Theoretical concepts: Underlying causes of antagony

As to the roots of partnership antagony, three concepts that have been advanced in the partnership literature will be highlighted here.

The first idea is therapeutic domination which occurs when the power differentials in the donor-recipient relations are like those in doctor-patient relations, the doctor knowing all and the patient accepting ‘expert’ advice/instruction [25]. Rottenburg [26] describes therapeutic domination as a superior power position taken by those with the biomedical knowhow to manage and direct treatment programs in countries that are poor and vulnerable to such power imposition. He argues that organisations like the President's Emergency Plan For AIDS Relief (PEPFAR) and Global Fund to fight AIDS, Tuberculosis and Malaria (which are seen by the world as holding the superior power of biomedicine) frame disease in terms of absolute emergency, like war and famine, and do not give a chance to address fundamental issues that are crucial to give sustainable solutions. Mawdsley [27] sees aid as a strange gift that is unreciprocated, adopting a lopsided social order where the superior givers do not allow the recipient the dignity of giving something back. Mawdsley [27] calls this ‘negative giving’ that carries ‘symbolic domination.’ The approach that is used to deliver these gifts is individualistic and destroys the local collective action under which recipient communities normally operate [28]. Alden and Schoeman [29] criticise Southern governments for not flexing their muscles strongly like Zimbabwe has done to decisively stand against the imperialistic discourse carried by the North. The same authors observe that it is difficult to balance both meeting local aspirations and expectations of global governance, the latter seem to always take supremacy. “While the language of global HIV/AIDS policy is partnership (ownership, alignment and mutual accountability), the reality is closer to therapeutic domination with donors controlling the nature and extent of interventions” [30:418]. Therapeutic domination shifts the sovereignty power of the indigenous government and gives it to organisations operating at global level, above national answerability [26].

The second idea is that antagony is fomented accidentally; the partners have good intentions, but the complexities of setting up and managing a partnership are demanding, creating unanticipated antagony (Corbin & Mittelmark, 2008). Antagony can also emerge from different value systems and culture, e.g. individualistic approaches cause unintended harm in a collectivist society. Iatrogenesis is a concept from the practice of medicine (meaning injury caused by a doctor) that has been applied to the aid context by McFalls [25] and termed iatrogenic violence. This is the term used to refer to unintended antagony in this paper. McFalls [25] uses the term ‘iatrogenic violence’ to demonstrate the political and social disruption that international donors bring into recipient countries while giving benevolent humanitarian services. Usually health intervention programs are declared successful, but long term consequences are only borne by the recipient after the international partners have left, a successful surgery yet a dead patient [25]. Daniel [30] adds that the donor is rather ‘arrogant’ in assuming his solution is the best solution for the recipient, that his solution works, but if it does not, the blame is on the recipient.

The third idea, aid as a Trojan horse, conceptualises aid as a deceitful strategy (though accepted willingly by the recipient) to gain control of the recipient country’s approach to health. Antagony arises from the strategic exercise of power, by a more powerful partner, with a hidden agenda to control the partnership. Fowler (31:7) uses the metaphoric phrase ‘Terminological Trojan horse of partnerships’ to describe the subtle power of the international donors from the North who come into the Global South with the deceptive tactic of empowering the weak and seeking to share responsibility of reducing disease burdens but instead bring destruction in many ways. He describes partnership relationships as an aid to foreign penetration, a subtle form of external power imposition [31]. Like with the Trojan horse, recipient countries receive global health programs as contributions to fight disease, while the same trophy is a deceptive way for donors to gain power and control in a battle situation [32]. Welcoming aid from the North into the Global South allows an infusion of foreign values into the domestic approaches to health and development processes [31]. But this act of welcoming also implies a degree of agency [33]. Critics see partnership within the new aid agenda as an instrument for deeper, wider and more effective foreign penetration into the country’s development choices [34, 35]. But it must be noted that the Southern countries allow and accept it. This perspective on partnership has implications for other aspects of the Paris Declaration, for example, ‘ownership’ and community participation is being questioned by researchers [33, 34, 36].

