Chapter 8 : A Law To Strengthen...Chapter 8 : A Law To Strengthen East African Pharmaceutical Manufacturing Capacity11

Chapter 10: Where Do We Go From... Chapter 10: Where Do We Go From Here?

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Michael Javid

In response to growing recognition of the AIDS pandemic as a serious threat to global stability and economic development, financing for access to essential medicines in countries devastated by the disease has multiplied.    International agencies have established the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund); the World Bank set up the Multi-Country HIV/AIDS program for Africa (MAP); and the United States created the President's Emergency Plan for AIDS Relief (PEPFAR).⁶³⁸   Furthermore, since the 2001 United Nations General Assembly Special Session on HIV/AIDS (UNGASS), individual governments around the world have accelerated their responses to the pandemic.⁶³⁹ 

Unfortunately, many developing countries remain ill-equipped to coordinate and implement the necessary actions to deliver these additional resources to their people.⁶⁴⁰   In particular, the lack of coordination between multilateral and bilateral donor institutions, private sector foundations and corporation, other international and national non-government organizations has contributed to the underutilization and misallocation of resources.⁶⁴¹  The following diagram illustrates the complex dynamics among stakeholders in Tanzania's national response, and demonstrates the need for effective leadership and coordination.⁶⁴²

Diagram 9-1:  The Relationship between various stakeholders in Tanzania's HIV/AIDS response

Guided by the problem-solving methodology, this Chapter examines the nature and causes of the behaviors that comprise the problems posed by the lack of coordination among the stakeholders engaged in implementing the international response to HIV/AIDS in East Africa and throughout the world.   Grounded on the available evidence, it will suggest possible legislative solutions to facilitate improved coordination of medicine delivery to those in need, especially in East Africa.

A.  Fitting EAC's problem of accessing imported medicines into the larger global context

Ensuring sustainable access to essential medicines, like those for HIV/AIDS, presents complex challenges likely to remain "a persistent feature of the international governance landscape for the foreseeable future."⁶⁴³ As evidenced by its inclusion in the Millennium Development Goals, however, the global community has recognized the urgency of achieving this goal.⁶⁴⁴  Only with a healthy population can a developing country embark upon a true, sustainable path to eradicate poverty and achieve a desirable level of economic self-sufficiency comparable to that of the developed world.

Sustainable access to essential medicines involves many factors, including:

1. Research and development;
2. Safety and Efficacy (including Liability);
3. Manufacturing Systems and Controls (Good Manufacturing Practices);
4. Intellectual Property (including Global Trade Agreements);
5. Procurement, Distribution, and Dispensing;
6. Health Care Personnel and Infrastructure; and
7. Financing.⁶⁴⁵

All of these factors remain associated with unique challenges and involve a myriad of players, all of whom contribute to the current difficulties of accessing medicines like those required for HIV/AIDS.   The World Health Organization has formulated a four-part framework to guide and coordinate collective action for addressing these factors to improve access to essential medicines:  (1) "rational selection and use of essential medicines"; (2) "affordable prices"; (3)"sustainable financing"; and (4) "reliable supply systems."⁶⁴⁶  Multilateral and bilateral donor institutions, private sector foundations and corporation, other international and national NGOs, and developing country governments must coordinate their efforts in line with this framework to effectively foster sustainable access to life-saving medicines.

B.  The History of the Difficulties of Coordinating National and International Responses to the HIV/AIDS Epidemic

Over the past several years, growing evidence has exposed the lack of coordination between government ministries, international aid agencies, community-based organizations, and other NGOs that has limited many developing nations' effective, efficient response to the HIV/AIDS epidemic.⁶⁴⁷ Too often, these groups  engage in parallel financing, planning, programming and monitoring.⁶⁴⁸  Recognizing this problem back in September 2003, a working group at the 13th International conference on AIDS and Sexually Transmitted Infections in Africa (ICASA) developed a set of guiding principles to improve coordination of national AIDS efforts.⁶⁴⁹

In April 2004, donor and host country representatives and major international organizations, meeting a Consultation on Harmonization of International AIDS Funding, endorsed and agreed to implement the "Three Ones" principles.⁶⁵⁰

These AIDS-related initiatives appeared in line with wider aid coordination actions, including the Rome Declaration on Harmonization, the Harmonizing Donor Practices for Effective Aid Delivery, and the Paris Declaration on AID Effectiveness.⁶⁵¹  Furthermore, the United Nations (UN) launched its own reform, including efforts to improve aid harmonization.⁶⁵²  The Joint United Nations Programme on HIV/AIDS, as facilitator responsible for ensuring coherent UN responses to AIDS, participates in these broader reform efforts.⁶⁵³  Despite these initiatives, however, difficulties continue to plague the coordination of aid, limiting the successful attainment of universal access to essential AIDS medicines.

