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International NGOs in Mozambique: The "Velvet Glove" of Privatization
... In just the last few years, at the same time that safe motherhood experts have been pushing to attain the status of a strong global health initiative, there has been growing concern that the "effectiveness" of health sector aid is in fact hampered by the competition, duplication and lack of coherence that topic-specific global initiatives generate (Lancet 2009a). There are also worries that global health initiatives encourage diseasespecific donor-funded "vertical" programmes that weaken health systems by detracting financial and human resources from government services (Pfeiffer 2004). 6 Nevertheless, it is often in the self-interest of global health initiatives, who are themselves dependent on donor financing, to focus on short-term performance and to see health in terms of crisis and humanitarian immediacy, rather than to pursue comprehensive change and focus on the long-term sustainability of interventions. ...
... In a similar vein, others have shown how structural violence -defined as a set of large-scale social forces, such as racism, sexism, political violence, poverty and other social inequalities rooted in historical and economic processes (see Farmer 1999) -become inscribed in public health problems such as high levels of maternal mortality, HIV/AIDS and tuberculosis (Scheper-Hughes 1993;Farmer 1999;Janes and Chuluundorj 2004;Pfeiffer 2004;Fassin 2007). Fassin (1992; in particular has drawn critical attention to the tendency of both social scientists and public health specialists to blame people for their health problems, or assign unhealthy behaviour to cultural factors rather than examine structural impediments to health. ...
Launched in 1987, the Safe Motherhood Initiative has brought together UN agencies, donors, NGOs and academics to galvanise a political, financial and public health response to women’s pregnancy-related death and ill health in low-income countries. This thesis presents an historical ethnography of the ‘making’ of this policy community over the past twenty years, as one of many so-called global health initiatives that populate the global health field. Compared with its competitors, the Safe Motherhood Initiative is often depicted as weak and in need of urgent revival. Drawing on in-depth interviews with over seventy actors within the field, participant observation and document review, I explore how safe motherhood practitioners have come to understand the problems that are credited for the field’s stymied status, and how their ‘diagnoses’ and situational analyses have informed their subsequent practices.
My findings demonstrate that the Initiative has continually had to reposition itself in response to broader ideological, institutional and epistemological struggles. An impulse for self-preservation within a competitive global health field favouring disease-specific approaches has been in tension with safe motherhood practitioners’ fundamental conviction that comprehensive, socially-based policy change is needed to reduce maternal mortality. In order to pursue their common policy objectives and to secure their survival as an expert group, safe motherhood practitioners have sought to enhance the credibility of their policy proposals, establish new institutions and funding mechanisms, elaborate advocacy campaigns and pursue more sophisticated research to demarcate their practices as scientific, rather than ideologically driven. However, the benefits of such ‘self-management’ practices remain to be established. In conclusion, I challenge the widespread, if implicit, assumption that the success of a single advocacy issue, as measured through the rise of a global health initiative and growing political commitment to the specific issue, will necessarily lead to health improvement.
... 25 Indeed, they often contribute to the deterioration of the public health system insofar as they divert financial and human resources from the government health sector when they could be feeding funds through it. 26,27 The current patchwork of services places an undue burden on those requiring care to seek it at multiple sites. While there is a growing focus on the importance of continuous and integrated care, which recognizes the failure of vertical programmes, and the importance of social determinants of health, these theoretical and policy shifts have been slow to materialize in programmes. ...
Women in sub-Saharan Africa are increasingly learning their HIV status in prevention of mother-to-child transmission of HIV (PMTCT) programmes in the context of antenatal care. This paper examines women's decisions about HIV testing and their experience of PMTCT and HIV-related care in one clinic in Lilongwe, Malawi. It is based on qualitative, ethnographic research conducted in 2004 and 2005, including interviews and focus group discussions with 55 HIV-positive women participating in a PMTCT programme, and 21 interviews with key informants from the programme and the health system. Women's expectations from testing were consistent with the benefits for their own health and their infants' health, as communicated by nurses. However, the PMTCT programme only poorly met their expectations. Reasons for this disjuncture included the construction of women as still healthy even when they needed treatment, a focus only on infant health, health system weaknesses, lack of integrated care and timely referral, and defining HIV exclusively as a medical issue, while ignoring the social determinants of health. Women's own health was particularly marginalised within the PMTCT programme, yet good models exist for comprehensive care for women, infants and their families that should be implemented as testing is scaled up.