The case

The partnership for the Botswana SMC program is an extension of a long term partnership between Ministry of Health (MH) and two international organisations that have been in the country for over ten years, assisting in treatment or prevention of infectious diseases of global concern, HIV/AIDS and tuberculosis. CDC and ACHAP are called Development Partners (DPs) because of their long term relationship with the Botswana government [23].

The partners joined in an effort to implement the World Health Organisation’s (WHO) recommendation that countries with high HIV prevalence and low rate of circumcision embark in circumcising HIV negative men, as a partial HIV-prevention measure [21, 37, 38]. MH signed the agreement with WHO in 2010 to implement SMC nationwide and to reach the set target within the context of the already existing support from DPs on HIV/AIDS interventions [21, 22, 24]. International donor organisations, PEPFAR and Bill and Melinda Gates Foundation, gave massive financial and pharmaceutical support through the DPs to help push the target of the adult SMC program: to circumcise 80% of HIV negative men aged 13–49, making 100 000 men per year, in a five year period [22]. Acceptability study for SMC in Botswana was done in 2003 and its implementation in 2009 while the acceptability study for infant male circumcision was carried out later, in 2010 [39, 40]. Adult SMC received massive campaigns in 2011 while infant male circumcision was done as a routine in the health centers and with choice from parents [24]. There were two approaches used in the implementation of SMC. Firstly, the SMC integration approach was locally initiated by MH in 2009, to make male circumcision (MC) one of the long term services within its health system throughout the country. The integration program included dissemination of information, education on SMC and made circumcision services available at all the health centres on a daily basis. Secondly, the Models for Optimized Volume and Efficiency (MOVE) approach for implementation was formulated by WHO and included immediately in PEPFAR best practice [41]. MOVE was introduced two years after integration (2011) to help push the target. The MOVE approach uses biomedical marketing strategies like demand-creating mobilisation campaigns, television and radio advertisements, and celebrities as program ambassadors to persuade men to circumcise [42]. Dedicated clinics do not do any marketing but are simply open to the public for access of SMC services.

Research sites

There were three research sites selected according to the distribution of participants of interest to the study: Gaborone the capital city where all program officers at national level were stationed; Mochudi village which was chosen because it is one of the communities in Botswana that practices traditional initiation which includes circumcision, and also because it is urban and located only 40km from the capital city; and Hukuntsi village which is a community that does not practice traditional initiation and is in a remote rural location.

Participants and recruitment

The first author observed a three-day SMC annual planning and strategic meeting in 2012 attended by thirty officers from MH and the DPs. The meeting helped inform the direction of the study, selection of participants and motivated the observation of the program over a three-year period. Following the meeting, the first author made direct contact with three officers from MH, one from ACHAP and the one from CDC. The required protocol to inform responsible top managers was followed in order to access willing officers and implementers from MH, DPs and DHMTs for further participation in the research. The following cluster of participants took part at community level: traditional leaders from the two communities; a team of young professional social workers from Hukuntsi village; a team of workers for the MOVE project in Mochudi.

Data collection

Data were collected using three different methods: Non-participant observation during the 2012 SMC annual meeting; interviews with key officers and traditional leaders; and focus group discussions (FGDs). MH participated in more interviews than the partner organisations; one key officer in MH was the only person to be interviewed three times at different phases of the program because officers from the DPs were unavailable on repeated requests and numerous attempts to follow-up. At community level the only interview was with the chief in Hukuntsi. A total of five FGDs were conducted: Two FGDs comprising five and nine participants in Hukuntsi and Mochudi respectively were conducted for officers managing the program at district level (DHMTs). The third FGD was conducted with a MOVE dedicated team in Mochudi comprising seven officers; the fourth one was with a group of six social workers indirectly involved with SMC in Hukuntsi and the fifth was a group of 25 traditional leaders in Mochudi village. We appreciate that this was too large to be called a focus group, however traditional protocol required that they all participate at the same time even though about ten were most active in responding, giving rich data. The main topics that were explored during data collection included establishing the mission of the partnership; resource contribution; approaches used for implementation; the functioning of the partnership including planning, reporting and communication; the interaction of the program with traditional practices; community response to the program. Data for this paper are largely drawn from the 2012 meeting, interviews with the five national lead officers, the MOVE team and DHMTs as they deal with the partnership directly.

