New Research on Governing Infectious Disease in South Africa

How should the response to infectious disease epidemics such as HIV/AIDS, TB, and Malaria be governed? That is, which authorities – ranging from local governments to national governments to global governance institutions –  should be in charge of setting policies, developing budgets, and ultimately serving citizens who need information and resources for prevention and treatment?

This is a question that has too often been answered with polemics, but with little solid research. And yet, as important as good bio-medical knowledge may be for protecting the health of people, so is the mode of implementing such practices, particularly in democratic contexts.

The “old” model of leaving national states 100% in charge, holds little currency these days, and for good reason: in low- and middle-income countries, “the state” is often weak, inefficient, unresponsive to citizens, and especially unable to reach the most vulnerable. As an alternative, a new model has emerged — what can be described as “Polycentric governance.” While this model (in form, but not name) has been advocated as a best practice for addressing public health issues in developing countries, there is good reason to believe that the model contains features that may simultaneously impede efficiency and democratic accountability. The journal Social Science and Medicine recently published the results of my case study of polycentric governance of infectious disease in South Africa, which highlights these limitations.

My study raises more questions than answers for policy and institutional design. It does not recommend a new “optimal” governance model. But it does suggest that much more research needs to be done that takes seriously the motivations of political actors and service providers, whose concerns are not always with the general welfare, but with (often understandably) parochial issues, such as ensuring the next round of funding, or satisfying other constituent or party priorities.

In the country with the largest number of HIV-infected individuals in the world, polycentric governance needs to be re-evaluated as the best solution for providing prevention, treatment, and support.

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