Last Impressions

As I am sitting here in the Cape Town Int’l Airport and thinking back on the past month, it is remarkable how much has happened. I have completed my Independent Study Project/Thesis entitled NPO Behaviour in the Context of Changing Funding Landscapes, lived in the Tekwini Backpackers in Durban for a month, lived in Cape Town for 11 days and have had to say goodbye to some of the most interesting people whom I have ever met in one of the most beautiful, diverse and – for lack of a better word (and really, I tried to find one)- fucked up places I have ever been. South Africa has stolen my heart. This is the first place where I have seriously contemplated missing my flight and staying indefinitely. I suppose I should back up and tell you about my last month in Durbs.

Before I moved into the backpackers, I had an incredibly limited perception of Durban. I had only experienced what SIT had specifically designed for us to experience in the townships, the waterfront, the shopping centers, etc. While a main point of the trip was certainly to experience life as Zulu South Africans do, you do not actually experience the inequalities and are unable to truly identify them, understanding their complexities, without seeing the other sides (white, Indian, coloured, immigrant, etc). I was one of six lucky students to spend time in Chatsworth with the Indian population and one of four lucky enough to stay in the Backpackers during ISP period. SIT did not want us to stay in the backpackers because they have an active bar and it is a place where students could easily get into trouble, especially students from the U.S. who have just began drinking legally. For me, this reasoning was absurd and I argued vehemently to stay in the backpackers where I was finally making local friends and experiencing the many sides of South Africa. The Backpackers was truly a melting pot of all colours and all nationalities. Luckily, I am quite persuasive when I want to be and was granted permission to stay in the backpackers for the month of November. While this created a divide between myself (and the three girls who stayed with me) and the rest of the group, who was content to sit in the beachfront flats on their laptops and Facebook friends from home, I was quite willing to make that sacrifice. I’m an adventurer and it took me awhile to find my footing in Durban, but when I found my fellow-adventure buddies, the experience really took off.

This was the best month in Durban. I stayed in a four-person room with Nina (who is from Boston and you will certainly meet), Katie and Janelle. We shared a kitchen, living area and bathroom with another single room that two guys shared. This apartment was separated from the main building of the Backpackers and was therefore perfectly conducive to studying. The Backpackers had a great pool with benches surrounding it, a comfortable lounge area when the days got cold and a pool table. My typical day would involve taking a taxi or mini-bus taxi to an interview, returning to the Backpackers, putting my bathing suit on and working by the pool while tanning. The poolside was perfect for studying because during the day all of the people passing through were either off sightseeing or had moved on; we basically had the place to ourselves with VH1 classics playing in the background. The Backpackers held a Braai (South African BBQ) on Sundays, Tuesdays and Thursdays, were you would have to buy meat while they would provide rolls and salads. This was a great way to have a cheap meal, meet fascinating people and unwind after a long day of report writing. Aside from all of this, the people at the Backpackers were absolutely wonderful. It is also a local hotspot for Durbanites to come play pool, braai and just chill. This was really fun and a great way to meet people who weren’t leaving after a few days. We made many really wonderful friends and it was so sad to say goodbye. Our favourite two guys who work there, Ben and Wati, both got up at 6 AM to say goodbye to us! I am very fortunate that I have a nerdy obsession with my ISP topic because otherwise it would have been quite difficult to motivate myself, but I actually finished two days early and never felt stressed or overwhelmed by it. I am more than happy to send it along to anyone who is interested in reading it. I haven’t received a grade yet, but have received some great feedback and suggestions to attempt to publish it. We shall see.

I want to tell you all about my most fascinating interview with an Organizational Development Practitioner. This woman’s job is to facilitate interactions between organizations (NGOs, NPOs, CBOs, Donors, etc). As a former founder and director of two NGOs, she realized that there was no longer a need for more organizations; the need is rather in the form of facilitation, collaboration and connectivity. South Africa has over 150, 000 registered non-profit organizations (NPOs) and over 50 000 unregistered ones (approximately). Despite this, HIV/AIDS is still endemic in KwaZulu Natal, unemployment is astronomical, poverty is rampant and preventable non-communicable diseases are increasing. The complexity of aid delivery is clearly evident, as elicited in my favourite Paul Farmer quote, “Doing good is never simple”. This is the essence of my Independent Study Project and if you find this interesting, please contact me about reading my paper. I would love feedback or discussions on it!