Résumé
En Afrique subsaharienne, de plus en plus de femmes connaissent leur statut sérologique grâce aux programmes de prévention de la transmission mère-enfant du VIH (PTME) dans le contexte des soins prénatals. Cet article examine les décisions des femmes sur le test et leur expérience de la PTME et des soins liés au VIH dans un dispensaire à Lilongwe, Malawi. Il est fondé sur une recherche qualitative ethnographique menée en 2004 et 2005 qui comprenait des entretiens et des discussions de groupe avec 55 femmes séropositives participant à un programme de PTME, et 21 entretiens avec des informateurs clés du programme et du système de santé. Les attentes des femmes quant au dépistage cadraient avec les avantages pour leur santé et celle de leur bébé tels que les infirmières les avaient exposés. Néanmoins, le programme de PTME répondait mal à leurs espérances, notamment du fait que les femmes se voyaient encore en bonne santé alors qu'elles avaient besoin d'un traitement. D'autres raisons étaient l'accent mis uniquement sur la santé du nourrisson, les faiblesses du système de santé, le manque de soins intégrés et de transfert ponctuel des patients, et la définition du VIH exclusivement comme une question médicale, au mépris des déterminants sociaux de la santé. La santé des femmes était particulièrement marginalisée dans le programme de PTME. Pourtant, de bons modèles de soins complets existent pour les femmes, les nourrissons et leur famille. Ils devraient être appliqués alors que le dépistage s'étend.
Resumen
Las mujeres en Ãfrica subsahariana están conociendo cada vez más su estado de VIH en programas de prevención de la transmisión materno-infantil (PTMI) del VIH, en el contexto de la atención antenatal. Este artículo examina las decisiones de las mujeres respecto a las pruebas de VIH y su experiencia con la PTMI y el tratamiento del VIH en una clínica de Lilongwe, en Malaui. Se basa en una investigación etnográfica cualitativa, realizada en 2004 y 2005, con entrevistas y discusiones en grupos focales con 55 mujeres VIH-positivas, que participaron en un programa de PTMI, y 21 entrevistas con informantes clave del programa y el sistema de salud. Las expectativas de las mujeres en cuanto a las pruebas concordaron con los beneficios para su propia salud y la salud de sus bebés, según informaron las enfermeras. Sin embargo, el programa de PTMI no logró satisfacer bien sus expectativas por las siguientes razones: ver a las mujeres como saludables aun cuando necesitaban tratamiento, centrarse sólo en la salud de los bebés, las debilidades del sistema de salud, la falta de servicios integrados y referencias oportunas, y definir al VIH exclusivamente como un problema médico sin prestar atención a los determinantes sociales de la salud. Aunque la salud de las mujeres fue particularmente marginada en el programa de PTMI, existen buenos modelos de atención integral para las mujeres, sus bebés y sus familias, que deberían implementarse según se vayan ampliando los programas de pruebas del VIH.
... In this contemporary Mozambique, a third area of research seems to be concerned with ideas of Mozambique's 'development'. Along with a rapid rise in HIV/AIDS infection rates and the influx of non-governmental organisations (NGOs) into the country to help curb this very real crisis, this line of enquiry also became the focus of a large number of relevant studies (Hanlon 2004;Pfeiffer 2004;Matsinhe 2005;Johnson 2009;Jones 2009;Igreja & Dias-Lambrança 2009). While this Special Issue has been made possible by development research in laying the necessary groundwork, we also wanted to envision postcolonial Mozambique as a complex space that is richly historical, cultural, and social at the same time that its citizens are experiencing these larger political and economic transitions, to varying degrees in their daily livesin short, we aimed at making a collection that is not concentrated nor restrained by ideas of 'colonialism', 'war', or 'development'. ...
