Getting off on the wrong foot? How community groups in Zimbabwe position themselves for partnerships with external agencies in the HIV response

The global HIV response, like so many international health and development responses, relies on productive partnerships between multiple stakeholders. Community groups have always played a critical role in the HIV response, whether it is through ‘behind the scene’ support, or induced more formally through partnerships with aid and development agencies [1]. Partnerships between local community structures and well-resourced external agencies are generally presumed critical for sustainable and successful global health responses. Community structures are generally seen as ‘close to the ground’ and able to reach ‘those most in need’ [2]. Partnership-working also has the potential to ensure that health interventions build on already existing community processes and structures, create locally appropriate and locally owned responses to health needs, and link community structures to otherwise unobtainable resources, such as technical assistance and funding [3–6].

Treating community structures as indispensible stakeholders in the HIV response is gaining momentum in much HIV programming policy and research. From a policy perspective, the Strategic Investment Framework posits community engagement and actions as ‘critical enablers’ for an effective HIV response [7, 8]. Recent World Health Organisation guidelines stress the importance of engaging communities in the delivery of HIV services. Guidelines on how to monitor national and international health sector responses to HIV see community groups as part and parcel of the health sector [9]. The consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection stipulate the need for community-centred and community led health care approaches [10]. The need to involve community structures in the HIV response is also recognised by the UNAIDS in their Fast-Track targets. They predict that community structures will play an ever increasing role in the HIV response and estimate that the proportion of global resource needs for community engagement activities will quadruple from 1% in 2014 to 4% in 2030 [11]. Commentators, however, note that we are long way from translating these policy commitments into action, truly recognising community structures as assets, and call for a paradigm shift in how we approach and involve local community structures [12].

Research indicates that community structures have much to offer the HIV response. We have in previous work shown that community group membership can have a positive effect against HIV infection for women [13, 14] and encourage faster uptake of HIV services [15]. A major World Bank report, evaluating 15 studies carried out in 8 countries, found community structures to make a critical contribution to the HIV response by helping to mobilise local resources, improve knowledge and behaviour, increase use of HIV services, instigate social change for improved health and reduce HIV incidence [16]. Randomised trials are beginning to emerge, pointing to the benefits of mobilising and involving community structures to ‘translate’ health services, often rooted in behavioural and biomedical interventions, into services that are accessible, relevant and responsive to local needs – enhancing both reach and impact. Project Accept, for example, implemented in 48 communities across Zimbabwe, South Africa, Tanzania and Thailand, found community mobilisation activities, such as community working groups, community ‘recruiters’, post-test psychosocial support and mobile out-reach testing services to contribute to a 25% increase in HIV testing and a reduction in HIV incidence of 13·9% [17]. Community structures can also be mobilised to challenge health-damaging norms and behaviours. SASA!, a trial in Uganda, has documented significantly lower levels of social acceptability of intimate partner violence in intervention sites where community structures were engaged through local community activists to critically reflect on gender norms and power asymmetries [18, 19]. Promising as this is, fine-grained analyses of partnership-working in real-life settings indicate that power asymmetries between ‘local’ and ‘global’ actors and knowledge systems, may undermine the success potential of such initiatives [20, 21].

Looking at NGO-CBO partnerships for HIV prevention amongst sex workers in India, Cornish and colleagues [22] found NGOs, despite their commitment to empower and engage local community structures, to undermine this potential by prescribing global management standards. Community organisations, in order to access resources, had to conform to certain funding practices, professionalising them in a way that distanced them from the very localism that attracted them funding in the first place. Similar observations have been made by Aveling [23], who in a study of aid-chain funding in the HIV response in Cambodia, found international NGOs to position local NGOs and community structures as recipients of aid and to prioritise capacity building for fund management. Aveling argues that while this provides local actors with important material and social capital in the HIV response, such representations and professionalising activities simultaneously perpetuate the inequalities that exist between international NGOs and local actors, undermining community leadership and recognition of local strengths. Nair and Campbell [24], reflecting on their experiences as facilitators of partnership-formations in South Africa, note both a misrecognition of local strengths (the capacity of community health volunteers to address challenges of the HIV epidemic), and the limited capacity of external change agents (who in turn are steered by their donors) to work productively with local actors in support of a community response, obstructing goals of local ownership and equal stakeholder involvement. They go on to argue that rather than focusing on the capacity needs of local actors, there is an equal need to strengthen the skills and competencies of HIV service providers to work with community structures.