Data analysis

An audio recorder was used to capture interviews and FGDs but not the partners’ three-day meeting where the first author was permitted only to take detailed written notes. Research assistants helped transcribe the data while the first author cross checked the recordings and translated them into English as necessary. Data were analysed using Thematic Network Analysis, following the steps of Attride Stirling [43]. We used NVivo 10, a computer software package designed for qualitative data management and analysis. Data for this paper were analysed in two phases. The first phase used an inductive approach. Data were coded; related codes were grouped into basic themes which in turn were clustered into organising themes. Finally four global themes were identified, giving four types of antagony. The second phase of analysis was deductive, using the three theoretical concepts–therapeutic domination, iatrogenic violence and the Trojan horse–as the frame to identify roots of antagony.

Ethics

Ethical permission to conduct the study was obtained from Norwegian Social Sciences Data Services and Ministry of Health (MH) in Botswana. CDC and ACHAP allowed access for research through the MH permit. Informed consent was obtained from all individuals participating. However, the chief in Mochudi gave consent on behalf of the 25 elders, as per traditional protocol. Confidentiality was assured to all participants. However, anonymity of organisations was not promised given the small number of organisations involved.

Antagony around approaches to the mission

As mentioned above the first SMC approach was the MH’s indigenous approach called integration which was implemented in all health centres in Botswana by government health workers within their normal work routines.

Antagony around local leadership and commitment

The DPs questioned Government leadership’s commitment and priorities at both national and district level. The national leadership was seen as aloof from the program: not owning it and advocating for it like it did other HIV intervention programs such as Prevention of Mother To Child Transmission (PMTCT). A DP2 officer said:

The leadership should give a public face and support to the SMC program but they are not .. they did with PMTCT

Meanwhile the national traditional leadership was also not impressed by the misuse of initiation phrases, making public demonstrations against MH for this.

MH national leadership was also questioned for not physically placing its regional coordinators closer to their on-ground operational regions (North and South). MH expressed a wish to be trusted on its decisions about coordination of the program. One MH officer reacted to this:

This is not the first time I hear this …will you be happy if I tell you how to structure and run your organisation?

One DP1 officer explained that their organisation brought in skills to teach government on how to operate partnerships and on higher roles like coordination of the program.

DHMT staff commitment was also queried by DPs. They reported that it was their MOVE teams only that were committed to SMC. The quotation below represents how many DHMT staff responded to this:

…a sick patient is more crucial to attend to than clients for SMC…We appreciate that the DPs’ MOVE teams can focus on SMC because we have many other duties to do.…but we support them with resources and we help where we can.

Antagony around financial power and ownership

The MOVE project as therapeutic domination, iatrogenic violence and the Trojan horse

The MOVE, of itself, is an act of therapeutic domination by the North. Designed and created by WHO and adopted by PEPFAR, it carried with it the arrogance of knowing best. The approach of the Global North dominated over the local integration approach, over the culture and traditional views on how things should work. However, the government of Botswana allowed the DPs to take the initiative and lead the MOVE activities. Botswana’s relaxed attitude and DPs domination created community resistance. Regardless of the resistance, and without seeking to learn from antagonistic tensions with communities, external approaches continued to dominate. When expectations were not met, partners pulled away. The North disregarded the responses from the local communities and did not even revisit its approach. Although the need to listen to local communities’ views was discussed in meetings as important, it was never made a priority. The MOVE has in it iatrogenic violence. We observe that it was brought in intended to do good. But when things went wrong–like the purchase (by partners) and waste of equipment–MH had to take responsibility. Likewise when the partners pulled out MH was left with the responsibility of equipping and managing the dedicated SMC clinics that had been set up. This is an act of a doctor starting medication and then withdrawing it—bringing harm instead of healing. The MOVE project was also a Trojan horse, a false ‘gift’ from the North presented as a solution to push the set target to circumcise 100 000 HIV-negative men in a year in Botswana. MH was happy to receive it since its ideas and strategies appeared good on the surface. However a closer look reveals that MOVE ‘carried hidden destructive motives’: of acting powerful and side-lining the indigenous approach–integration; operating as a separate entity and creating dependency instead of building on the Botswana health system that exist to improve it; pulling away and leaving MH with no resources. The irony here is that MH accepted the “gift” and even contributed to the partnership. The DPs are more tied to donor driven expectations regarding outputs than the ministry of health.Therefore MH could be held accountable for not standing strong to ensure that the voice of the community is heard and that integration of services as well as the desired indigenous approaches are followed.