On December 1 (World AIDS Day!) we flew to Cape Town. This was a very sad goodbye and we were quite late for the taxi because we didn’t want to leave the Backpackers. Thula, our driver/lifesaver/Zulu-program-assistant picked up the other students at their flats and specifically drove past the Backpackers because he had a feeling we wouldn’t want to leave. And he was right; we weren’t out at the taxi when he arrived, 15 minutes past when we were supposed to leave. We did have a “valid” excuse, we were getting music from Wati!

We were quite busy in Cape Town for the first five days with the group giving presentations and doing touristy explorations of the city. I really hate travelling in such a large group and many of the students were so ready to go back to the U.S. that it wasn’t very fun. It’s amazing how many people did not enjoy South Africa. They really didn’t try at all though, so I don’t feel sorry for them. On the fifth, we separated from the group and myself and five others went to stay in a Backpackers on Long Street. This was a very cool place, albeit the local vibe that Tekwini had. The best part of this place was their rooftop bar and huge rooftop lounge area that had an amazing view of the city. After a few days, it was down to four of us, myself, Chloe, Casey and Alie. We had a great time exploring the city, went surfing twice and overall had a wonderful experience.

We went surfing at Muizenberg Beach, about 40 minutes outside of town. This was a wonderful spot that is known as one of the best beginner surfing beaches in the world. Apparently there are a lot of sharks, but we all survived! You only live once, right? I also really wanted to go paragliding and/or skydiving but I refrained (this time). Another highlight of Cape Town was meeting up with one my old Franklin friends who graduated two years ago. He is a really great South African guy who lives in the “Beverly Hills of South Africa” (his words). We went to some really eclectic-hidden treasure restaurants and had a great time catching up. There is just something about being around Frankliners that reminds you how no one else can compare. We are a unique breed, but I love it. It does make it hard to make lasting friendships with non-Frankliners.

As I stood with my Franklin friend, Jacques, on the rooftop of the hostel last night, we were talking about the uniquely African smell that South Africa has, that Switzerland, Europe and the U.S. don’t. It’s weird; they don’t smell. Even the grocery stores are sterile, as though the people are disconnected from the places that they live in and the nature that should be innately connected to our beings. I have really learned to relax since I’ve been here, to enjoy life and to not sweat the small stuff. While I am still impassioned and excited to work in the global health and development fields, I am beginning to understand the importance of enjoying life and taking time for myself. While looking out over the city, we talked about the overwhelming amount of hope that South Africans possess. While South Africa has a plethora of corruption, inequalities and horrific injustices, most people see South Africa as a land of promises, where dreams can really become realities. Following Nelson Mandela, or Madiba, his clan name’s death, many said that the country would either erupt into mass civil unrest or be united by his memory. I have overwhelmingly seen the latter. Everywhere you go, there are signs, people remembering, people talking, all surrounding Madiba and his legacy. I passed a billboard on my way to the airport that had a picture of Madiba on it and said, “Hamba Kahle Tata, although you are gone, your dreams live on in all of us”.  Hamba Kahle Tata means Go Well, Father.  Madiba’s legacy is incredible. I have never seen anything like it, anywhere in the world and in any history book. It is impossible to describe the hope that he provides people, even in his passing. Madiba passed away the day our program ended. It was a strange feeling, to have our time in South Africa officially end on the same day that Madiba’s did.

Before leaving for Cape Town, Durbanites kept telling us that while Cape Town is more visually beautiful, Durbs is more authentic. While I tend to agree with this, as in Cape Town you meet more international people than South Africans, Cape Town is the most diverse, eclectic and cosmopolitan city I’ve ever been to. I have had the best food, conversations and experiences since I’ve been here and I was really only experiencing it for five days. Every night there are impromptu live bands, eclectic restaurants, and diversity around every corner. As South Africans would say, it’s a really vibey city. The city has an incredible mix of traditional Xhosa, Zulu and other tribal vibes and design with a fabulous European flourish. South Africa, and Cape Town in particular is truly a melting pot, in all of the ways that the U.S. was established or anticipated to be.

