The power of context in health partnerships:Exploring synergy and antagony between external and internal ideologies in mplementing Safe Male Circumcision (SMC) for HIV prevention in Botswana

Abstract

Background The aim of this thesis is to explore partnership functioning and the power of context in a North-South partnership in Botswana whose mission is to promote sexual health via Safe Male Circumcision (SMC) for HIV prevention. Specifically the study explores the power of cultural relevance as well as elements that bring synergy and antagony in a partnership. The Botswana SMC partnership comprised Ministry of Health (MH) and two international organisations, US Centers for Disease Control (CDC) and African Comprehensive HIV/AIDS Partnership (ACHAP), both funded by unseen international donors. The mission of this partnership was to circumcise 80% of HIV negative men (100,000 per year) over a five year period. Partnerships between the global North and the global South are a tool used in global governance of aid to mobilise resources to particularly assist developing countries where the poor and vulnerable are concentrated. HIV/AIDS is a global disease, with efforts to fight it coordinated by international institutions like UNAIDS and World Health Organisation (WHO). The global organisations and donors are commended for supporting global scientific efforts in prevention and cure for infectious and chronic diseases and for being a platform that facilitates funding efforts to the developing countries. The view of HIV/AIDS as a global disease has been observed to bring some good but has also generated ‘local pain’ as approaches used to combat it are applied with assumptions of universal effectiveness. Some partnerships have faced disappointing shortfalls and many fail before fulfilling their goals. There are few studies that analyse partnership functioning and processes, especially in Africa. Most of these studies explore what brings about synergy - producing more results than those of a single entity operation. Thus far, very few studies identified ‘antagony’ in partnerships and few address partnership context issues in a more generalised way. There are, to my knowledge, few studies that explore global and local contextual environments that cause antagony and the underlying causes thereof. This thesis aims to bridge this gap and to add to the knowledge of partnership functioning. Methods This study used qualitative ethnographic design to explore the Botswana SMC partnership over three years. Data were collected in three research sites in Botswana; Gaborone city where national officers to the program operate; Hukuntsi and Mochudi villages which have two contrasting cultures to the tradition of initiation. The methods for data collection were observation, in-depth interviews (IDIs), focus group discussion (FGDs) and informal discussions. Thirty national and district SMC officers were observed in a three-day meeting. I also observed two SMC public campaigns where I interacted with a range of stakeholders. All in all, 39 IDIs and five FGDs were conducted for the whole study. Paper I and III draw on data from observation of the 30 officers, IDIs and FDGs while paper II adds experiences of program campaigns to the list. Results Results of Paper I reveal that the Botswana SMC partnership experienced a range of partnership outcomes; additive – Botswana Government had been doing SMC without partnership, synergistic – more was achieved through the partnership and antagonistic – resistance that caused counter-productivity. A combination of inputs – planning together, developing training and implementing materials, giving financial resources, sharing skills, donating capital and medical equipment – helped push their target of circumcising 100,000 HIV negative men in a given year. However, the same resources brought tensions in the partnership, especially where there was no transparency and where international organisations used different reporting tools. Although there are tensions between partners, they are working together in strategising to address some challenges of the partnership and implementation. Pressure to meet the target caused tension and challenges between the in- country partners to the extent of international organisations retreating and not pursuing the mission further. Paper II shows that program officers’ consultation with traditional leaders was done in a seemingly superficial, non-participatory manner. While SMC implementers reported pressure to deliver numbers to the WHO, traditional leaders promoted circumcision through their routine traditional initiation ceremonies at breaks of two-year intervals. There are conflicting views on public SMC demand creation campaigns in relation to the traditional secrecy of circumcision within initiation. Paper III reveals that the partnership experienced antagonistic results during operational processes and as the ultimate outcome. Target setting, financial power of the North, superficial ownership given to the South, and ignoring local traditional realities result in antagony. There are three underlying causes of antagony identified: 1. therapeutic domination – medical expertise given with arrogance; 2. iatrogenic violence – good intentions that cause unintended harm; 3. the Trojan horse – deceptive power positioned under the pretext of benevolence. To tie the three papers together, I identify three main findings that were given less attention. First, all three in-country partners had attitudes that were counterproductive to the success of the partnership. Second, there was resistance at different levels by the recipient government and communities. Third, it was the international donors rather than the in-country partners who put pressure in partnership. Discussion Results of Paper I reveal that external influences that come from the unseen international donors influenced the working of the in-country partnership, unfortunately crippling it from resolving implementation challenges as experienced within the context of partnership functioning. Global mechanisms used for accountability are sabotaged by the same global context where the exercise of power and financial leverage by international donors reign. A combination of inputs by partners brought some progress towards achieving set program goals. However, prioritising externally formulated programs and lack of appreciation for local symbolic funding undermined local efforts and gave blurriness in leadership and ownership of the program. Externally formulated goals and targets, as well as subsequent expectations from external donors placed the functioning and contextual interaction of the partnership at risk. Tensions around target, ownership, financial contribution and accounting caused antagony, resulting in international partners withdrawing before accomplishing the mission. Results for Papers II and III reveal that antagony can be experienced at two levels: during the collaborative process and as the ultimate outcome of the partnership. The two papers also show that the local and global context has not been harmonised in a way that inspires collaboration rather it create tensions. Ignoring to address contextual issues like the ideology of neoliberalism and traditional practices of collectivism caused continuous conflict and resistance. Lack of genuine community consultation and SMC program implementers’ unwillingness to address traditional leaders’ views of locally appropriate approaches to program implementation caused tensions and resistance. Paper III specifically showed that inputs such as finance and oversupply of medical equipment can be a source of antagony. It is also observed that attitudes of the international donors bring antagony: Therapeutic domination – was shown in prioritising external approaches such as the MOVE project which was more concerned about numbers than other implementation realities, side-lining the local government’s approach of integration. The international partners’ lack of acknowledgment for Ministry of Health’s (MH’s) non- financial contribution indicated their belief in the superiority of their modes of involvement; Iatrogenic violence – was evident when MH was left with the sole financial and operational responsibility for all aspects of the program once the DPs pulled out; The Trojan horse – is illustrated by the international donors’ approach that brought false hope of victory but was a vehicle for donor control. Consistent throughout the three papers is that more can be achieved through partnerships than single actors acting alone or parallel, but attention needs to be given to partners’ inherent attitudes as well as global and local contexts of partnerships to minimise antagony. Also, consultation at all levels would better be done in a genuine, participatory manner. Community’s initial cooperation was a loud message for openness and flexibility while the ultimate resistance was a cry to be heard. The main conclusion of this study is that North- South partnerships should not only be between organisations but also between organisations and people in order to account for the context of local realities.