A Top-Down Approach to Bottom Up Development: NGO Implementation of Early Childhood Development Programs in Rwanda

The institutional puzzle addressed in this research is how institutional norms within global health networks influence NGO adoption of structures and processes, and how this adoption shapes effectiveness of programming, as there is little research that connects these concepts. The dissertation considers if and how effectiveness of Early Childhood Development (ECD) programs is shaped by these decisions. Using New Institutionalism as the theoretical framework, the research compares two NGOs operating in Rwanda and across geographical scales, Save the Children and Global Communities. New Institutionalism helps us better comprehend global health governance, networked power, and how both shape organizational behavior. To understand relationships between networks and NGOs as they relate to organizational legitimacy and effectiveness, research must analyze NGO behavior across scales, from global to local. NGOs are the primary actors through which ECD interventions are implemented in Rwanda and globally, therefore research about why and how they choose to implement particular programs -- and the impact these decision-making processes have on effectiveness -- is imperative to ensure health security throughout Rwanda and elsewhere. From August 2018-September 2019, qualitative methods including 45 semi-structured in-depth interviews and six focus group discussions, were deployed to gain greater insight into the dynamics between institutional norms, global health networks, and international NGOs (INGOs) implementing ECD programming. Findings illustrated the presence of normative expectations (best practices) in Rwanda that influence behaviors enacted by INGOs: the most salient of which is partnerships between INGOs and national NGOs. Proponents of such partnerships argued that they achieved “win-wins” for both the INGOs and national NGOs due to their ability to ground projects in the local context while building capacity of national NGOs, thereby increasing organizational survivability. Partnerships also presented challenges which, notably, resulted from engaging in assumed best practices. Those challenges included time in the field versus time spent on reporting mechanisms; translating global and national priorities at the local scale; and navigating funding uncertainties. Therefore, that which makes NGOs more legitimate organizations also stretches internal resources, setting up trade-offs and tensions between organizational legitimacy and program effectiveness. Findings yield a greater understanding of the contribution NGOs make to global health and global governance; the challenges they face when operating across scales; and the role they play in both shaping and perpetuating institutional norms

Towards ending the US HIV epidemic by 2030: Understanding social determinants of health and HIV in Mississippi

The disproportionate burden of HIV-related inequities borne by African Americans in the US South amplifies the role of social determinants of health (SDH) in shaping social patterning of illness. Despite some attention, SDH remain overlooked in a biomedically oriented, federal HIV policy. Mississippi is the poorest state with the worst HIV outcomes, nationally. Using qualitative methods, we investigated how primarily African American, HIV-positive Mississippians experienced SDH and health inequities in their daily lives. Employing grounded theory and in-depth interviews (n = 25) in an urban and rural site in 2015 yielded these findings: (1) absence of an enabling structural environment; (a) HIV-stigma constructed via social discourse; (b) lack of psycho-social support and HIV education; (c) insufficient economic and social support resources; and (2) presence of family support for coping. Due to stigma, being HIV-positive seemed to lead to further status loss; diminished social position; reduced life chances; and contractions in particular freedoms. Stigma further compounded existing inequalities – contributing to the moral, social experience of those living with HIV. Trump’s plan to end HIV by 2030 creates the opportunity to rethink the biomedical-paradigm and fully engage SDH – using social science theory and methods that address multi-level social determinants in ways that are also policy-responsive

Getting to zero HIV/AIDS in sub-Saharan Africa: Understanding perceptions of locals using the social determinants of health framework

This study explored a community perception of the facilitators and inhibitors of Getting to Zero (GTZ) in rural Zambia, sub-Saharan Africa. Data were collected in 2017. We use the Social Determinants of Health framework to guide organisation of key themes emerging from semistructured, focus group interviews with community members (N = 52). Data were analysed through an iterative descriptive/thematic approach which allowed for the highlighting of key themes. Emerging themes point to the significance of (a) individual, (b) sociocultural, (c) environmental and (d) economic factors, for example, treatment adherence, gender norms, food security and access to health care as important in GTZ. Implications for policy, practise and scholarship are suggested