Good Governance and Good Health: The Role of Societal Structures in the Human Immunodeficiency Virus Pandemic

Excerpts from the Abstract

Background

"Only governments sensitive to the demands of their citizens appropriately respond to needs of their nation. Based on Professor Amartya Sen's analysis of the
link between famine and democracy, the following null hypothesis was tested: 'Human Immunodeficiency Virus (HIV) prevalence is not associated with
governance'."

Methods

"Governance has been divided by a recent World Bank paper into six dimensions. These include Voice and Accountability, Political Stability and Absence of

Violence, Government Effectiveness, Regulatory Quality, Rule of Law and the Control of Corruption. The 2002 adult HIV prevalence estimates were obtained from

UNAIDS. Additional health and economic variables were collected from multiple sources to illustrate the development needs of countries."

Results

"The null hypothesis was rejected for each dimension of governance for all 149 countries with UNAIDS HIV prevalence estimates. When these nations were divided into three groups, the median (range) HIV prevalence estimates remained constant at 0.7% (0.05 – 33.7%) and 0.75% (0.05% – 33.4%) for the lower and middle mean governance groups respectively despite improvements in other health and economic indices. The median HIV prevalence estimates in the higher mean
governance group was 0.2% (0.05 – 38.8%)."

Conclusion

"HIV prevalence is significantly associated with poor governance. International public health programs need to address societal structures in order to create

strong foundations upon which effective healthcare interventions can be implemented."

Excerpts from the Paper

Background

"It has been argued that famine only occurs in nations that are immune to the political will of their people. Political freedom in famine free countries is

additionally coupled, albeit unevenly, to other freedoms such as education, health, the control of family size and the ability to seek employment.

Relatively recently, global institutions such as the World Health Organization (WHO) and the World Bank have made the link between macroeconomics and health.

Analysis of poverty around the world highlights those countries that are 'very unlikely' to meet the World Bank groups' millennium development goals (MDGs).

These MDGs include the combat of HIV/AIDS, malaria and other diseases, improvement in maternal health, achievement of universal primary education, promotion

of gender equality and empowerment of women, reduction in child mortality and the eradication of extreme poverty and hunger.

Some of the shared societal structures underpinning economic growth and health are the absence of violence, government effectiveness, the rule of law, lack

of corruption and the ability to select a government. Even though all of these are clearly desirable the relative weight of each societal structure necessary

for a strong nation state is debatable. The risk of infectious disease is determined not only by pathogens and the response of the patient but also by

powerful societal forces that override individual knowledge and choice. Paul Farmer has coined the phrase 'structural violence' that reflects the limit of

life choices, particularly of women, by racism, sexism, political violence, and grinding poverty.

The 2004 World Health Report discusses the challenges of tackling the HIV pandemic. In the African continent, HIV is implicated in poor economic performance

and falling gross domestic product (GDP). Within this document it describes the wide range of international support garnered to meet this challenge. However,

even though the requirement of local and national government co-operation is stressed within this document, it does not elaborate on the massive

heterogeneity inherent within this mandatory component.

In order to investigate the strength of the relationship between the quality of societal structures and the HIV pandemic, World Bank and UNAIDS sources were

used to test the null hypothesis: 'HIV prevalence is not associated with governance'."

Methods

"A recent World Bank paper entitled Governance Matters III collated governance indicators for 199 countries / regions. Governance in this document has been broken down into six dimensions..." Using these definitions, this research collected data for each country from 18 sources..." "Governance data were then aggregated for each country and plotted along a continuum. Only the 2002 Governance data has been used in this paper. This dataset is available in a spreadsheet format from the World Bank website."

Results

"There were fifty distinct HIV prevalence rankings from the 149 countries with UNAIDS HIV prevalence estimates in 2002. Botswana had the highest HIV
prevalence estimates (38.8%) in the world that year whilst the majority of countries were placed within the lowest ranking, where HIV prevalence estimates
were reported by UNAIDS to be < 0.1% (written as 0.05%)."

"The negative correlations indicate that HIV prevalence falls as the governance improves for each governance dimension and mean governance. The three most influential dimensions of governance were government effectiveness, the rule of law and corruption. All correlations were significant thus rejecting the null hypothesis."