Participation, decentralisation and déjà vu: Remaking democracy in response to AIDS?

Abstract

Participation, decentralisation and community partnership have served as prominent motifs and driving philosophies in the global scale-up of HIV programming. Given the fraught histories of these ideas in development studies, it is surprising to encounter their broad appeal as benchmarks and moral practices in global health work. This paper examines three intertwined, government-endorsed projects to deepen democratic processes of HIV policy-making in Lesotho: (1) the ‘Gateway Approach’ for decentralising and coordinating local HIV responses; (2) the implementation of a community council-driven priority-setting process; and (3) the establishment of community AIDS councils. Taken together, these efforts are striking and well intentioned, but nonetheless struggle in the face of powerful global agendas to establish meaningful practices of participation and decentralisation. Examining these efforts shows that HIV scale-up conveys formidable lessons for citizens about the politics of global health and their place in the world. As global health initiatives continue to remake important dimensions of political functioning, practitioners, agencies and governments implementing similar democratising projects may find the warnings of earlier development critics both useful and necessary.

Keywords:

• participation
• decentralisation
• democracy
• HIV/AIDS
• citizenship

Acknowledgements

I am most grateful to numerous colleagues and informants in Lesotho who allowed me to access data, attend meetings, and sit in on council proceedings. Earlier versions of this benefitted from the feedback and input of Richard Parker, Ron Bayer, Mamadou Diouf, Kim Hopper, and Rosalind Petchesky, as well as two anonymous reviewers. I would like to thank the Lesotho Ministry of Health and Social Welfare for research clearance, and the National University of Lesotho for research support.

Funding

This material is based upon work supported by the National Science Foundation under [Grant No. 1024097], the US Fulbright IIE program, the American Association of University Women American Fellowship, and the Leitner Family Foundation.

Notes

1. Unfortunately, <70% of those in need of HAART were able to access it in 2010, and further expansion has been stymied by funding shortfalls (Médecins Sans Frontières, 2011; NAC, 2010).

2. In Sesotho, the Gateway Approach is often referred to as Khoro, which means an entrance, or a mountain pass.

3. Many trainings were, sadly, implemented by hiring Ministry of Health officials to come speak to communities or councils at exorbitant rates. For some councils, this took up much of their budget.

4. Herdboys are young men – some as young as 8 or 9 – who spend long periods of time tending livestock away from home, with little access to education or services.

5. Similar patterns of social fissure in Lesotho are observed by Turkon (2008), Coplan (1994), and perhaps most prominently, Ferguson (1994).

Additional information

Funding

Funding: This material is based upon work supported by the National Science Foundation under [Grant No. 1024097], the US Fulbright IIE program, the American Association of University Women American Fellowship, and the Leitner Family Foundation.