Interaction with the community as therapeutic domination, iatrogenic violence and the Trojan horse

The SMC program promoted medical circumcision as ‘better’ than traditional circumcision within initiation. Communities were expected to integrate SMC into their traditional practices but the views of communities were neither listened to nor their values respected–especially regarding circumcision within initiation. The community experienced therapeutic domination from the SMC program. In fact, even beyond a lack of respect for their values, their social and cultural customs were disturbed, for example through the use of women conducting the circumcision operations. This disruption represents iatrogenic violence which was exacerbated by the introduction of MOVE. In response to resistance by the chiefs, MOVE sought ways to recruit men and boys without the chief’s support, for example by campaigning in schools or with a popstar ‘ambassador’, thus finding a way in behind the community defences–just like the Trojan horse.

Therapeutic domination

Partnership implies an equal, respectful collaboration in achieving a common goal, but the inequalities in roles and status of the partners caused tension and confusion. The MOVE approach carried with it Northern domination and control, proving to be powerful while diminishing local approaches and the local partner. The MH seemed to have uncertainty concerning its position as the owner of the program, and its ownership was also questioned and doubted by the DPs. The MH presented itself with three metaphorical descriptions at different times: as the owner, the parent and the baby. In view of itself as the host, beneficiary and health systems manager MH claimed the position of the “the owner.” It also called itself “the parent” or “parental state” that signed the agreement with WHO and has the obligationto report country performance and financial stand to OECD. The irony is that it did not know all the financial undertakings of the DPs since transparency was limited. When the DPs were threatening to pull out it claimed the position of a “baby that should not be weaned.” In contrast, the development partners gave Botswana the title of “owner” yet labelled it as slow to push its own target; they accused MH of professing ownership yet not acting as owner. Also, the highest leadership of the country was criticised for not supporting the program as its “face.” Therapeutic domination by donors gives ambiguous roles to the local partner, calling them “owners” of the program, but treating them as less-able recipients who should follow rather than lead [25, 44, 45]. This domination leaves the recipient countries unsure of their status in the partnership [30]. Critics argue that the fancy leadership/ownership phrases given the recipient countries are just a facade to cover the continuous exercise of power by the international financial agencies [46]. Indeed financial power makes survival of aid partnerships grossly depend on the decisions and interests of the international donors [46]. This is because international agencies see themselves as experts. Recipient countries in turn endorse external new and exciting programs that they may not have the capacity to sustain [47]. This is because they see the donor as ‘expert’ as a patient might view a doctor. The implication here is that while the language of global HIV/AIDS policy is partnership, the reality is closer to therapeutic domination with donors controlling the nature and extent of interventions for the “good” of the recipient [25].

In practice ownership was demonstrated through financial power. Financial resources, implementation speed and the social marketing approach made the international partners seemingly more efficient as they effectively took control of the implementation, mystifying the ownership of the program. However government health workers were also overwhelmed with other duties and had little space for SMC. The development partners insisted to know MH’s financial contribution, hardly giving acknowledgment to MH’s contribution of infrastructure and human capital. Instead, they viewed themselves as doing better than MH on financial contribution, yet without being called “the owners”.

There is another contra observation in this partnership: Although in practice, ownership was demonstrated through financial power, the balance of power here seems more delicate than financial contribution. MH had given in-kind contribution through infrastructure, human resources, supply chains, policy and overheads. Therefore, instead of being powerless against the DPs and donors, the MH shifted the burden of SMC scale-up (and particularly MOVE) both in terms of finances and other resources on to DPs. Alden and Schoeman [29] argue that accepting the “gift” is a sign of agency and comes with responsibility. Therefore blaming the DPs does not take away the responsibility of the local partner. As a “parent” MH could have given more voice to their citizens and traditional leadership.

