From brothel to boardroom: Prospects for community leadership of HIV interventions in the context of global funding practices
Highlights
► Social empowerment of marginalised groups is a key pillar of global HIV policy. ► The funding environment may promote or undermine community empowerment. ► We studied 2 HIV prevention projects for sex workers in India. ► Sex workers are empowered at the local level, but disempowered by a managerial funding system. ► A contradiction: funding agency policies promote community leadership, their practices inhibit it.
Introduction
Given evidence that disempowerment is a root source of vulnerability to HIV (e.g. Blankenship et al., 2008), empowerment of marginalised groups is widely advocated in funding agencies' HIV policies. Empowerment, in this context, is understood not only in the narrow sense of people gaining greater control over their health-related behaviours, but also in a broad sense, of gaining greater control in their everyday lives (Dworkin and Ehrhardt, 2007). But to what extent does the funding system itself promote or undermine community empowerment? This paper offers an answer to this question by examining the relation between two local HIV/AIDS intervention projects for sex workers in India and their funding environment. To sustain their activities, projects must succeed, not only in their health promoting work in the brothels, but also in their proposal-writing and reporting work oriented to funding agencies' boardrooms. We shall argue that the complex administrative practices required by funding agencies effectively disempower sex workers, undermining funders' stated aim of grassroots leadership and empowerment.
Critical development literature articulates the intricate relation between global funding regimes and local implementation practices (e.g. Hilhorst, 2003, Mosse, 2005). This work shows that it is not possible to properly understand intervention practices without placing them in the context of the demands emanating from the aid system (Kelly and Birdsall, 2010). The aid system is not a neutral facilitator of interventions, but deeply implicated in the forms that projects take. In the HIV/AIDS literature, which is motivated by an interest in improving health outcomes (rather than theorising development), however, the influence of funding regimes has been a blind spot. Efforts to explain the success or failure of intervention practices focus on the behaviour of ‘target groups’, frontline health promotion workers, or at most, the local context, neglecting the role of powerful systems and actors (CampbellPlease complete and update the reference given here (preferably with a DOI if the publication data are not known): (Campbell and Cornish, in press). For references to articles that are to be included in the same (special) issue, please add the words ‘this issue’ wherever this occurs in the list and, if appropriate, in the text. and Cornish, in press, Stephens, 2010). It is rarely acknowledged that funding agencies themselves comprise an important environment for projects, with concrete implications for their health promotion practices (for an exception, see Aveling, 2011, Aveling, 2012).
By questioning how funding regimes implicitly constitute the activities of HIV/AIDS projects, and how projects creatively adapt to these regimes, we seek to make visible how the demands of the funding system may bring about unanticipated and undesired consequences. We do so through multi-level ethnographic studies of two HIV prevention projects for sex workers in India, focusing on a contradiction between funders' policies of empowerment and the disempowering nature of their procedures for obtaining and administering funding.
Section snippets
HIV policy: favouring a local response?
Around the globe, it has become widely accepted that HIV/AIDS interventions are most appropriately delivered by local, non-governmental organisations (NGOs), using peer education to encourage behaviour change (De Waal, 2003, Seckinelgin, 2008). In India, following the policies of the major national and international funders, a plethora of local non-governmental organisations and community-based organisations (CBOs) are charged with delivering ‘targeted interventions’ to the ‘high risk groups’
Theory: projects adapting to fit their environments
It is tempting, given the vast asymmetries of material and symbolic power between global funding agencies and local community projects, to map this relationship onto longstanding binaries, such as global–local, powerful–powerless, structure–agency, or centre–periphery. However, careful scrutiny of how projects play out in practice refutes the validity of such binaries. As Massey (2004) argues, what we term the ‘global’ is just as concrete and embodied as the ‘local’. ‘Global’ processes, such as
The studies
We report on ethnographic studies at the interface between two HIV prevention projects for sex workers in India and their funders. In this context, sex workers are overwhelmingly poor women with little formal education, selling sex to provide for their own survival and their families' needs. As is standard in India's targeted interventions, both projects use peer education (i.e. train sex workers to be health workers), to promote condom use and attendance at health clinics. Their duration is
Adapting intervention design to reflect local realities
While funding policies are prescriptive regarding official project structures, activities, and reporting, paperwork is their medium of operation. Turning official project definitions into practices allows for leeway in adapting funders' definitions to suit local constraints. The definition of a ‘sex worker’, a ‘meeting’, and ‘appropriate remuneration’ all came up for local debate during our fieldwork. One project's funders expected a certain number of community meetings to be held per month, to
HIV project organisation: NGO–CBO pairs
The mode of delivering HIV/AIDS interventions in India has developed a peculiar organisational form, which could be called ‘NGO–CBO pairs’. In individual red light areas, not one organisation, but two are typically jointly involved in HIV prevention activities: one NGO and one CBO. NGOs are generally staffed by ‘technical staff’, people who are not ‘from the community’, who have professional qualifications and skills (such as social work, counselling, accountancy, or project management) deemed
Continuing reliance on project founders
In both projects, the original highly-educated, upper middle class project founders remained an important presence. In the early days, the founders took responsibility for all aspects of the projects, gradually handing over leadership responsibilities to sex workers and other NGO workers. The single activity that remained largely the founders' preserve, however, was the work of interfacing with the funders. We identified three ways in which founders mediated between the distant world of funding
Prospects for sex workers' project leadership
Both projects had achieved significant progress towards their aims of sex worker leadership and empowerment. In this section, we follow the development, over time, of sex workers' leadership capacities.
To empower one of the most excluded and marginalised groups in Indian society was a challenging goal. When the projects began, local sex workers' experience was predominantly of the world of the red light areas. Many described having no confidence even within their occupation, for example, to
Conclusion
In this paper, we have examined how funding agencies comprise an important environment to which HIV intervention projects adapt. The projects that we have studied had to adapt to two quite different environments, namely, they had to organise health promotion activities suited to impoverished sex workers, while also fulfilling funding agencies' requirements in relation to global conventions of management, monitoring, and accountability. Moreover, they have had to adapt to a contradiction between
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