C.  Brief statement of this report's methodology

ILTAM's four-step problem-solving methodology structure the remaining Parts of this research report:

Step 1 (Part II) describes, using the limited available evidence, whose and what behaviors contribute to the problem of coordinating national and international aid efforts; 

Step 2 (Part III) offers explanatory hypotheses for those problematic behaviors, suggesting the necessity for gathering further evidence to warrant them;

Step 3 (Part IV) mentions one possible alternative solution, but recommends a second which, assuming that more evidence demonstrates that, logically, it will prove most cost-effective in helping to induce new behaviors likely to ensure greater coordination to improve all East Africans' access to essential, affordable, and effective medicines; and

Step 4 (also in Part IV) proposes a transparent, accountable, and participatory monitoring and evaluation mechanism to empower all the relevant stakeholders to access the facts necessary to assess the implementation and social impact of the new law in making those medicines available to all who need them.

This Part first outlines the nature and scope of the current aid coordination problem with respect to ensuring developing country citizens have access to essential medicines.   It then defines whose and what behaviors contribute to that problem:   The administrators and staff of multilateral and bilateral donor institutions, private sector foundations and corporations, other international NGOs, and developing country governments.   This section concludes with a brief summary of who suffers and who benefits from this problem's persistence.

A. The nature and scope of the problem

As its overriding goal, aid coordination efforts aim to ensure national ownership of plans and priorities since national partners remain accountable to their people for the services provided, including access to essential medicines.⁶⁵⁴ 'National ownership' refers to broad partnerships led by the national government working with local civil society organizations, private sector, and academic organizations.⁶⁵⁵ Multilateral and bilateral donor institutions, private sector foundations, corporations, and other international NGOS should support these nationally owned plans' design and implementation procedures.  At the same time, national governments should ensure take those international organizations' activities into account in formulating their national plans.⁶⁵⁶  

The UNAIDS Global Task Team on Improving AIDS Coordination among Multilateral Institutions and International Donors identifies four critical obstacles to 'ownership' in developing-countries like those in the EAC: 

1. "challenges to inclusive national leadership and ownership;"  
2. "challenges to alignment and harmonization of multilateral institutions and international partners";"challenges to the effectiveness of the multilateral response;" and
3. "challenges to accountability and oversight."⁶⁵⁷

1. Challenges to country nationals' leadership and ownership

Despite the national AIDS action principles of the "Three Ones," few of the existing national AIDS strategies appear 'evidence-based', backed by annual priority action plans with clear divisions of labor⁶⁵⁸.  Failure to agree on priorities, timing and responsibility often hinders rapid effective use of increasing financing.⁶⁵⁹   Furthermore, few country governments have analyzed the technical support needed to scale up initiatives to meet AIDS treatment targets.⁶⁶⁰  Too often, human resource constraints result from migration shifts of personnel from public to private sectors, and inadequate training, utilization and loss of staff due to HIV-related morbidity.⁶⁶¹  Uneven progress in mainstreaming AIDS interventions in social sectors beyond health, in establishing internationally agreed assessment criteria, and linking AIDS initiatives to broader development frameworks also tend to limit inclusive national leadership.⁶⁶²  Finally, government responses too often exclude inputs from civil society (particularly those living with HIV) and private sector elements contribute to various groups' mutual mistrust.⁶⁶³