After just four months, I feel such a sense of connection to South Africa and a feel a resounding sense of pride whenever I see the South African flag waving. Aside from its awesome colours, the flag represents the plight of the underdog, the incredible adversity that the South African people overcame. It’s really incredible how this country transformed, and while it still has a long way to go, Mandela created this brilliant atmosphere that enabled people to acknowledge those proverbial elephants in the room, which is really the only way to overcome them. South Africans are blunt about their race issues, blunt about the vast problems the country faces- corruption, nepotism, and much more. But they are also blunt about their past. Mandela and Desmond Tutu’s Truth and Reconciliation Commission are somewhat representative of how South Africa addresses and overcomes its problems.

This was a fascinating time to be in South Africa, with the death of the legacy, Madiba and the crossroads that South Africa is now facing. With a huge election coming up next year, it will be great to see what South Africa decides. Is the country at a point where it can become a true democracy and elect a party aside from the ANC? Will the ANC split up into two different parties, one more socialist in nature than the other? Will the DA take over? South Africa is certainly the place to watch and as I spent my last day surfing at Muizenburg, eating the best Argentinian food of my life with four great friends and relaxing on the rooftop overlooking the city and signal hill, I cannot wait to return in the near future.

I’m going to leave you with a few of my favourite Mandela quotes:

·      “A good head and a good heart are always a formidable combination.”

·      “There is no passion to be found in playing small- in settling for a life that is less than the one you are capable of living.”

·      “For to be free is not merely to cast off one’s chains, but to live in a way that respects and enhances the freedom of others.”

·      “No one person is born hating another person because of the color of their skin, or his background, or his religion. People must learn to hate, and if they can learn to hate, they can be taught to love, for love comes more naturally to the human heart than it’s opposite.”

·      “There is nothing like returning to a place that remains unchanged to find the ways in which you yourself have altered.”

I cannot believe that there is less than a month left of my time in South Africa. I have only begun to understand the complexity and truly appreciate South Africa in the last week or two. On 1 November, I was supposed to move to Chatsworth to stay with a family in an Indian community where one of our programme partners was going to set up several interviews. Unfortunately (well, now I’ll say fortunately), this programme partner is rather flaky and our plans fell through. I ended up saying in the Tekweni Backpackers (a backpackers is the same as a hostel) with two other girls. This backpackers is right on Florida Road, which is a hot spot for restaurants and things to do. It’s a 20-minute walk from the beach and our office- the ideal location! The best thing about this place is the atmosphere, which is fun, relaxing and incredibly chill. It’s run by a bunch of locals and the people who stay here are so interesting! It’s also a local hang out spot so I’ve finally met a lot of locals who are more than excited to talk to us about Durbs, take us surfing and show us around. It’s amazing how incredibly friendly everyone is.

The other two girls who were staying with me were both quite sick. One had a stomach bug and had to return home from the rural home areas and the other had some crazy bacterial infection and ended up in the hospital for a few days. Needless to say, I was on my own for making friends at first. This was intimidating in the beginning; I would just walk up to a group of people and introduce myself. So far, I have met only incredibly friendly people, so it has worked out quite well.

The other day I was thinking about what I love so much about Durbs and I came up with a few conclusions. I love how diverse it is. South Africa truly is a rainbow nation and with the “most inclusive/liberal constitution in the world”, it is truly a country of hope. South Africa has only been a free and democratic country for 20 years and while it still has a long way to go, people (for the most part) are hopeful. They have a strong faith in humanity, I mean, South Africa turned over one of the most oppressive regimes in world history without a civil war. Mandela and Tutu’s Peace and Reconciliation Commission is considered one of the most profoundly successful justice initiatives. For an aspiring development/health person such as myself, Durban has it all. It’s absolutely stunning aesthetically, with lots of cultural events and things going on but it also has a long way to go developmentally. The socio-economic divide is striking. The upper class and predominately white area of Umshlanga is like Newport Rhode Island, with restaurants, shops, beautiful beaches and a posh atmosphere. This is within 10 – 15 minutes of some of the poorest townships where HIV, TB and other diseases are rampant. Then in another section, also next door, is the largest diasporic Indian community in the world (although SSB would disagree with the word diaspora as it is used here – there is no desire to return home to India in these people – for the most part – and they consider themselves South African, not Indian).

