The global "scale up" of externally-funded public health programs has precipitated dramatic political and legal changes in host countries. This project will examine the impacts of institutional changes triggered by program scale up on policymaking processes, political culture, and citizenship in Lesotho. The research involves twelve months of ethnographic research--including participant observation and interviews with policymakers, community leaders, patients, and health providers -- will be carried out in communities surrounding two different treatment sites. The two sites operate under contrasting policies, interests and governance systems: one is a government-run primary care clinic; the second is a multinational partnership.
The research will provide crucial insight into an under-researched aspect of global health policy, African political development, and transnational legal systems. A broader objective of the project is that its findings can begin to inform communities, institutions and organizations about the changing political realms in which public health programming continues to operate, and suggest strategies for increased representation of local populations.
The global ‘scale-up’ of externally-funded HIV programs has precipitated dramatic political and legal changes in recipient countries. These changes include institutional re-arrangements, power shifts, alterations in procedural democracy and methods of citizen engagement, and frequent revisions of citizens’ rights, responsibilities, and participation. This project examined the meanings and impacts of these changes for citizens in Lesotho, a country where HIV program scale-up has been particularly rapid and widespread. The research aimed to capture and understand alterations in citizens’ everyday political lives, as well as their attempts to engage with policymaking, priority-setting, program management, and political processes. This data was situated within a broader investigation of the processes of HIV program development and deployment by international and domestic actors within the country. Ethnographic research using a range of qualitative methods was undertaken in Lesotho during the award period, from Sept 2011-Aug 2012. Research was conducted in two communities surrounding HIV treatment programs: one, a peri-urban community-based health center providing primary care in addition to HIV treatment; the second, an urban garment factory in which HIV services were provided within the workplace as part of a private-public partnership agreement. Research methods included semi-structured in-depth interviews with patients getting HIV services, patients getting other services, clinicians, counselors, support group members, peer educators, family members, and others. Key informant interviews were conducted on an ongoing basis with community leaders, clinicians, local government and NGO representatives, and other stakeholders. Participant observation took place throughout the research in clinic and community spaces, especially with support group activities and home-based care efforts. Focus groups were conducted with clinicians and patients to elicit information on certain issues in greater detail. To better understand political and policy-making processes at regional and national levels, the project included archival research, policy discussions with national stakeholders, and frequent observations of meetings and workshops related to emerging policy issues. To better understand the unique issues in rural, underserved areas, research was also conducted on a limited basis with participants in a rural site that lacked consistent access to HIV services. The multi-sited research design facilitates a comparison of political impacts across contrasting HIV service provision models. Yet there are striking similarities in findings across sites. Citizens now face additional challenges to participation in HIV programming, and feel increasingly isolated from institutions of power, whether governmental or non-governmental. Distrust—not only of programs and agencies, but of the basic functions of democratic institutions—is rampant. It is in the context of this isolation and distrust that patients and citizens are engaged in alternative strategies of political survival—a ‘politics of recipiency’ which has broad-reaching impacts on the quality of programs and citizens’ health. Amidst these dynamics, however, citizens remain engaged in robust forms of associational life, which, in the absence of formalized social contracts, provide crucial forms of communal care and meaningful participation. And HIV services remain a rich terrain on which broader contestations over resources, rights, and entitlements are playing out. This project contributes to two interrelated and under-examined sub-fields in global public health. First, it brings attention to the political consequences of global health programs, highlighting how global health scholars and practitioners alike must pay additional attention to the ways that global health programs elicit long-lasting alterations in state power, institutional arrangements, and citizen participation. Second, it lays initial groundwork for further studies to examine how citizens’ interactions with health programs—and their subjectivity as citizens in a changing institutional environment—alters long-term health outcomes.