2. Challenges to alignment and harmonization of multilateral institutions and international partners

    Multinational institutions and donors have made some progress in aligning their aid efforts with national stakeholders' priorities.  Nevertheless, a few persist in requiring country nationals to prepare specified project proposals. They insist that developing country personnel adopt their own project cycles, including timing of reviews.⁶⁶⁴  Furthermore, recent international AIDS programs have tended to require their own project modalities to initiate activities, neglecting the possibility that project modalities ties in with broader national development efforts might prove more effective in fostering longer-term sustainability.⁶⁶⁵   In addition, the use of separate implementation channels (for example, through both the ministry of health and a national AIDS coordinating authority) may actually hinder coordination efforts.⁶⁶⁶  Multilateral institutions' and international donors' attempts to harmonize and align policies have proven difficult to implement, worsening efforts to build local capacity in these areas.⁶⁶⁷  Finally, the multilateral institutions' and donors' failure systematically to share information has led to duplicative efforts and thwarted synergy-building.⁶⁶⁸

3. Challenges to the effectiveness of the multilateral response

Among the challenges to effective multilateral response, the uneven coordination of the UN system's response to AIDS at the country level tends to prevent establishment of a truly joint program.⁶⁶⁹  The lack of a clear division of labor among UNAIDS co-sponsors, the Global Fund and the World Bank at both the global and national levels tends to foster confusion as to leadership and accountability.⁶⁷⁰  To build on the Co-sponsors' relative strengths on the ground, that global division of labor must prove flexible at the country level.⁶⁷¹ Lastly, the estimated need for technical support may appear incompatible with the funds available.⁶⁷²  On the other hand, insufficient coordination of technical support and multilateral competition may foster under-utilization of local and regional technical support sources.⁶⁷³

4. Inadequate systems of accountability and oversight

Challenges to accountability and oversight include structures in the AIDS response that typically overemphasize accountability upwards (i.e., to funding partners) and neglect downwards accountability (i.e., to local communities) ⁶⁷⁴ Mechanisms holding government entities accountable rarely seem sufficiently developed, and few have the tools necessary to assess and hold numerous multilateral institutions and international doors accountable.⁶⁷⁵    Furthermore, in many countries, the single national authority often lacks capacity to adequately oversee implementation of aid programs and act rapidly to resolve emerging problems.⁶⁷⁶   Lastly, of multilateral institutions' and international donors' failure to provide sufficient support and systematically share information with local government authorities has prevented the effective monitoring and evaluation essential to ensure accountability.⁶⁷⁷

Successfully tackling these four challenges identified by the Global Task Team should improve coordination, alignment and harmonization of aid.   In the context of the "Three Ones' principles, the Millennium Development Goals, UN reform efforts, and the Paris Declaration on Aid Effectiveness, this should strengthen the overall impact of the national and international response to the AIDS epidemic.⁶⁷⁸

B. Whose and what behaviors constitute the difficulty

To analyze the aid coordination problem with respect to HIV/AIDS in development countries, like the EAC member states, it seems useful to categorize the primary role occupants into four groups.   Members of each category display similar problematic behaviors that significantly aggravate the difficulty.  The analysis here aims to identify the responsible individuals and the detailed features of their problematic behaviors.  These problems reflect the general problematic behaviors and do not necessarily point to specifics in any one EAC country. 

1. Donor institutions and private sector foundations

Donor organizations include the UN system (i.e., UNAIDS, UNDP, Who), the World Bank, the IMF, the Global Fund, EADB, and industrialized country government aid organizations (like USAID, PEPFAR) ⁶⁷⁹  Private sector foundations include the Gates Foundation, the William J. Clinton Foundation, and the Ford Foundation.⁶⁸⁰   For many least developed countries, these external donor institutions and foundations provide the largest percentage of funds available for the national AIDS response.⁶⁸¹ The donor-country relationships prove complex, but, for the most part, country nationals do a good job managing the expenditure of funds and providing technical assistance the donors require.⁶⁸² Unfortunately, however, certain repeated problematic behaviors and actions of the donors have hindered efforts to coordinate their aid with the national efforts.

