Antiretroviral treatment roll-out in Zambia and South Africa - a policy analysis to sub-national policy implementation processes

From 2002 international and national policies transformed the availability of antiretroviral medicines for people living with HIV/AIDS in Africa. By the end of 2008 an estimated 42 percent of people requiring such treatment were accessing medication and anti-retroviral treatment (ART) programmes had been rolled out in many countries (UNAIDS and WHO 2009). However, this expansion was implemented unevenly across and within different countries raising questions about the gap between policy intention and execution. This thesis addresses this gap. It examines the processes of implementation, comparing rapid ART roll-out in Zambia with South Africa where implementation was initially much slower. It draws on both top-down and bottom-up perspectives to better understand factors hindering and enabling implementation. The focus is on actors and their networks and how they were able to exert power on the implementation of policy. It is a qualitative study that relies on document review and over 150 interviews conducted with actors in the policy processes in both countries, during field work in 2007 and 2008. Findings confirmed the importance of communication, resources and structures in determining implementation, but the comparative analysis indicated their influence varied considerably according to context. The findings also offer new insights into how contrasting networks of actors affected implementation. A broad range of actors made it possible to roll-out ART in South Africa despite a hostile policy environment, by drawing on diverse sets of skills and ties that dated back to the anti-apartheid struggle. In Zambia the network which most influenced ART roll-out was an epistemic community of clinicians, which, by forging alliances with PEPFAR implementing agencies was able to rapidly scale up access to treatment in spite of health systems constraints. The economic capital of donors allowed them to shape policy and blur boundaries between state and non-state actors in Zambia while social capital of networks was important in South Africa. Findings suggest that focusing on the sources of power of networks in implementation enriches the understanding of health policy processes