This article looks at the relations between Mozambique and transnational dynamics in nature conservation, and the consequences in terms of identity and practice. More specifically, it focuses on Mozambican nature as a political construct, its evolution over time since the independence of Mozambique in 1975, its management during the war and its (re)creation into 'pristine' areas after 1992, which facilitated new forms of inclusion in transnational networks and of disjunction at national level. We argue that the shift from relative isolation to inclusion in transnational networks (both regional - particularly South African – and global) brought new ways to deal with nature. In particular, it has radically transformed what was conceived as 'nature' and thus what was worth protecting, managing and controlling.
... The political economic structure of the health care system in the United States is such that the charity organizations, social safety nets, and NGOs fill a void left by government institutions providing needed services for citizens it no longer provides, due, in no small measure, to the neoliberal economic model. What is more, this model has been transported to other parts of the world (Cammack 2004;Gideon 2005;Judt 2010;Maupin 2009;Pfeiffer 2004;Smith-Nonini 2000). ...
Using the framework of critical medical anthropology “Health Care Experiences of the Uninsured at the Dawn of the 21st Century” investigates how those lacking health insurance in a U.S. mid-sized northeastern city strive to meet their health care needs. Fieldwork was based on in-depth semi-structured interviews, participant observation, and demographic data of patients who sought care at a non-government, non-profit primary care mobile health clinic, between November 2012 and July 2013. In addition to exploration of health care seeking strategies, I investigated how migration issues played an important role in the health and health care experiences of participants since 80% were born in another country. These participants exhibited symptoms of migration trauma to various degrees. Their narratives described their anxiety, stress, and frustration as they struggled to meet family and financial obligations and the impacts these had on their health and well-being. Participants also explained how they utilized their support networks to overcome the financial and health care challenges they faced and described their views about the differences between right and deservingness in health care. This work highlights how individuals from this particularly vulnerable population experience the political economic forces that are behind the social origins of disease, and how migration also impacts health. It also sheds light on shortcomings of current biomedical system ideology, policies and practices and highlights participants’ sufferer experiences, and their medical pluralism practices.
... Ethnography has also powerfully helped to document the local consequences of structural adjustment and privatisation of the health sector (e.g. Foley, 2010;Pfeiffer, 2003Pfeiffer, , 2004Pfeiffer & Chapman, 2010). ...
... Ethnography has also powerfully helped to document the local consequences of structural adjustment and privatisation of the health sector (e.g. Foley, 2010;Pfeiffer, 2003Pfeiffer, , 2004Pfeiffer & Chapman, 2010). ...
Over the past decade, growing recognition that weak health systems threaten global health progress has galvanised renewed global and national commitment to strengthening health systems (Hafner & Shiffman, 2012). Global health leaders from the World Health Organization to the GAVI Alliance, national governments and donors today endorse the goal of health system strengthening (HSS), though there is little, if any consensus on what this entails. Mirroring the business-oriented and technical bias of dominant global health actors (Birn, 2006), HSS is often approached as a technical challenge, focused on efforts to strengthen implementation and management structures within health service delivery, with little attention to the politics and social relations that shape health systems. This special issue aims to demonstrate the potential of ethnographic enquiry to reinvigorate a political – rather than technical – debate about ‘health systems’.
... Anthropologist James Pfeiffer followed the early Kaya Kwanga process during the 1990s. I agree with Pfeiffer's uncertainty as to why the code of conduct was necessary: it could imply a certain level of misconduct and it could be an empty strategic gesture considering its non-legal nature (Pfeiffer, 2004). However, it could signal an ideological compromise between the government, the donors and implementers. ...