Donors often become impatient with what they perceive as "failures of political commitment and leadership, weaknesses in organizational structure or technical incompetence in countries."⁶⁸³  Instead of working with the responsible country personnel to address these weaknesses, donors too often bypass national AIDS authorities and frameworks.⁶⁸⁴  At times, donors' goals do not seem aligned with country-set priorities.⁶⁸⁵ Too often, without reference to overall country programs, donors simply provide direct funding to their own projects.⁶⁸⁶ Donors often insist on transparent country-project decision-making, but they themselves do not always employ transparent procedures, fueling host country officials' suspicions.⁶⁸⁷ Occasionally, donors' promised support never materializes, disappointing country officials.⁶⁸⁸  Donors often display 'preferences' for particular countries, offending other countries desperately in need of outside support.⁶⁸⁹ These seemingly conflicting aims, double standards, misleading promises and favoritism all tend to general feelings of disrespect among host country officials.⁶⁹⁰

2. Developing Country Governments (like those in East Africa)

Each developing country's political and governmental structures, and decision-making processes, prove unique.   Furthermore, in each country, the circumstances influencing the coordination of the AIDS response differs, depending o the urgency of the need for outside help, and the donor organizations' willingness to contribute.   Nevertheless, several recurring problematic behaviors and actions seem to appear.

First, national processes for establishing an AIDS response framework often exclude key stakeholders (i.e., local civil society organizations, the donor organizations) ⁶⁹¹ Second, those responsible for establishing the response frameworks frequently do not translate them into clearly specified work plans and budgets.  This limits the donors' ability to identify national priorities to which they may contribute.⁶⁹²  Third, the highest levels of government personnel, responsible for local, national and international issues, may not provide national AIDS authorities with strong mandates and support.⁶⁹³   That deprives these AIDS authorities of the accountability and legitimacy they need to lead the national response.⁶⁹⁴  Fourth, sometimes, in developing countries, different organizations, working in different forums, may express contradictory positions, confusing external partners as to country priorities.⁶⁹⁵  Lastly, many national AIDS authorities lack the required human resources to successfully execute planning, mobilization, coordination, information management, and monitoring and evaluation.⁶⁹⁶

Low public sector salaries and inadequate training contribute significantly to this problem.⁶⁹⁷

3.  International NGOs

The international NGOs, dealing with access to essential AIDS medicines in developing countries, include Medicines Sans Frontiers and Oxfam International.⁶⁹⁸   In the mid-1990s, as the negative implications for health of emerging global trade regimes became increasingly evident, international NGOs became increasingly deeply involved with the AIDS issue.⁶⁹⁹ These NGOs helped to raise public awareness about the issue, mobilizing the media, providing technical and legal expertise to developing countries, and organizing campaigning initiatives.⁷⁰⁰  International NGOs have generally provided positive assistance to developing countries in working towards universal access to essential medicines; however, some of their behaviors have proven problematic with respect to the goal of national ownership and coordination of the AISS response in developing countries. 

First, driven by demands of their donors, which may or may not correspond with those of developing countries, international NGOS occasionally fail to listen and respond to what they hear from country nationals.⁷⁰¹  This failure to adhere to country priorities tends foster a loss of trust.⁷⁰²  Second, often the relationships between international NGO personnel and developing country representatives remains personal, rather than formally institutionalized. ⁷⁰³  The replacement of a well-liked NGO person by an unknown individual may undermine continuity.⁷⁰⁴ Third, the perception that NGOs, particularly in multilateral for a, work primarily with large, middle-income countries, breeds some distrust in least-developed countries.⁷⁰⁵ Fourth, by failing to present information even-handedly, or trying to play an overtly political role beyond that requested, some international NGOs have lost credibility with developing country governments.⁷⁰⁶  Fifth, some international NGOs focus on a limited range of issues, apparently ignoring developing country governments' need to address and balance a range of interests.⁷⁰⁷  Sixth, international NGOs  have not consistently provided levels of support to developing countries  at the national level similar to that provided to international multilateral institutions.⁷⁰⁸  This lack of support at the national level tends to lead to confusion as to the implications of decisions made at the international level, and appropriate adjustments to national AIDS responses. ⁷⁰⁹ Lastly, a lack of coordination among the international NGOs has led to unnecessary overlaps and duplicative AIDS responses at developing country levels.⁷¹⁰

4. National NGOs

In many developing countries, national NGOs have played a critical role in the fight for universal access to medicines at the national, provincial, and community levels.⁷¹¹   Some of the NGO staff members, however, have contributed to difficulties in coordinating national AIDS responses.

