‘All they do is pray’: Community labour and the narrowing of ‘care’ during Mozambique's HIV scale-up

Abstract

This paper tracks the intertwined biographies of a community home-based care (CHBC) volunteer, Arminda, the community-based organisation she worked for, Mufudzi, and the HIV scale-up in Mozambique. The focus is on Arminda – the experiences, aspirations, skills, and values she brought to her work as a volunteer, and the ways her own life converged with the rise and fall of the organisation that pioneered CHBC in this region. CHBC began in Mozambique in the mid-1990s as a community-level response to the AIDS epidemic at a time when there were few such organised efforts. The rapid pace and technical orientation of the scale-up as well as the influx of funding altered the practice of CHBC by expanding the scope of the work to become more technically comprehensive, but at the same time more narrowly defining ‘care’ as clinically-oriented work. Over the course of the scale-up, Arminda and her colleagues felt exploited and ultimately abandoned, despite their work having served as the vanguard and national model for CHBC. This paper considers how this happened and raises questions about the communities constituted by global health interventions and about the role of and the voice of community health workers in large-scale interventions such as the HIV scale-up.

Keywords:

• HIV/AIDS
• Mozambique
• community health
• community home-based care
• ethnography

Funding

This article was written with the support of the Center for Biological Futures at the Fred Hutchinson Cancer Research Center. The research was funded by a Fulbright-Hayes Doctoral Dissertation Research Award, the University of California, Berkeley Center for African Studies, and the University of California, San Francisco School of Medicine.

Notes

1. Names of people and organisations in this paper are pseudonyms.

2. Mufudzi is Chiteve for Shepherd.

3. Fieldwork was conducted over 4 visits for 2 months in 2003, 2 months in 2004, 12 months in 2005–6 and 2 months in 2010.

4. Frelimo is the Portuguese acronym for Frente da Libertação de Moçambique (Mozambican Liberation Front), the group that fought the Portuguese for independence and has since been the ruling political party.

5. Renamo is the Portuguese acronym for Resistência Nacional Moçambicano (Mozambican National Resistance).

6. The other two initiatives, pastor and youth education and training for HIV/AIDS prevention, are not discussed here.

7. See Maes (2012) for an example of similar dynamic in Ethiopia with a secular organisation.

8. Volunteers visited all suffering from chronic disease in order to avoid visiting only PLWHA and thereby inadvertantly revealing someone's serostatus.

9. Motivations include prosocial values, such as compassion and a desire to reduce suffering, fulfilling civic and religious values of sacrifice and service, desires for better compensation and stable employment, as well as recognition and appreciation, and opportunities for education and self-improvement (Akintola, 2011; Maes, 2012; Maes & Kalofonos, 2013; Rödlach, 2009; Swidler & Watkins, 2009). Also in keeping with this literature, spiritual motivation was commonly cited by volunteers working for secular NGOs providing CHBC in Chimoio and elsewhere in Mozambique, and not exclusively in faith-based organisations.

10. The ‘community and other social sectors’ are also referenced, but the majority of new services were medical.

11. Problems specific to children were transferred to volunteers who specialised in ‘OVC.’

12. The pace and scale of Mufudzi's growth was typical of the trajectory of similar organisations across Africa at the time. See Droggitis and Ooman (2010) and Oomman et al. (2007).

13. Tellingly, OVC work involved no clinical care and no incentive. Swartz (2013) similarly discusses distinct experiences along generational lines for CHWs in South Africa.

14. These amounts were down from the 2006 allotment of 36 kg rice, 18 kg CSB, 6 kg legumes, andd 1.5 L oil. The available food supplements did not keep pace with the increasing number of patients.

Additional information

Funding

Funding: This article was written with the support of the Center for Biological Futures at the Fred Hutchinson Cancer Research Center. The research was funded by a Fulbright-Hayes Doctoral Dissertation Research Award, the University of California, Berkeley Center for African Studies, and the University of California, San Francisco School of Medicine.