PhD thesis (2019)

Full thesis

Abstract: International non-governmental organisations (INGOs) play an increasingly prominent and multifaceted role in the field of global health – as policy advocates, recipients of donor funds, and implementers of donor-funded programmes. This thesis examines how INGOs implement ‘global’ programmes in ‘local’ context.Based on 10 months of ethnographic fieldwork conducted in rural Malawi, it focuses on a donor-funded INGO project that aimed to improve maternal health by reducing teenage pregnancies through interventions designed to keep girls in school and increase their use of reproductive health services. The thesis examines the dynamics of project and policy implementation within a context characterised by many overlapping development initiatives, shifting donor priorities, a weak public sector, unsustainable donor-funding and short term projects.The analysis focuses on various local individuals who operate within fields of unequal power and ‘broker’ between donors, and local communities. They translate global norms and aims into programmatic practice, to fit the local context but also to derive benefits for themselves. The first article discusses how primary school teachers deal with, and implement, various overlapping NGO initiatives targeting girls, and the implications for public sector institutions. The second article examines how INGOs’ programmatic focus on behaviour change interventions inadvertently results in staff blaming culture for teenage pregnancies and school dropout, denying socio-economic and socio-political realities and the complexity of girls’ aspirations. The third article places the aim to reduce teenage pregnancies within the broader context of maternal health and the Malawian health system. It analyses how dynamic responses and accountability relationships can help explain problems with the implementation of policy and their inequitable effects when confronted with broader malfunctions of health systems.The thesis argues that examining brokers’ practices within fields of unequal power can shed light on why projects are unsustainable and how similar unintended effects repeatedly occur despite the intention of donors and INGOs to strengthen existing public and community structures. The intense professionalisation and donor dependence of INGOs working with the fields of global health and development may undermine their ability to challenge structures of power and reduce inequality.

INGO behavior change projects: culturalism and teenage pregnancies in Malawi

Published in: Medical Anthropology (2019)

Full article (open access)

Abstract: Adolescent girls are at the center of many health development interventions. Based on ethnographic research in rural Malawi, I analyze the design, implementation, and reception of an international non-government organization’s project aiming to reduce teenage pregnancies by keeping girls in school. Drawing on Fassin’s theorization of culturalism as ideology, I analyze how a tendency to overemphasize culture is inherent to the project’s behavior change approach, but is reinforced locally by class-shaped notions of development, and plays out through reinforcing ethnic stereotypes. I argue that culturalism builds upon previous health development initiatives that dichotomized modernity and tradition, and is strengthened by short-term donor funding.

When things fall apart: Local responses to the reintroduction of user-fees for maternal health services in rural Malawi

With Bregje de Kok and Gertrude Finyiza

Published in: Reproductive Health Matters (2018)

Full article (open access)

Abstract: Despite the strong global focus on improving maternal health during past decades, there is still a long way to go to ensure equitable access to services and quality of care for women and girls around the world. To understand widely acknowledged inequities and policy-to-practice gaps in maternal health, we must critically analyse the workings of power in policy and health systems. This paper analyses power dynamics at play in the implementation of maternal health policies in rural Malawi, a country with one of the world’s highest burdens of maternal mortality. Specifically, we analyse Malawi’s recent experience with the temporary reintroduction of user-fees for maternity services as a response to the suspension of donor funding, a shift in political leadership and priorities, and unstable service contracts between the government and its implementing partner, the Christian Health Association of Malawi. Based on ethnographic research conducted in 2015/16, the article describes the perceptions and experiences of policy implementation among various local actors (health workers, village heads and women). The way in which maternity services “fall apart” and are “fixed” is the result of dynamic interactions between policy and webs of accountability. Policies meet with a cascade of dynamic responses, which ultimately result in the exclusion of the most vulnerable rural women from maternity care services, against the aims of global and national safe motherhood policies.

Public servants as development brokers: The shaping of INGOs’ reducing teenage pregnancy projects in Malawi’s primary education sector

Published in: Forum for Development Studies (2018)

Full article

Accepted version (open access)

Abstract: As intermediaries between donors and beneficiaries ‘local development brokers’ play a crucial role in shaping the implementation of development initiatives. They tie together different interests through acts of translation and organise development interfaces, but also pursue their own ambitions. This article examines junior public servants in Malawi’s primary education sector, who as a result of shifting aid modalities and priorities, have become development brokers in the implementation of multiple non-governmental organisation (NGO) projects. Studying their various ‘broker’ roles provides an analytical lens through which to examine the active co-construction of development initiatives, and how brokering affects their position and the school as a public institution. The analysis is based on ethnographic fieldwork at an under-resourced primary school in Mangochi district and on the implementation of norm-promoting projects aiming to keep girls in school and reduce teenage pregnancies. This article describes how brokers facilitate NGO activities, translate global norms into messages that resonate locally, and strategically present successes in line with project discourses. This article argues that these strategies are intended to sustain the projects to benefit the school, the students and to supplement low salaries, thereby prioritising short-term benefits over the quality of education. Donors’ and INGOs’ well-intentioned efforts to strengthen country systems, might result in undermining broader educational goals if these attempts come in the form of multiple small-scale NGO projects. These critical reflections do not travel up the aid chain, as brokers are incentivised to produce successes.