These examples illustrate the challenge of putting partnership-working into practice. To build the competence of HIV service providers, and to address the challenges outlined above, we need to scrutinize the social psychological foundation of partnership-working in the HIV response, a hitherto under-explored area of study: How do community groups position themselves for partnerships with external agencies? How do representations of self and other shape the foundation of aspiring partnerships? How do power-asymmetries, reflecting the aid architecture, manifest themselves in community groups’ strategic positioning? These are some of the questions that we explore in this paper, as we seek to unpack the foundation of partnership-working between community groups and non-governmental organisations (NGOs) in the context of HIV in Zimbabwe.

We draw on data from a qualitative study that sought to explore community responses to HIV in southern Zimbabwe. The study forms part of an on-going research project with ethical approval from the Medical Research Council of Zimbabwe (A/681) and Imperial College London (ICREC_9_3_13). Informed and written consent were gathered from all research participants with the assurance that their identities would not be revealed. Pseudonyms have therefore been used throughout.

We set out to ascertain how community group members view their role in the HIV response, either on their own or in partnership with NGOs. We did this to better understand some of the processes that lay the foundation for much partnership-working in the HIV response and asked the following questions: How do community groups position themselves for partnerships with aid and development agencies? How do representations of self and other shape the foundation of aspiring partnerships? How do power-asymmetries, reflecting the aid architecture, manifest themselves in community groups’ strategic positioning? We will in this discussion react to these questions through a reflection and discussion of key findings.

We drew on Aveling and Jovchelovitch’s psychosocial theory of partnerships to help us disentangle how instantiations of ‘self’ and ‘other’, as well as encounters with the experience and knowledge of others ([25], p.35) shape community-NGO partnership working. It is clear from our findings that community group members saw themselves, and the community group structure, as important to the HIV response (representations of self). The group setting provided members with an opportunity to help each other during times of hardship, and occasionally, to look beyond the group and assist others in the community. The language they used to explain the benefits of coming together, not only exemplify their agentic capabilities, but is consistent with a broad African ethic of redistribution and reciprocity [30] – key to the HIV response [1, 14, 31, 32]. Accepting there is a limit to what they can do in isolation, community group members actively sought to position themselves for partnerships with more resourceful organisations (representational project). NGOs were perceived as authoritarian, expecting a certain professionalization of the community groups, and whose teleological aim was to identify obedient community groups who could implement their activities (representations of other). Goffman’s [33] dramaturgy provides a useful metaphorical technique to explain how the community groups, in the context of these knowledge encounters, positioned themselves for partnerships. We observed community groups, through ‘impression management’, and based on recognition that NGOs were looking for local partners (representational project), to try and present a ‘supportable’ version of themselves. This involved first some ‘back stage’ work in terms of coming together, and successfully working in formal community group structures, and second, a ‘front stage’ performance, which involved representing themselves as active, organised and obedient actors in the HIV response (communicative strategy). Key to this process was social representations of self and NGOs, ‘the audience’ to whom they were putting on a front, and the role of these representations in shaping perceptions of how best to perform and position themselves as attractive to NGOs for partnership-working (see Fig. 1).

Our findings speak to some deep-seated power asymmetries between local community structures and NGOs. Although the community groups represented themselves as key contributors to the HIV response, such discussions were followed by recognition of their own limits and dependency of external change agents, like NGOs, for a more impactful response. In discussions about partnership-working with external change agents, NGOs were described as authoritarian and prescriptive, entering the communities with pre-packed aid solutions. These observations resonate with a survey distributed to 439 civil-society organisations in six sub-Saharan African countries, which noted that civil-society organisations in the region remain largely involved as service providers for externally formulated programmes, and offered few opportunities to participate in the planning and design of programmes [2].

These processes, coupled with the need for local community structures to strategically position themselves for partnerships with NGOs, highlight just how partnership-workings may be infused with relations of power from the get-go. Looking at a Partnership for Governance Reform initiative in Indonesia, Crawford ([34]: p. 156) found international agencies to exert their power over local actors in driving the partnership agenda forward, resulting in what he calls a “myth of partnership” permeated by an “ongoing exercise of power”. Although our findings resonate with this one-dimensional donor-recipient dichotomy, some commentators have warned against such accounts, arguing they are over simplistic and assume a level of homogeneity at either ‘side’ [35]. While we are in full agreement that stakeholders in partnership-working can “wear multiple hats” (ibid., p. 924), the social representations emerging from the community groups in southern Zimbabwe do suggest instances of ‘us’ and ‘them’.