The large-scale introduction of HIV and AIDS services in Mozambique from 2000 onwards occurred in the context of deep political commitment to sovereign nation-building and an important transition in the nation's health system. Simultaneously, the international community encountered a willing state partner that recognised the need to take action against the HIV epidemic. This article examines two critical policy shifts: sustained international funding and public health system integration (the move from parallel to integrated HIV services). The Mozambican government struggles to support its national health system against privatisation, NGO competition and internal brain drain. This is a sovereignty issue. However, the dominant discourse on self-determination shows a contradictory twist: it is part of the political rhetoric to keep the sovereignty discourse alive, while the real challenge is coordination, not partnerships. Nevertheless, we need more anthropological studies to understand the political implications of global health funding and governance. Other studies need to examine the consequences of public health system integration for the quality of access to health care.
http://dx.doi.org/10.1080/17441692.2014.881522
... Focused ethnographies by anthropologists have confirmed that health policies typically do have social impacts on the wider society even where these are not intended (Castro & Singer, 2004;Hahn & Inhorn, 2009;Janes & Corbett, 2009;Tesler, 2010). Pfeiffer's (2004) ethnography of the impact of health policy in Mozambique illustrates one way in which this can occur. Pfeiffer describes how international donor policy to support NGOs in health service delivery in Mozambique not only undermined the public health system but also increased socioeconomic inequality within communities served by the NGOs. ...
Significant challenges face world health and diverse theoretical and methodological approaches have been engaged to both better understand the issues and put forth potential solutions. In the past two decades global health and economic development have become more intricately intertwined. Over the same time the proliferation of the use of the term global health requires interrogation of our assumptions of what is meant by “global health” and how it is constructed as a set of problems and processes. This review of recent developments in the global health literature across sociology, medical anthropology, history, and public health is focused specifically on the interrelationships between global health and globalized neoliberal capitalism. This lens reveals the production of global health as an industry and amalgamation of technologies that allow for new types of medical subjects and objects, as well as movement of patients, professionals, and biologies. Presenting three domains through which neoliberalism and global health intersect, I show that rather than a place or entity, global health exists as a set of complex processes that occur in specific places at the intersections of multiple transnational networks and are best studied within the fraught interactions of human and non-human actors, technologies, and institutions. This may be best accomplished through interdisciplinary work that takes historical and social contexts into account and questions taken-for-granted epistemologies of global health. This brief theoretical grounding of our current scholarship is meant to encourage discussion and promote critical standpoints within the discipline.
The number of global polio cases has fallen dramatically and eradication is within sight, but despite extraordinary efforts, polio retains its grip in a few areas. Anthropologist Svea Closser follows the trajectory of the polio eradication effort in Pakistan, one of the last four countries in the world with endemic polio. Journeying from vaccination campaigns in rural Pakistan to the center of global health decision making at the World Health Organization in Geneva, the author explores the historical and cultural underpinnings of eradication as a public health strategy, and reveals the culture of optimism that characterizes-and sometimes cripples-global health institutions. With a keen ethnographic eye, Closser describes the complex power negotiations that underlie the eradication effort at every level, tracking techniques of resistance employed by district health workers and state governments alike. This book offers an analysis of local politics, social relations, and global political economy in the implementation of a worldwide public health effort, with broad implications for understanding what is possible in global health, now and for the future. This book is the recipient of the annual Norman L. and Roselea J. Goldberg Prize for the best project in the area of medicine.
In 2008, Northern Nigeria had the greatest number of confirmed cases of polio in the world and was the source of outbreaks in several West African countries. Elisha P. Renne explores the politics and social dynamics of the Northern Nigerian response to the Global Polio Eradication Initiative, which has been met with extreme skepticism, subversion, and the refusal of some parents to immunize their children. Renne explains this resistance by situating the eradication effort within the social, political, cultural, and historical context of the experience of polio in Northern Nigeria. Questions of vaccine safety, the ability of the government to provide basic health care, and the role of the international community are factored into this sensitive and complex treatment of the ethics of global polio eradication efforts.