Some grassroots organizations, distrusting international NGOs' seeming lack of concern about local interests, may hinder coordination with them at the national level.⁷¹²  Some national NGOs lack the depth of technical knowledge and training to facilitate coordinated national AIDS responses.⁷¹³  Lastly, at times, local NGO personnels' uneasy relationships with their countries' national policy-makers indicate they remain more critical of them than do international NGO staff members.⁷¹⁴

5. Who benefits and who suffers from the uncoordinated efforts of local and international organizations to the AIDS pandemic?

It seems probable that none of the role occupants benefit from the lack of coordinated response to the HIV/AIDS pandemic.  One might argue that donor organizations find it easier to adhere to their own programs/projects when they confront no strong national ownership or coordination of the AIDS response.   Some national government officials may prefer not to deal with coordinating the urgent, complex response required.

Unfortunately, those who suffer most constitute the developing country inhabitants, like those in East Africa, who still find it difficult to obtain essential, affordable medicines.   The lack of coordination also may undermine developing country governments who have trouble in providing essential medicines essential to stave off social devastation, which will likely hinder economic growth and stimulate political unrest.

This Part II has outlined the current problem of coordinating and increasing access to essential medicines to treat HIV/AIDS.   It identified and described the problematic behaviors of the donor institutions and private sector foundations, developing country governments, international and national NGOs that seem to hinder an essential coordinated AIDS response. 
Finally, this Part points out that few parties significantly gain from the present situation, while developing countries inhabitants, denied essential life saving drugs, suffer the most.

Using institutionalist legislative theory's ROCCIPI categories,⁷¹⁵ this Part identifies several hypotheses to explain the interrelated causes of each set of relevant social actors' problematic behaviors, identified in Part II.  These hypotheses (really little more than 'educated guesses') partially derive from foreign law and experience, not only in East Africa, but in developing countries elsewhere.   This Part suggests the kinds of evidence required to demonstrate that these hypotheses seem consistent with East African regional and/or member state experience.   Gathering that evidence should help to lay the essential basis in facts for problem-solving's Step 3, the design and drafting of a legislative solution likely to ensure more effective coordination of the relevant organizations' aid. ⁷¹⁶

If an initial hypothesis proposed for a set of role occupants, listed below, does not appear consistent with available East African evidence, the workshop participants, drawing on their knowledge of EAC regional and member state realities, may take one or a combination of the following steps:

1. reject the hypothesis outright as unwarranted by EAC experience;
2. revise the hypothesis until it does appear consistent with the available EAC evidence (which may include additional facts grounded on the workshop participants' own experience); or
3. recommend a legislative solution (perhaps in the form of a mandate directed to the proposed EAC Health Commission)   That mandate might call for further research, perhaps guided by elements of the original hypothesis as amended by the workshop participants, to gather additional evidence as a basis for designing legislative solutions in Part IV.  (For each hypothesis specified below, the text raises questions, in italics, as to kinds of new evidence which might prove useful for designing new legislative provisions logically likely to help change the current problematic behavior)

A.    International donor institutions and private sector foundations

Rule:  The available evidence suggests that little or no overall international or EAC law prescribes the appropriate behaviors of donor institutions and private sector foundations to foster a coordinated AIDS response.   This gives administrators and staff have broad discretion to behave within the constraints and resources, including their nation's as well as their own organizations' rules, as they deem appropriate.  (More evidence seems necessary as to the nature and extent of member state efforts, like that of Uganda, to reach an agreed –upon structure of rules.   In addition, further facts might illuminate the extent to which the institutions' and foundations' own by-laws prescribe these organizations behaviors.)

Opportunity: These organizations accumulate funds from supporters based outside East Africa.   Their administrators decide on which projects, in which countries, they will fund, sometimes resulting in overlapping, conflicting and missing efforts.   (Further detailed evidence should provide insight into how different institutions and foundations function, and the extent to which they do, or do not, coincide with each East African country's AIDS programs.) 

