Huge thanks to Alanna Shaikh for peer review comments and edits
Back in 1997, Robert Chambers argued that top-down attempts to manage complex processes of change have not worked in development aid.
…Development projects can be paralysed by overloads at their centres of control…[generating] dependency, resentment, high costs, low morale and actions which cannot be sustained’ (Chambers, 1997).
According to a recent post by CGDev ’What Bush Got Wrong on AIDS’, this is precisely what we have seen with the ongoing US PEPFAR programme:
…U.S. foreign assistance should focus on helping poor countries to help themselves. With PEPFAR, our assistance instead fuels the accumulation of millions of AIDS patients who are unable to support their own medical treatment, requiring lifelong assistance from the United States for their very survival. Instead of an AIDS program focused on prevention, which would have both protected and empowered the people of affected countries, PEPFAR has engendered increased dependence on the United States…”
Looking at HIV-AIDS responses as a whole, however, there have been some interesting examples of different approaches being used, especially on the prevention side.
For example, the well publicised example of Uganda’s 1990s HIV/AIDS campaign (Cohen, 2003), referred to by some as a social vaccine, is synonymous with the ‘ABC approach’ to HIV/AIDS prevention. ABC stands for ‘Abstain, Be faithful, use Condoms’, and refers to the necessary changes in individual behaviours, as well as the programmatic tools and techniques designed to promote these behaviours.
An intense program of public education, information and skills-building reached into every corner of the country. The evidence shows that a combination of important changes in all three of these sexual behaviours contributed both to Uganda’s extraordinary reduction in HIV/AIDS rates and to the country’s ability to maintain its reduced rates through the second half of the 1990s.
This drastic reduction can be seen as a result of following a ‘minimum rules’ approach to the national prevention programme. Such an approach required those in the position to design the programmes and projects to define no more than was absolutely necessary to launch a particular initiative. The role of grand designer was avoided in favour of the role of facilitation, orchestration and creating the enabling environment that allowed each element of the response to find its own locally relevant form.
Chambers describes such efforts as contrasting with centralised approaches (in ways which Bill Easterly will probably recognise):
… the key was to minimise central controls, and to pick just those few rules which promote or permit complex, diverse and locally fitting behaviour’ (Chambers, 1997).
However, in specifying such ‘minimum rules’, it is crucial to understand the dynamics of local circumstances and actors. In working towards change and improving the lives of poor people, aid agencies are dealing with huge numbers of interacting problems, factors and actors. As a result, there are inevitably degrees of non-comparability across, and unpredictability within, these complex systems. As Chambers has warned:
…[aid] projects deal with varied environments and idiosyncratic people… The simple rules which then work have to go further, allowing and enabling people to manage in many ways with their local, complex, diverse, dynamic and unpredictable conditions, and facilitating not the uniform behaviour of flocks but the diverse behaviour of individuals’.
This sets some necessary limits on attempts to scale up such ‘minimum rules’ approaches. These are particularly evident in the HIV-AIDS context, where the top down mentality has proved pervasive.
Instead of ‘scanning globally and reinventing locally, as Joseph Stiglitz famously suggested, most HIV-AIDS efforts have attempted to ‘discover the top performers and export as best practice’. Overall, the approach has been less Ebay and more BP – and this ‘pipeline’ approach seriously underestimates the complexity of HIV-AIDS challenges.
For example, subsequent to Uganda’s success, a number of Western leaders backed the export of the ABC approach elsewhere in Africa, for example in Botswana, with considerably less success. The same minimum rules did not have the same effect everywhere.
Moreover, minimum rules mean exactly that – there needs to be the space to allow for localised processes of reinvention. Such innovations can only be effective if they are embedded in economic, social and political contexts.
This was one of the major errors of PEPFAR in the Bush era, interestingly not mentioned by the CGDev blog piece. Ideologically driven approaches to prevention banned and inhibited specific kinds of responses, limiting local adaptations so that funded programmes were consistent with the norms of the US conservative right. This was most notable in Uganda itself, despite AIDS activists arguing that such actions would undermine community efforts to reduce HIV prevalence and HIV transmission.
The pressure of PEPFAR funding requirements led – directly and indirectly - to a third of prevention funds being spent on abstinence-until-marriage programs, sex-workers condemned as immoral, and rising anti-condom rhetoric with some 32 million quality-approved condoms being impounded in government warehouses. Concerns about donors latching onto dangerous ideas have not gone away, as highlighted by a recent Guardian blog on cash transfers for HIV-AIDS prevention.
Is there any message in all of this for how HIV-AIDS is dealt with in the coming years, apart from wariness of silver bullets? Perhaps it is simply to try and replace the search for ‘best practices to fix the problem’ with a focus on ‘good principles that trigger local invention.’
Whether there is the space and appetite for such a shift remains to be seen.
This piece was adapted from segments of Exploring the Science of Complexity, an ODI Working Paper published in 2008