The relative failures of equity-promoting health policies in Africa are often attributed to shortcomings of content or implementation modalities, thereby sidestepping any in-depth understanding of the actors' roles in this process. Yet any analysis of such failures cannot afford to neglect the social actors' behaviour logic. Therefore, to this end, we conducted a study in a health district of Burkina Faso using a socioanthropological field survey. This article empirically documents the recurrence of specific logics that provide a better understanding of these relative failures. The logics uncovered were: monopolizing, neutralization/domination, discourse construction, clientelism, opacity, connivance, avoidance, suspicion, substitution and disdain for public service. The study emphasizes the need, when analyzing the interpretation and implementation of health reforms by social actors, to take into account the concept of power.
Universal notions of a "right to health" for unauthorized migrants operate together with incongruous state and international policies. These ambivalent policies demand ethnographic attention, since they have resulted in a two-tiered system in host countries and foster short-term, improvisational remedies. Medical care for unauthorized migrants is typically left in the hands of non-governmental organizations (NGOs) and permitted under the guise of sympathy and generosity rather than anchored in policy. This paper draws upon ethnographic fieldwork in Germany to present the viewpoints of physicians engaged in medical humanitarianism and discuss the complications associated with filling access gaps through NGOs. It explores the range of motivations-political, religious, and humanitarian-that drive physicians to provide care to marginalized populations. In recent years, I argue that NGO demands upon the state have moved from requests to decriminalize medical aid to demands for compensation for the significant amount of services they provide. Finally, as improvisational medical aid has shifted from being an exception to becoming the rule, volunteers have become frustrated by serving as "stopgaps" while simultaneously arguing for systemic change. The paper examines physicians' roles as gatekeepers and the moral/ethical dilemmas that arise, illustrating how NGO practices underscore neoliberal forms of govemmentality.
Africa has emerged as a prime arena of global health interventions that focus on particular diseases and health emergencies. These are framed increasingly in terms of international concerns about security, human rights, and humanitarian crisis. This presents a stark contrast to the 1960s and ‘70s, when many newly independent African governments pursued the vision of public health “for all,” of comprehensive health care services directed by the state with support from foreign donors. These initiatives often failed, undermined by international politics, structural adjustment, and neoliberal policies, and by African states themselves. Yet their traces remain in contemporary expectations of and yearnings for a more robust public health. This volume explores how medical professionals and patients, government officials, and ordinary citizens approach questions of public health as they navigate contemporary landscapes of NGOs and transnational projects, faltering state services, and expanding privatization. Its contributors analyze the relations between the public and the private providers of public health, from the state to new global biopolitical formations of political institutions, markets, human populations, and health. Tensions and ambiguities animate these complex relationships, suggesting that the question of what public health actually is in Africa cannot be taken for granted. Offering historical and ethnographic analyses, the volume develops an anthropology of public health in Africa.
What do attempts at documentary standardization in a clinic in Maputo, Mozambique, reveal about transnational medical governance? By following medical and bureaucratic practices in an NGO‐supported public clinic, I illustrate how documentary practices enact and complicate medical authority in Mozambique. In efforts toward standardization, medical documents are made multiple, simultaneously articulating a range of ethical, bureaucratic, and knowledge‐producing activities. Concurrently, medical authority itself is multiplied, as a plurality of agencies and institutions come to intervene in and on practices of documentation, measurement, knowledge production, and care in the clinic. Anthropologists have shown how pluralities of medical care present both predicaments and opportunities for patients and healers; I extend these insights to the material life of postcolonial and transnational medical governance, suggesting that governmental and medical multiplication through the document form presents opportunities as well as challenges for the patients, local health workers, and staff of international organizations who navigate this varied documentary terrain.