The social representations identified in this paper form the symbolic field in which meanings and understandings of self and other are constructed [36]. We noted, that in the process of positioning themselves for NGO partnership-working, there is a risk that community groups may internalise some of their perceptions of how NGOs ‘see’ them, for instance ‘lazy’, as articulated by some of our participants. In a worst case scenario such perceptions can come to constitute how they see themselves, and become part of their own development initiatives, such as staging plays to discourage what one of our participants referred to as ‘laziness’. The use of such language, spoken by community members who aspire to, or have had experience of NGO partnership-working, arguably reflects an elitist distancing, more than a reality of some community members being lazy. Escobar ([37]: p.5) refers to such processes, in a development context, as a ‘colonisation of reality’, claiming that “certain representations become dominant and shape indelibly the ways in which reality is imagined and acted upon”. While it is difficult for us, in this study, to disentangle whether the ‘reality’ we report on is indeed imagined, or instances of subversion, with community structures ‘playing the game’ [38], it is clear that the scale of the HIV epidemic, and the institutions responding to HIV, have influenced how communities mobilise support, come together and view themselves and external change agents.

Our findings are constrained by some methodological limitations. First, as with any qualitative study, our findings may not generalise to other settings, as our geographic and cultural environment may well vary from others. Second, the study relies in self-reported data from community group members only. It is difficult for us to ascertain what happens in practice. This however does not negate the fact that the social representations of self (community groups) and other (NGOs) discussed in this paper, provide insight to some of the processes that may lay the foundation for partnership-working.

As we believe NGOs play a critical role in the HIV response, and do not wish to misconstrue the important work of NGOs, our findings should be located within a broader understanding of the AIDS governance system (cf. [39]) in which NGOs operate. This includes recognition of how financial accountability increasingly shapes and constrains the relationships NGOs have with their local partners and their donors. Ann Swidler [38] has argued that increasingly rigid bureaucratic controls and institutional isomorphism limits the opportunity for NGOs to translate and tinker programmes to fit the reality of different actors. Such realities, coupled with the growing difficulty for NGOs to attract long-term and multi-sectorial funding, have led Kelly and Birdsall to conclude that “the funding environment in which they [large-scale HIV programmes] exist actively undermines the unique contributions usually attributed to CSOs and it has done relatively little to strengthen the capacity of the sector as a whole” ([2], p.1587). Cornish and colleagues argue that this ‘new managerialism’ forces NGO workers to conform to rigid global management standards, which are ill-suited to engage and empower local actors [22]. It is arguably this context which has led to the failure of some NGOs in our study setting to engage with community groups in a meaningful and empowering way, resulting in social representations that influence how community groups position themselves for NGO partnership-working.

Many community groups in Zimbabwe recognise their role in the HIV response and actively navigate representational systems of self and other to showcase themselves as capable actors. While this commitment is admirable, the dynamics that govern this process reflect knowledge encounters and power asymmetries that are conditioned by the aid architecture, undermining aspiring efforts of more equitable partnerships from the get-go. Aveling and Jochelovitch [25] argue that it is “within the scope of development organisations to reflect on how the institutional conditions they sustain support or undermine the renegotiation/re-elaboration of particular representations” (p. 43). Our findings provide plenty of opportunities for such reflection. One, development organisations, NGOs and their donors alike, need to come together and reflect on how their ‘new managerialist’ workings, often centred around short-term ‘upward’ accountability to donors, political leaders, and tax payers, may in fact feed processes that lead to disingenuous partnership workings that contradict their intended goal to empower communities in a way that takes full advantage of their engagement and participation in health programmes. Two, and relatedly, there is a need for greater elasticity in the HIV funding and governance system. NGOs need to have the space and flexibility to be able to act as brokers between incongruent worlds. They need to have the time and resources to be able to involve and incorporate the views of local people at all stages of the programme cycle. Three, this leads us to recommend a complete re-think of accountability altogether. We need to re-balance the focus, and shift the attention more towards our accountability to local people, the intended beneficiaries of a programme [40]. Only by developing accountability mechanisms that take a more long-term, strategic and local view, will we be able to challenge how the community members view themselves and external actors, which may undermine aspiring efforts for more equitable partnerships from the get-go.