It’s so fascinating that twenty years post-apartheid, the effects are astronomical and still ever present. Apartheid is still apparent in a structural sense; the Black townships, Indian communities and White areas were created by this government and even though the government was overthrown, the areas remain the same. The townships were strategically placed with very limited access from highways and main areas; they were often hidden over a hill or in a forest- out of sight out of mind. This has had incredible implications on development. You could presumably live your whole life here and not see the squatter camps (informal settlements) or townships. Apartheid also created the perfect recipe for HIV and TB. The mining industry was established and was staffed by Black South Africans, mostly from the rural areas. They lived in poorly ventilated and overcrowded housing with poor nutrition and were frequently visited by commercial sex workers. This is the ideal situation for both TB and HIV to spread. THEN, to exacerbate this, the men return home to their families in the rural areas, bringing TB and HIV with them. Now we’re faced with these structural limitations of development and these social determinants of healthcare. So far, the most effective TB prevention method has been to reform housing (as seen historically in London late 19^th century), unfortunately South Africa doesn’t have the infrastructure to completely redo all of the housing (not to mention, the government already built all of the houses in the townships).

I have been exposed to the incredibly complexity of health. I really enjoy the slogan of public health, “providing the greatest good to the greatest number”, but it’s really hard. How do you break such a pervasive cycle of poverty and disease? Also, where to the Whites fit in? A lot of White South Africans whom I have met are really struggling to find jobs because of a “Blacks come first” mentality. Then, where do the Coloureds and Indians fit it? They face similar problems as the White populations, but they feel as though the struggle is always labelled as black versus white, when there are far more ethnicities. This isn’t even mentioning the MASSIVE immigrant population from other African nations, which is clashing with South Africans and resulting in Xenophobic violence. It’s really mind-boggling.

On the other hand, the 1994 Constitution is incredibly liberal and is the only constitution in the world that addresses all people, not just the country’s citizens. Legally, every single person has equal rights, gay marriage is legal, everyone has the right to shelter and other things that the U.S. and many other counties consider privileges. The only problem is that none of these rights are upheld because of corruption, capacity limitations, logistical problems, societal norms, or in my opinion, a constitution that is too idealistic in nature. While I agree with most of the rights listed in the constitution (that also has a really difficult task of combining traditional and modern rights/laws), they are unlikely to be implemented because of their extreme idealism.

Another complexity that I have come across in my research (and you’ll hear more about this if you read my ISP when it’s complete) is that funding for HIV/AIDS and health related NGOs from foreign governments is drastically decreasing. These donors believe that other African countries are more desperate for aid in areas that the South African government has the funds and capacity to fulfil. Now the funding is drying up and the SA government is overflowing with corruption and a lack of effective local capacity building systems. It’s also nearly impossible for grassroots organizations to even apply for funding.

Anyways, I’ll stop ranting about the complexity of South Africa. I honestly barely started this discussion; the complexity runs SO deep. I’m not sure how this country is going to be in the future, but I certainly hold a great amount of hope for it. They have an election next year and there is a strong opposition to the ANC. A common perception is that the ANC is very corrupt and the elections are not really democratic because there hasn’t been competition against the ANC. We’ll see what happens!

As Paul Farmer says in Haiti After the Earthquake (a great read about the complexity of disasters), “Doing good is never simple”. And, as Nelson Mandela says in A Long Walk to Freedom (another must-read. The Boston Globe said that it is “a manual for human beings…should be read by every person alive”), “it is a long walk to freedom”.  From the time in the backpackers, I’m really learning to chill out and enjoy life, something I sometimes forget to do- stop and smell the roses, if you will (hehe). I’m learning about incredible resilience, similar to what I saw in Kenya, but with even more structural enforcement of oppression. In the beginning of the programme I was feeling disappointed because I didn’t feel challenged. I still haven’t been challenged like I was in Kenya, but right now, what I feel like I have learned is how remarkably similar humans are across the globe. In the Zulu township, the Zulu rural areas, the Indian community of Chatsworth, the fancy Umshlanga Rocks, and my wonderful little backpackers, everyone loves, laughs and cries the same. I feel much more connected to people whom I had never met and see myself looking at people as individuals, not just strangers. Perhaps it is a strange thing to take away from the programme, but I’m enjoying it for now and am going to be so sad when I leave.

Hospital Visit and Research Topics

I visited St. Mary’s private-public hospital outside of Durban today; it was wonderful! St. Mary’s was founded in 1927 and allegedly (although not likely) serves a population of 1 million people with 200 hospital beds. The hospital is relatively comprehensive with casualty units, obstetrics, surgery/theatre, medical, and outpatient and tuberculosis units. I found the politics of the hospital and the tuberculosis unit the most interesting.