This article draws from fieldwork conducted with the staff, volunteers and recipients of programs run by NGOs in Morrumbala, a rural district in central Mozambique. During the Mozambican conflict in the 1980s and early 1990s, a majority of district residents lived in refugee camps in Malawi. This article explores how recipients and volunteers draw on nostalgic memories of humanitarian experience in Malawi to critique and make claims on the humanitarian regimes that now provide services in Morrumbala. Anthropological literature has shown that refugee experience can be central to processes of political subjectification, becoming the grounds through which claims are articulated on neoliberal regimes of rights and services. These memories, and the nostalgic humanitarian lexicon they deploy, point to the historicity of humanitarian experience. As Morrumbala residents engage new configurations of aid and welfare today, the afterlives of previous interventions also allow for ambivalent and critical engagements with humanitarian practice in the present.
This study analyzed the meanings given to the Brazilian National Men's Health Policy (PNAISH) by those involved in its implementation to find out how a policy formulated at national level is reflected in local contexts. In five cities, from each macro region of the country, a set of 6 narratives and 21 semi-structured interviews were held with health managers and professionals; the information on the Policy was developed according to the Meaning Interpretation Method. The Policy is generally perceived as positive. Among the meanings given, it is emphasized that the policy is seen, by some, as a comprehensive care that guides actions to address men as a whole in Primary Care; then again, others perceived it as a reduction to urological problems. The policy was also perceived as something vague, which does not detail how to proceed to take men to the services and to better assist them, or something episodic, being the policy reduced to the accomplishment of specific events rather than ongoing actions in everyday services. The different meanings guide practices and actions, which may signal the effective and continued engagement of the professional with the policy, being a key element for its monitoring and evaluation.
Global health is a field of research and practice that examines how assemblages of global processes converge on a health issue, problem, policy, or outcome within an identified social context. The goal of global health is to reduce health inequities and to contribute to the development of salutogenic social systems. This entry focuses on the five dimensions of globalization and health that form the core of social and behavioral sciences inquiry: (1) the social causes or determinants of health inequities; (2) the global circulation of science and technology and its impact on local populations and communities; (3) the development, circulation, and implementation of health policy; (4) global health governance; and (5) the effects of global environmental change on health.
For medical humanitarian organizations, making their sources of legitimacy explicit is a useful exercise, in response to:
misperceptions, concerns over the ‘humanitarian space’, controversies about specific humanitarian actions, challenges about
resources allocation and moral suffering among humanitarian workers. This is also a difficult exercise, where normative criteria
such as international law or humanitarian principles are often misrepresented as primary sources of legitimacy. This essay
first argues for a morally principled definition of humanitarian medicine, based on the selfless intention of individual humanitarian
actors. Taking Médecins Sans Frontières (MSF) as a case in point, a common source of moral legitimacy for medical humanitarian
organizations is their cosmopolitan appeal to distributive justice and collective responsibility. More informally, their legitimacy
is grounded in the rightfulness of specific actions and choices. This implies a constant commitment to publicity and accountability.
Legitimacy is also generated by tangible support from the public to individual organizations, by commitments to professional
integrity, and by academic alliances to support evidence-based practice and operational research.
Women in sub-Saharan Africa are increasingly learning their HIV status in prevention of mother-to-child transmission of HIV (PMTCT) programmes in the context of antenatal care. This paper examines women's decisions about HIV testing and their experience of PMTCT and HIV-related care in one clinic in Lilongwe, Malawi. It is based on qualitative, ethnographic research conducted in 2004 and 2005, including interviews and focus group discussions with 55 HIV-positive women participating in a PMTCT programme, and 21 interviews with key informants from the programme and the health system. Women's expectations from testing were consistent with the benefits for their own health and their infants' health, as communicated by nurses. However, the PMTCT programme only poorly met their expectations. Reasons for this disjuncture included the construction of women as still healthy even when they needed treatment, a focus only on infant health, health system weaknesses, lack of integrated care and timely referral, and defining HIV exclusively as a medical issue, while ignoring the social determinants of health. Women's own health was particularly marginalised within the PMTCT programme, yet good models exist for comprehensive care for women, infants and their families that should be implemented as testing is scaled up.
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