Capacity: Depending on their own financial and human resources, mainly provided from outside the developing countries in which they operate, these organizations' administrators assess their own capacity to determine whether and what kinds of AIDS programs to implement.   (Additional detailed evidence would help to clarify the financial and human constraints of each organization's AIDS response in East Africa)

Communication: Assuming a developing country's responsible government authorities have formulated rules regarding 'national ownership,' little evidence exists ass to whether or how they communicate those rules to international donor institutions' and private sector foundations that seek to participate in their country's AIDS response.  (To examine and perhaps revise this hypothesis in the case of a particular country requires gathering detailed evidence.)

Interest:  Donor institutions and foundations decisions as to whether and how to behave in the face of East African member states' rules undoubtedly vary depending on the private as well as public concerns of those institutions' administrators and staff members.   (To determine any given donor institution's or foundation's 'interest' will require obtaining evidence about the relevant individual administrator's or staff member's concerns, as well as those announced publicly by the organization.)

Process:   The organizations' decision-making processes, usually involving participants from their home countries, not the recipient developing countries, remain relatively unknown.   (Detailed evidence about specific decision-making processes of organizations involved in AIDS response in East African member states, and how East African governments and NGOs might participate, would seem very useful!)

Ideology:  Most of these organizations administrative personnel and staff seek to respond to the AIDS pandemic in ways helpful to developing countries' inhabitants.   However, they also have constituents in their 'home offices' who may try/want to set limits on the ways they interact with recipient country governments and citizens.   Some may seek to bypass national AIDS authorities because they believe those authorities suffer from intractable ineptitude, problematic cultural attitudes, and even corruption (The more evidence available about specific organizations' contradictory Ideologies, as well as Interests – note above – the more useful for analyzing those causal factors' probable influence on each individual organization's administrative and staff members' behaviors.)

B.  International NGO administrators and staff

Rule:   Some international NGOs organizational guidelines do encourage their officials and staff to work closely with and respect developing country government officials' efforts to retain and strengthen national (and in the EAC case, regional) capacity to participate in formulating and implementing an adequate AIDS response.  Others focus on shaping decision-making processes to favor their own organization's influence, rather than empowering the country/regional nationals' role.   (This recognition guides research to examine the detailed evidence – that is, the wording-- of each NGO's working rules to assess the likelihood that they will foster NGO policies to strengthen country nationals' capacity to participate effectively in coordinating their country's AIDS responses.)

Opportunity:   Too often, apparently, international NGO officials exercise their influence to dominate country nationals' AIDS responses, rather than encourage them to participate as equals in the decision-making processes. ⁷¹⁷  (To determine whether these hypotheses seem consistent with the available evidence in East Africa requires gathering the relevant facts as to the behaviors of international NGOs each EAC member state.)

Capacity:  Some international NGO staff members may not have the knowledge, skills or resources to work together with country nationals to ensure coordinated national/regional AIDS responses.   (To assess whether this constitutes a possible causal factor for some NGO personnel's failure to contribute to improved coordination of AIDS responses in the EAC states requires gathering the relevant available facts.)

Interest:   A few international NGO staff members may have greater interest in advancing their status in the international community than in working to strengthen country nationals' capacity to participate more effectively in coordinating national and international AIDS responses.   (This, too, suggests the importance of searching for evidence as to whether any NGO staff members' interests influence them to discourage EAC member states nationals from playing an effective role in coordinating their countries' AIDS responses.)

Process:   The criteria and procedures by which international NGO personnel engage in deciding whether and how country-nationals should contribute to national/regional efforts to coordinate AIDS responses sometimes appears non-transparent, non-accountable, and non-participatory.   In other words, by their very nature, those criteria and procedures may deny country-nationals the opportunity to contribute effectively to international NGOs' efforts to coordinate AIDS responses.  (This hypothesis calls for gathering the available evidence as to whether and how, in East Africa, international NGOs' decision-making process may reduce the likelihood of strengthening country-nationals' role in coordinating AIDS responses.)

Ideology:   International NGO personnel may adopt the belief that country-nationals simply do not/can neither understand nor alter the factors, which hinder coordination of their country's AIDS responses.   (To assess the validity of this hypothesis in the case of East African Community members necessitates conducting research to determine whether it seems consistent with the available relevant evidence.