As a private-public hospital, St. Mary’s has funding form the South African government and private funders. The private funding was previously dominated by PEPFAR (the Presidents Emergency Plan for AIDS  Relief)– the African HIV/AIDS funding provided by the US government during the Bush administration). However, PEPFAR was not supposed to last forever and has been steadily decreasing in funding. As a Catholic hospital, St. Mary’s does not want to become a fully public hospital and solely exist on government funds because it would have to give up on some of its Catholic values, namely abortion and family planning. This was interesting to me because apparently the hospital could receive much more funding from the government if it became fully private, however because of religious affiliation, they are reluctant to do so.

The PEPFAR funding also provides a really interesting discussion. PEPFAR is considered one of the most successful aspects of the Bush administration, however it has been critiqued for it’s earmarked funding (funding that can only be used for certain purposes). Before Obama came to office, 2/3 of PEPFAR funding could only be used for pro-abstinence programs; none of the PEPFAR funding could promote safe sexual practices or contraceptives to prevent HIV transmission. Obama overturned this, but it does provide an interesting example of the complexities surrounding foreign aid. If this is interesting to you, check out Dead Aid by Dambisa Moyo; she provides a fascinating synopsis of the complexity surrounding foreign aid and provides a critical analysis of its effectiveness.

The topic of my consolidation paper is Tuberculosis in South Africa, focusing on the DOTS programme. Our consolidation has to be on a health promotion policy in South Africa and I chose Tuberculosis as the heath problem because it is a truly interesting disease: Tuberculosis is truly a disease of the poor. As I have previously discussed, HIV is a disease that effects approximately 30% of South African youth. HIV itself does not usually cause mortality; it weakens the immune system, making the person susceptible to opportunistic infections such has Tuberculosis. Tuberculosis is an airborne disease and is most commonly transmitted through sneezing. It is most commonly found in areas of high density, inadequate housing (dark and damp areas) and in people with poor diets. Therefore, poverty exacerbates tuberculosis while tuberculosis exacerbates poverty- talk about the pervasive cycle of poverty and disease!

To matters more complicated, despite being curable, TB requires a rather extensive treatment plan that involves a six-month antibiotic course. The BCG vaccination against Tuberculosis is effectively useless, especially in adults. There are four epidemiologic patters of TB: 1) in persons with HIV in developing countries 2) in immigrants in developed countries (the Southern US has high TB rates) 3) in areas with economic decline, poor TB control and substandard health 4) Globally, Sub-Saharan Africa is disproportionately effected by TB. TB used to be a disease of young men, however with the HIV co-infection (women are more susceptible to HIV), TB in sub-Saharan Africa is now becoming a disease of women. This is even more interesting because it is attributed to societal/gender norms, namely intergenerational sex. Women are typically seven years younger than men and men typically have multiple and irregular sexual partners and often engage in high-risk sexual behaviour. You can really see how HIV and TB go hand-in-hand. A quote from our visiting professor exemplifies this: “Nothing in the history of the world predisposes people to TB like HIV”.

Now, I get nerdy and into my favourite global health figure: Paul Farmer. This is an example from Mountains Beyond Mountains by Tracy Kidder. Globally, the WHO initiated the DOTS programme: Direct Observational Therapy. This policy was tried and tested in a central African country before being recommended by the WHO as a worldwide solution for TB. This programme dealt with people who were not recovering from TB, despite allegedly taking the drugs. However, the study found that due to inherent conflict and displacement in the experimental community, patients were not completely adhering to their drug regimes. They countered this by giving more drugs to the patients and directly observing them to ensure that they took the drugs. When this policy was implemented globally, Partners in Health in Lima, Peru found a problem. Despite adhering to DOTS principles, patients were getting worse and worse as they continually adhered to the programme. Finally, Paul Farmer and his colleagues found that the DOTS programme worked in the Central African context specifically because people were defaulting on their drugs. However, in Peru, people were taking the drugs and were still getting sicker. The problem was that the TB patients in Peru had a different strain of TB. Pumping the patients with more drugs that weren’t really working effectively served to create multi-drug resistant tuberculosis (MDR-TB), which has now evolved into XDR-TB (an even worse version of multi-drug resistant TB that is almost universally fatal).

For my consolidation paper, I am excited to explore the effectiveness of DOTS in South Africa. South Africa provides such a unique perspective for diseases like TB, especially because of their social determinants and vast social inequality following Apartheid.

