April 2008

The main purpose of this article is to qualify HIV/AIDS in relation to state fragility in Mozambique, based on fieldwork and literature review to contextualize it within other African countries facing the HIV epidemic. This is pursued by an analysis of epidemic evolution, ethnography of treatment access and delivery, HIV fragility, and absorptive capacity. First, Mozambique is considered a ‘stable low-income country’, which provides an environment of ‘easy partnership’. It is not a ‘fragile state’ as defined in development discourse. Second, the most fragile states benefit the least from international support. Third, the weak Mozambican public health system and the political avoidance of private health care point to particular forms of fragility. Many die of HIV related diseases due to the fragile public health system with limited absorptive capacity. The article concludes that the question of how the epidemic aggravates already weak states is conspicuously absent from measure- ment of state fragility now more than 25 years since its inception. This is particularly unfortunate in Mozambique, a low-income country with exceptional partnerships and progress in antiretroviral treatment (ART) expansion, yet only treating 16 percent of people in need of antiretrovirals (ARVs) by the end of 2006. Mozambique experiences crowded health services, excess illness and deaths in some age groups, large numbers of orphans, loss of active labour force, and thus an unprecedented human resource crisis. Health and disease pertain both to national and social welfare, an argument reinforced by the unfolding HIV epidemic that affects all levels of society. The question remains when Mozambique will move from 'weak' and 'fragile' to 'strong', independent of foreign health care support. The article finally recommends measuring state fragility ‘with and without AIDS’ in order to properly understand its impact and to take appropriate action. The ‘states of HIV fragility correlation’ is a starting point towards this endeavour.

ASCI Research Paper 11-Erling Hoeg.pdf