Pills, Politics and Partners: NGOs and the Management of the HIV/AIDS Epidemic in the Eastern Cape, with special reference to the Lusikisiki Project, 2004-2014

Abstract

South Africa is one of the few countries in sub-Saharan Africa where HIV prevalence rates remain stubbornly high.1 This trend is both concerning and difficult to explain given that South Africa is economically well-resourced with a better health care infrastructure relative to other African countries. The African National Congress identified the HIV/AIDS epidemic as a major public health threat to South Africa as early as the 1990s (Parikh and Whiteside, 2007; Gevisser, 2007). In response, international donors provided a substantial amount of financial resources to support improvements in South Africa’s health care infrastructure. The persistently high rates of HIV/AIDS in the population beg for answers to questions such as why South Africa’s political leadership has been unable to control the spread of the disease and what particular social, behavioural and economic factors have contributed to South Africa’s disproportionate share of the global HIV/AIDS burden. At this point in time, public health experts still have not been able to definitively isolate the factors that explain the severity of the HIV/AIDS disease burden within South Africa’s population. While international donor aid continues to play a central role in the social, economic and health betterment in developing nations, its political impact on local governance structures has been much debated.2 In particular, the roles played by non-government organisations (NGOs) in the fight against HIV/AIDS in South Africa have been found to be complex, controversial, and their lasting value contested. Specifically debated is the disproportionate global investment in HIV/AIDS prevention, care and treatment in South Africa and the ways in which it has shaped intervention strategies, public and private policy, and the governance roles assumed by various national and local governmental agencies. Despite the threat of diminished financial support from international donor agencies that has loomed heavily over recipient countries in recent years, a number of key international donors have actually scaled up their global response to HIV/AIDS, particularly in South Africa.3 These donor agencies include the U.S. government’s Presidential Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund, as well as non-profit humanitarian organisations such as Mèdecins Sans Frontiéres (MSF), commonly known as Doctors without Borders. This study aims to critically examine the prevailing intervention strategy used by these international donors to “push the pill;” that is, to push a public health agenda that holds antiretroviral (ARV) therapy as the preeminent solution to fighting the HIV/AIDS epidemic at the expense of other intervention strategies. While a biomedical approach remains the most compelling intervention strategy, the fight against HIV/AIDS needs to be more comprehensive in its scope taking into account local knowledge and culture. This study will discuss how political rhetoric delivered through the media and monitoring, evaluation, and reporting systems has been used to embed a biomedical pill agenda into the organizational culture and intervention strategies implemented by local community-based organizations. Through a process of strategic translation, HIV/AIDS has been portrayed as the number one health problem facing South Africa today; in fact, across all of Sub-Saharan Africa (World Health Organisation 2005a, 2005b). As such, the magnitude of the HIV/AIDS epidemic has justified the focus on making ARV drugs available throughout Sub-Saharan Africa at the expense of other interventions that could aim more precisely at the key social and health problems faced by the South African population which compromise health and well-being. The question about whose interests are donors and donor-funded agencies representing, and what are the intended and unintended consequences that result from these interests is the subject of this study. The study will attempt to shed light on these questions through a critical examination of the widely publicized HIV/AIDS intervention programme, the Lusikisiki Project, located in the Eastern Cape Province of South Africa. I have drawn extensively from the development discourse literature and such scholars as Ferguson, 1990; Escobar, 1994 and 1995; Rist, 1997; and Mosse, 2005, to provide theoretical grounding for answering the questions posed.4 The study will critically analyse the social and political factors that defined this reputedly successful HIV/AIDS intervention project. Further, the study wil elucidate other cultural and behavioural factors that shaped the initiative in its battle against HIV/AIDS.Thesis (PhD) -- Faculty of Management and Commerce, 201