I figure I should also clue you into my ISP project as of now. I am still planning on exploring the impact of donor funding in HIV non-governmental organizations. As I discussed above with the PEPFAR reference, donor funding can have a profound impact on an organization’s behaviour and successes. The Global Health arena is dominated by six main agencies: The Global Fund to Fight AIDS, Tuberculosis and Malaria, The Bill & Melinda Gates Foundation, PEPFAR, the World Health Organization, the International Monetary Fund and the World Bank. All of these organizations are Western and Northern based and mostly work in the Eastern and Southern hemispheres. I have pasted a passage from my electronic journal that discusses my proposed topic:

HIV/AIDS In KwaZulu Natal

According to the SANAC KwaZulu Natal Provincial AIDS Spending Assessment Brief, the prevalence of HIV/AIDS is the highest in Durban of all the provinces in South Africa, with prevalence at 37.4% in 2011 and a population of 1,576,025 people in KZN living with HIV/AIDS in 2011(SANAC 2013).

As elicited in Reimagining Global Health, biosocial approaches to health dictate that “biologic and clinical processes are inflected by society, political economy, history and culture and are thus best understood as interactions of biological and social processes (Farmer et al, p.735, 2013). Thus, HIV/AIDS is a disease that is social in nature and as such is complex with many factors influencing its prevalence and incidence.

Shifts in Funding

The onset of the HIV epidemic and the establishment of NGOs were relatively synonymous. According to Jeffery Sachs and Amir Attaran (2001) from 1996 – 1998 the donor funding for HIV programs was US$170 million (US$69 million went to Sub-Saharan Africa (SSA). Since 2001, donor funding for HIV programs has drastically increased, with total resources for AIDS rising from US$1.6 billion in 2001 to US$8.9 billion in 2006 (Attaran and Sachs 2001).

The epidemic coincided-with and lead-to further increases in funding for global health programs. It is estimated that “development assistance for health from private and public institutions rose from US$8.65 billion in 1998 to US$21.79 billion in 2007” (Farmer et al, p2518, 2013). The Gates Foundation, a primary donor of global health programs has donated over US$10 billion to global health programmes (Farmer et al, p2567, 2013). In a period of less than ten years, an unparalleled level of massive global health programmes were initiated: the Global Fund to Fight AIDS, Tuberculosis and Malaria, the U.S. President’s Emergency Plan for AIDS Relief, UNAIDS, and programs by the WHO, IMF, and World Bank. Development funding for health increased from US$5.6 billion in 1990 to US$9.8 billion in 1999 and even more to US$21.8 billion in 2007 (Farmer et al, p. 2567, 2013). This increase was not only unprecedented, but astronomical.

This incredible influx of international funding for global health programs, especially for HIV/AIDS programs lead many African countries into dependency, relying on foreign and seeing their “health budgets dwarfed by foreign aid and health policies determined by donor organizations” (Johnson, p. 496, 2008) South Africa has attempted to avoid dependency and now has the world’s largest public sector antiretroviral treatment (ART) programme, which is 95% funded by South Africa and not by outside donors (Johnson, p.496, 2008). Despite this, as Krista Johnson states, South Africa still has a long history of tension between the government and the donors, namely perpetrated by “western paternalism and South Africa’s determination to avoid dependency” (Johnson, p.496, 2008). The increases in donor funding have been drastic and in some cases even overtake government budgets. “In Uganda and Zambia external donors exceeded public health expenditures by almost 185%” (Johnson, p. 498, 2008). A donor representative told Johnson that the “tepid relationship between the [South African] government and USAID/PEPFAR in part stems from US support for the apartheid regime” (Johnson, p.502, 2008).

Despite the less-than-ideal relationships between the South African government and the United States (USA) and other donors, the USA provided US$584 million through PEPFAR to South Africa. Furthermore, the Global Fund had provided over US$88 million for AIDS and TB (Johnson, p.506, 2008). Johnson also found that significant amounts of donor funds are being refunded to the donors because they are earmarked for specific objectives or programs (507, 2008). A key point in Johnson’s article is:

“According to Ndlovu, ‘Although earmarked funding is beneficial in ensuring that new and critical projects are funded, donor funds may hinder or clash with national government priorities, leading to decreased flexibility for implementers when spending on vital local priorities.’ In addition, spending donor funds is hindered by weak provincial health systems and insufficient capacity of government to commit the money to augmenting key programmes. In recognition of this, several donors, the European Union and the United Nations in particular, have targeted capacity building within the public sector”

(Johnson, p.507, 2008).

