (SRH) services are thin and fall far short of demand. Rates of maternal death, unplanned pregnancy and unsafe abortion -- especially among young women -- are persistently high. Contraceptive stockouts have become more frequent and community-based SRH outreach throughout rural Zambia is non-existent, thanks to the Global Gag Rule. While the U.S. is one of a handful of donors providing FP/RH assistance and donated contraceptives to Zambia (about $6 million in FY07, compared with $216 million in PEPFAR funding), this small amount of U.S. assistance is hamstrung by Global Gag Rule restrictions and consequently is narrowly focused on providing technical assistance to the public sector.
2) While we observed and documented some impressive prevention programming funded with PEPFAR, it is as far from a comprehensive approach as one can imagine. Higher risk groups, such as sex workers, seem mostly neglected by PEPFAR and rarely talked about in a country with major trucking routes and new copper mines drawing migrant workers from the region. Condoms, as well, are not as actively promoted or distributed as they were pre-PEPFAR in Zambia -- where prevalence is around 17 percent and rises to 30 percent or more in some parts of the country. And based on our conversations with Zambian and U.S. NGO staff, there is a lot of confusion about what you can and can't say about condoms under PEPFAR. The notion that other donors -- miniscule in comparison to PEPFAR -- will step in to meet needs specifically jettisoned by PEPFAR in practice has not been borne out in Zambia.
3) Sexuality education is the missing foundation for effective prevention of the sexual transmission of HIV/AIDS. In one classroom, we observed a group of students being told that certain body fluids can transmit HIV. The students looked utterly bewildered and the skilled educators realized that it was because these students had a deficit in the basics of how their bodies work. The educators stepped in to describe what these body fluids were, but no patchwork quilt of HIV/AIDS prevention is going to maintain a long-term curbing of the epidemic if the education system does not play its part and begin providing comprehensive sexuality education as a foundation for other efforts.
4) PEPFAR in Zambia operates largely in isolation. This has been observed in other PEPFAR focus countries and is endemic to the U.S. approach to foreign policy in other settings. This has profound implications for harmonizing with the Zambian government and its priorities for tackling the epidemic, as well as for coordinating with other donors to minimize duplication and maximize comparative advantages. For example, while it is true that the Zambian government works with the PEPFAR team there to develop an annual "country operational plan," it is a bit akin to a borrower setting the entirety of the terms for a bank loan -- it just doesn't work that way. Zambian providers and advocates repeatedly told us that U.S. political priorities drive PEPFAR planning and programming, not the reality of HIV/AIDS on the ground.
5) Again, as seen in other focus countries, PEPFAR has created a discernible break between local NGOs and international and U.S.-based groups working in the country. The experience of many Zambian NGOs is that PEPFAR has not benefited from the development and capacity building of indigenous groups doing this work, but rather has led to the growth of U.S.-based NGOs, especially faith-based groups, who are the major recipients of PEPFAR's largesse. That said, international and U.S. NGOs are clearly doing impressive work in the areas of treatment and care under PEPFAR, but at present the relatively tiny investment in home-grown, Zambian NGO efforts on the prevention side speaks to concerns about the sustainability of current activities and the development of Zambian professionals to lead this work in the future.
Reauthorization of PEPFAR's prevention components needs to move beyond the persistence of the destructive political and ideological shenanigans of the bill's first iteration. To this end, our field research in Zambia highlights key areas that must be addressed if PEPFAR's promise is to be truly realized, and new infections averted.
William Smith is Vice President for Public Policy at the Sexuality Information and Education Council of the United States (SIECUS).
Wendy Turnbull is the Senior Policy Research Analyst at Population Action International (PAI).