C. National NGOs' administrators and staff

Rule:  Developing countries' 'cage of laws' relating to the role of country-based NGO administrators and staff members – if those rules exist at all – vary widely.   For the most part, they remain vague, offering neither mandates nor guidelines as to whether and how NGO personnel should 'behave' to facilitate any kind of coordinated AIDS response.    (This hypothesis suggests the necessity for more research to obtain the specific wording of each EAC member state's existing rules relating to nationally based NGO personnel's appropriate behaviors.)
  
Opportunity:  The existing national NGO personnel used their own human and whatever limited financial resources they could find to help alleviate the severe human problems posed by the AIDS pandemic in their own countries.   (More research should explore the EAC member state based NGOs' personnel to discover these resources' uses, limits, and social impact.)

Capacity:  It seems impossible to generalize on the capacities of nationally based NGOs' personnel.  Undoubtedly, these vary widely, depending on the individual leaders' and members' community contacts, skills and resources.   (That observation calls for further research to discover more details concerning  the range of behaviors and social impacts of EAC state-based NGOs as an aspect of their countries' and the region's AIDS responses) 

Communication:  It seems probable that national governments devote few resources to informing their country-based NGO's personnel of existing laws – if any – that purport to prescribe their behaviors, let alone monitoring and evaluating their social impact. (More detailed research would reveal whether and how EAC member state governments communicate whatever existing laws prescribe as to national NGO personnel aid behaviors, and monitor and evaluate those NGOs' roles in coordinating national and international resource use for aid purposes.)

Interest: National NGO personnel's interests undoubtedly vary significantly from organization to organization with widely differing social consequences.  (Insofar as this seems a critical issue in EAC member states, research might explore the nature and extent of individual national NGO personnel's likely interests and their possible impact on their organizations' aid giving roles.)

Process:  As always, the decision-making process of complex organizations, even small national aid givers, proves a critical question, especially if the NGOs involved play a significant role in coordinating the use of aid funds. (This suggests the potential advantages of conducting research as to whether EAC member state-based NGO personnel's decision-making processes do significantly influence their countries' aid programs; and, if they do, whether those processes prove sufficiently transparent, accountable, and participatory.)

Ideology:  Undoubtedly, the ideologies – the values and beliefs – of national aid-giving NGOs' personnel influence their decisions concerning whether and how to coordinate national and international aid programs.  (To the extent that this seems a major cause of EAC member state-based NGO personnel's counter-productive policies and practices, further research seems necessary to lay a basis for designing laws to reduce their possible negative consequences.)

D.  Relevant developing-country government officials

Rule:  The 'cage' of a developing country's laws relating to aid programs varies significantly depending on that country's unique circumstances.   (To understand the impact of existing laws requires gathering detailed evidence as to how the wording of each EAC member state's relevant laws prescribe the responsible national officials' behaviors for dealing with donor institutions and NGOs, whether based in-country or overseas:  How much discretion to those laws grant country nationals in dealing with donor agencies?   What criteria and procedures, if any, do they require?)

Opportunity:   As indicated by the description of the problematic behaviors in Part II, country officials' behaviors may vary significantly in light of the extent to which they have opportunities to influence international or national donor or NGO agencies 'behaviors' in response to the AIDS pandemic.  (Research that provides detailed evidence as to the circumstances shaping each set of EAC member state officials' opportunities to interact with donor agencies could help member states' as well as the EAC's officials more effectively coordinate those agencies' AIDS responses.)

Capacity: Country-national officials' capacity to deal with donor agencies vary significantly, depending on available national human and financial resources.   Uganda apparently has already established an agreed procedure for coordinating donor agencies' activities within Uganda⁷¹⁸.   (This underscores the necessity of conducting research to discover evidence as to the extent of those resources in each country and government officials' capacity to coordinate and improve their contribution to all their countries' inhabitants.)

Interest:  Given the overwhelming complexity of the issues, and the associated political implications involved with taking or not taking actions, developing country government officials must decide whether and how to lead the national AIDS response.   Low salaries may prove insufficient to spur officials' interest in tackling the additional responsibilities.⁷¹⁹   A few officials' desire to increase their incomes might encourage them to behave corruptly in handling AIDS funds.   (The implications of these hypotheses point to the advantages of gathering evidence to determine whether, in the EAC or member state governments, the facts warrant government legislation to avoid possible the suggested dangers.)

