Are Country Reputations for Good or Bad AIDS Leadership Deserved? An Exploratory Quantitative Analysis

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Are Country Reputations for Good or Bad AIDS
Leadership Deserved?An Exploratory Quantitative
Analysis

• Nicoli Nattrass
• AIDS Society Research Unit
• Centre for Social Science Research
• University of Cape Town

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Testing the Conventional Wisdom

• Some countries (e.g. Brazil, Thailand, Uganda)
  are seen as demonstrating good leadership on
  AIDS, whereas others (notably South Africa) are
  infamous for poor leadership.
• But are these reputations deserved, or do they
  just reflect different challenges, constraints
  and opportunities?
• This paper uses regression analysis of HAART
  coverage to explore which countries performed
  above expectation, as expected or below
  expectations.

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Costa Rica
Botswana
Cuba
Thailand
Chile
Brazil
Cambodia
Mexico
Venezuela
Namibia
Rwanda
Uruguay
Trinidad Tobago
South Africa
Latvia
Russia
Kazakhstan
Iran
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Highly Active Antiretroviral Therapy (HAART)
coverage is positively associated with per capita
income and HIV prevalence but substantial
variation remains.
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Explanatory variables to account for factors
governments cannot change in the short-term

• level of development (GDP per capita)
• external support (being a PEPFAR country or in
  receipt of Global Fund 1st round funding),
• scale of the epidemic (HIV prevalence, the
  absolute size of the HIV population and its
  distribution between urban and rural areas)
• other heath-related demands (non-AIDS DALYs per
  capita)
• politico-institutional context (political
  stability and established democracy, of births
  with skilled personnel).
• Sensitivity analysis also conducted controlling
  for language fractionalisation and region

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• Model 1 predicts
• Being a PEPFAR focus country raises HAART
  coverage by 67
• For every 1 increase in HIV prevalence, HAART
  coverage rises by 0.2
• For every 1 percentage point increase in the
  share of the HIV-positive population in urban
  areas, HAART coverage rises by 2.5 and
• Being an established democracy raises HAART
  coverage by 55.

Y HAART coverage 1. 2. 3.
(Log) GDP per capita (PPP) (2005) 0.094 0.220 0.261
PEPFAR focus country 0.556 0.581 0.512
Global Fund 1st round recipient 0.293 0.311 0.402
(Log) adult HIV prevalence (2005) 0.202 0.222 0.176
(Log) HIV population (2005) -0.098 -0.075 -0.007
Proportion of HIV people in urban areas 0.881 0.793 0.522
Political stability (2005) 0.107 0.072 0.105
Established democracy 0.483 0.438 0.062
of births with skilled health professionals 0.004 0.001 0.002
(Log) non AIDS DALYs per capita (2002) -0.347 -0.011 -0.021
Language fractionalisation   -0.948 -0.643
Latin America the Caribbean     0.982
Southern Africa     0.265
West Africa     0.561
East Africa     0.215
N 82 78 78
Adjusted R2 0.5017 0.5697 0.6494
Selected Country Residuals Selected Country Residuals Selected Country Residuals Selected Country Residuals
Brazil 43.6 31.6 16.2
Uganda 16.7 19.9 18.2
South Africa -36.1 -24.1 -42.6
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A regression residual of 0 means the country has
precisely the predicted/expected level. Those
countries with regression residuals ranging from
-15 to 15 were classed as performing as
expected. Those with residuals greater than 15
were classed as performing better than expected,
and those with a negative residual below -15 were
classed as performing below expectations. The
figure displays the results from regression 1 for
those countries whose regression residuals fell
into the same category for all three
specifications.
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This supports the conventional wisdom about SA.
I have been to every country in East and
southern Africa, many of them two, three and four
times. I can say confidently and categorically
that every single country . is working harder at
treatment than is South Africa, with fewer
relative resources, and in most cases nowhere
near the infrastructure or human capacity of
South Africa. It is a situation which is
absolutely mystifying Steven
Lewis, 2005 (UN Special Envoy on
AIDS)
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Further research is needed into those countries
which performed significantly better than
expected, but which do not have established
reputations for good AIDS leadership (notably
Mali, Burkina-Faso and Suriname). It is possible
that in the general discourse about AIDS
leadeship, insufficient attention has been paid
to the role that governments can play in
facilitating the importation and distribution of
generic antiretrovirals (as occurs in
Burkina-Faso) and in ensuring that the health
system is well organised and efficient (as is the
case in Suriname, but not in Trinidad and Tobago.