There are several key points to be made. As shown above, a lack of sustainability, balance and even distribution of HIV/AIDS funding threaten its success and lasting influence. As Johnson states, a vast civil society influence is necessary but will not happen without funding. Given the unpredictability of funding, it is difficult to adequately plan and implement programs (498).

I will need to undertake further research on how these funds are spent and within the private sector, where they come from and which programs they fund. I also hope to look at Global Fund and Gates Foundation presence in South African HIV/AIDS programs and how much influence they have over which programs run. However, I am slightly concerned that I will hit a ‘dead-end’, as South Africa has clearly gone to extreme lengths to avoid the dependency trap that many other African nations have fallen into with foreign aid.

Donor Influence: Significance

Donor funding is important to address because it has many underlying implications. When donor funding exceeds government budgets or is substantial enough to compete with government budgets, macroeconomic stability and fiscal management are threatened and even potentially undermined (Johnson, p.498, 2008). Donor funding can also undermine the public sector simply by bypassing it; if the government does not have the stability or resources to properly utilize the donor funds or direct them, the funds can subvert institutional capacity and exacerbate government problems (Johnson, p.498, 2008).

PEPFAR provided over US$584 million in 2008 for HIV/AIDS programmes in South Africa and worked with over 300 NGOs. None of the money went to the South African government, but the United States Agency for International Development (USAID) does work with national and provincial departments in South Africa. This is significant because PEPFAR is the largest donor that does not give funds to the South African government; other large donor organizations such as the European Union and the Global Fund provide funds to the South African government. At a 2006 PEPFAR conference in Durban, the South African Health Minister stated that “PEPFAR in South Africa ‘started off on the wrong foot. We were not consulted’” (Johnson, p.507-508, 2008)

This touches upon the significance of donor influence. As stated by Johnson, undermining the government and directly funding NGOs and local programmes “creates a coordination problem” (p.508, 2008).

As seen in Haiti and described by Dr. Paul Farmer: “It wasn’t a good idea to funnel foreign assistance exclusively through NGOs and private contractors. Without real and sustained commitments to strengthening the public sector-including its capacity to monitor and coordinate services offered by NGOs- who would make sure development funds were used effectively?” (Farmer, p.1097, 2011).

Donor influence in health organizations is an important area to study, especially as the world is increasingly dominated by a few select organizations. As discussed above, the main organizations dominating global HIV program funding are the Bill & Melinda Gates Foundation, PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank, the IMF and the World Health Organization (Farmer et al, p2567, 2013). It will be important to explore and begin to understand whether these organizations are funnelling their funding through the South African government or directly to NGOs and programs.

On the other hand, Johnson identifies further potential implications of donor influence. U.S. Secretary of State Condoleezza Rice implemented a plan for “transformational diplomacy” where the aid will go to governments and not to NGOs. This not only divides up funding for disease specific programs (ie by overriding the Global Fund), but also increases the likelihood for aid to reflect U.S. strategic interests in a more overt manner (Johnson, p508-509, 2008).

Another area of complication of PEPFAR funding is pharmaceuticals. PEPFAR funding for ARVs can only be used for US Food and Drug Administration (FDA) approved ARVs- AKA brand-name drugs that are extremely expensive as opposed to generic brands that are exactly the same, just cheaper (Johnson, p.509, 2008). This is yet another example of U.S. big business interests trumping cost-effective alternatives to pharmaceuticals.

As you can probably see and as Dr. Paul Farmer states in Haiti After the Earthquake, “Doing good is never simple”. I hope to address some of the complexity surrounding global health and development programmes through my independent study project.

I am enjoying my time in South Africa and am relatively busy with schoolwork. I haven’t found much of the work to be challenging, just lengthy, which is a bit frustrating. I am still enjoying the group, despite the lack of adventure-ness. I am certainly having a socially – relaxing semester compared to my Franklin semesters. It makes me recognize how unique Franklin students are and makes me miss always having someone to call upon for an “adventure”. At Franklin and travelling with Frankliners, we almost universally consider going out a vital part of visiting a new place and consider our travels unsuccessful if we don’t meet locals. It’s interesting being around so many Americans who actually enjoy being considered Americans; this is totally new territory for me.