Integrating HIV/STD and primary health care services : international policy developments and national responses, with special reference to South Africa.

The overall aim of this thesis was to understand how new policies are reflected in national policy, and subsequently implemented. It suggests a fruitful way of analysing how policies fare is through exploring the notion of policy transfer - a complex process, mediated by different groups of actors. The focus for this study was on one particular policy: that of integrating management of HIV and sexually transmitted diseases (STD) with primary health care (PHC) services. During the 1990s, after clinical trials showing that HIV transmission could be slowed if STDs were controlled at the PHC level, the international community strongly promoted the idea that management of HIV and STDs should be integrated into PHC services. This thesis explores the trajectory of this impetus: from policy development at international level, to the response at national level. It suggests that integration of these services was driven by strong leadership from women's groups and international donors. New technologies, such as syndromic management of STDs, were perceived to be one of the ways in which integration could be introduced at the primary level. However, reviewing such experience that exists, shows that the enthusiasm for integration of HIV/STDs with PHC services was soon tempered as limited political, financial and technical resources hindered effective implementation. The study argues that limited political interest in integration was due partly to the fact that some countries were characterised by a relatively coercive relationship between external funders and national policy makers. This meant that efforts to introduce policy reforms were not strongly supported by governments, through allocation of financial or other resources, and donors were forced to spend according to their own priorities. Thus while there was agreement at national levels to policies, in fact, at sub-national levels implementation was weak. The thesis then goes on to explore South Africa's experience, which provides a contrast to the experience of many other African countries. Relatively isolated from international discourse until the early to mid 1990s, South Africa developed its own policies on integration, reflecting many of the same concerns and interests of the international community, but generating such concern from within the country, rather than having it imposed from outside. The thesis analyses developments in policy in the country, from agenda setting to policy formulation, and then looks at what happened during implementation in the Northern Province, one of the poorest parts of South Africa, and more akin to its northern neighbours than other areas. It shows that policies were developed in a context of radical and rapid political and economic change and, as a result, national policy makers sometimes failed to take account of impediments to implementation at sub-national levels, or of the constraints to service delivery. The thesis concludes by expanding on an analytical framework for policy which incorporates the notion of policy transfer, as a necessary adjunct to understanding how policies are formulated and implemented. It suggests that where international agendas are not reflected in national policy discourse, they are less likely to be fully absorbed or implemented. However, even where policies are transferred between national and sub-national levels, problems remain with implementation which need to be addressed.