Process: The extent to which the processes, by which government officials make aid decisions, prove transparent, accountable, and participatory tends to influence their decisions to act in their own or the broader public interest.   (That emphasizes the importance of gathering evidence to assess whether or not those processes – whether at a state or regional level – (1) requires the publication of reasons for channeling aid in particular ways; (2) remains subject to monitoring by the relevant stakeholders – especially impoverished aid recipients; and (3) whether the whole process facilitates stakeholders' participation in making decisions at every stage.)

Ideology:  Government officials' beliefs or attitudes as to the importance of adequate medical assistance, especially for poor rural folk, may influence their decisions as to the appropriate criteria and procedures for improving the coordination of aid agencies' AIDS response.   (To adequately warrant this hypothesis in the EAC context requires gathering facts as to the values and attitudes expressed by officials responsible for AIDS response

The above review suggests a broad range of hypotheses as to the possible causes of relevant social actors' problematic behaviors in formulating and implementing policies likely to affect the distribution of aid funds in the case HIV/AIDS.   That review underscores the necessity of conducting research as a basis for designing and grounding proposed legislative solutions for improving aid delivery on evidence.  

The next Part of this research report, Part IV, weighs several possible alternative legislative solutions for the problem of using law to coordinate aid

As required by problem-solving's Step 3, this Part first considers alternative possible legislative solutions to the pervasive problem of inadequately coordinated aid provided by multilateral and bilateral donor institutions, private sector foundations and corporations, other international and national NGOS and developing country governments.   In East Africa, as elsewhere, this lack of coordination has further aggravated the difficulties of most East Africans – especially those living in remote rural areas – have experienced in using aid to access affordable, essential and effective medicines.

Several alternative solutions seem available.   These include (1) continued reliance on the status quo; (2) encouraging individual member states to enact legislation to coordinate international and national aid programs within their own borders; and (3) the legislative solution here recommended, that is, mandating proposed EAC Health Commission ⁷²⁰ to prioritize appointment of a sub-committee to conduct the necessary research to draft an evidence-based bill, justified by a logically constructed, research report, to coordinate all aid initiatives in the region to maximize its use for improving health care for all East Africans --especially the poorest and most vulnerable.

This research report's Part II adequately described the problems posed by the currently responsible authorities' seeming inability, under existing law, to coordinate the rapidly increased national, regional, and international responses to the HIV/AIDS epidemic.    In Part III, it reviewed the possible hypotheses as to causes of the problematic behaviors that apparent contributed to their failure.   It emphasized the necessity of conducting further research and -- if necessary – revising those hypotheses in light of East African realities.  Nevertheless, the evidence already available seems sufficient to argue that preservation of the status quo seems unsatisfactory.

A second possible solution might require existing EAC member states to draft their own laws, accompanied by research reports to provide the evidence as to the likelihood that those laws would prove effectively implemented to improve coordination of available aid to more adequately serve their inhabitants' health needs.   However, evidence from other regions indicates that to the extent that EAC member states work collectively to negotiate agreements to foster greater coordination with and between donor agencies, they will likely improve the use of aid to achieve greater health benefits.⁷²¹

This research report, therefore, recommends that, as a better option, the newly proposed EAC Health Commission establish a subcommittee to conduct the relevant research for essential evidence.   That subcommittee, working with experts from all five-member states, will employ ILTAM's four-step problem-solving methodology to structure a research report to conceptualize and justify drafting EAC legislation to coordinate aid from all national and international sources to maximize all East Africans' access to essential, affordable health care.
 
Appendix A – Country-Specific Findings

(Need for concerted action on AIDS Responses – Country-specific findings, UNAIDS, 2004, p. 4, 21-22, 35-36, 49-50, 53-54, http://data.unaids.org/Publications/IRC-pub06/JC1047-3-Ones_en.pdf (last visited Aug. 28, 2008) )

Chapter 8 : A Law To Strengthen...Chapter 8 : A Law To Strengthen East African Pharmaceutical Manufacturing Capacity11

Chapter 10: Where Do We Go From... Chapter 10: Where Do We Go From Here?