Iatrogenic violence

Partnership intends to do good and to produce harmonious results but in this case it also caused unintended harm. Iatrogenic violence was experienced at different levels [25]. The severity of the HIV epidemic generates a need for external help. MH appreciated the support from WHO and the development partners, seeing that the country alone would not manage the target oriented program [24]. Indeed the MOVE approach helped achieve greater numbers even though the set target was not reached. External partners usually bring gain to recipient countries: skills, human and capital resources, and expertise on operations [33]. On the contrary, as McFalls [25] argues, humanitarian intervention on a genuine existing problem can cause havoc instead of help, the harm being unintended. There are several examples of such unintended harm in this case. Firstly, MH observed that external help created dependency at national and district level. The DPs complained that the DHMTs were not prioritising SMC and were only dependent on the MOVE teams to do all the work. The creation of dependency and stripping local people of their agency is a form of iatrogenic violence [30]. Secondly, the abrupt pulling away of donors’ resource and implementation support caused operational disruption, “the pain” and the “violence.” One officer explained that whereas DP2 had been downsizing support slowly, with minimal effects, DP1’s pulling away its massive resources was sudden, within a month’s notice. This caused a sudden collapse of the activities of the program because DP1 was the main source of support to both local and national level. It was the donors behind the DPs–PEPFAR and Bill and Melinda Gates Foundation–rather than the in-country DPs, who were seen as the perpetrators of this iatrogenic violence. The MH officer identified international donor organisations’ sudden cutting off their financial power as the root of the problem and expressed that the DPs had no choice but to pull out. McFalls’[25] conclusion that the governing of humanitarian aid is a dictatorship (all-be-it a benevolent one) that is unfortunately exempt from the challenges and critiques of normal politics. He contends that no matter what the nature or context of the intervention ‘iatrogenic violence is inherent in the formal structure of international intervention’ [25:320].

The Trojan horse

Partnership implies transparent collaboration to achieve a common mission but in SMC the agenda of the Northern partners seems hidden in the term ‘partnerships.’ The North is accused of having a hidden agenda to control, of practicing foreign penetration and imposing power [48]. Fowler [31] calls this ‘the terminological Trojan Horse of partnership.’ Several authors add to Fowler’s description in different ways. Guilhot [49] describes external agencies as pretending to be ‘catalysts’ under the pretext that they are quickening processes to achieve locally set goals, yet exerting their external control. Abrahamsen [35] argues that external partners appear kind and claim to be on the back seat, yet they use indirect forms of external control to direct the recipient countries’ health development choice; pushing their own agenda rather than that of the local Government. St-St-Pierre [48] cites an example of how humanitarian aid brings harm to recipient countries instead of helping, that: when countries like Nigeria decreed a lawsuit to freeze clinical trials, Pfizer biopharmaceutical company alluded that no help will be given to Nigeria if the country encounters another epidemic outbreak.

In this partnership, MH’s approach of SMC integration into the national health systemwas “overpowered” by donors’ technocratic accountability mode of dollar-to-numbers that brought in the “MOVE project to push numbers towards set targets” as one DP2 officer explained. The MOVE project brought in American values–the approach of biomedical marketing that targets individuals, as opposed to the collective approach preferred by the communities receiving the service [42]. Foreign penetration is evident on the US pharmaceutical companies pushing their commerce agenda [48]—supplying surgery kits in large quantities regardless of the low response from men. It turned out that MH was scapegoated for lack of use of surgery kits. WHO and the World Bank recommend that countries receiving aid be given the liberty to make choices and work out their own objectives [1, 33, 35]. The same WHO that recommended consideration of culture and indigenous ideas during implementation of programs, demands reports that focus on numbers while and not capturing local responses [42]. These findings characterise how the domineering power of the North over the South is concealed [31]. Abrahamsen [35] contends that it is a struggle to attain genuine partnership based on fairness and mutual respect under circumstances where one party owns and controls the purse and the other the begging bowl.

The MH is not blameless. The Southern partners’ are responsible to ensure that their voice is heard and not silenced by their lack of financial power and expertise [29]. The MH’s voice;—to advocate for equity; to pursue and meet traditional expectations; to show off its financial contribution in the form of infrastructure; to address their query on incoherent reporting; to refuse unequal accountability; to ensure a realistic view on target against WHO target—was not strong enough and therefore easily suppressed by the DPs’ zeal to achieve target. MH accepted the target from WHO when agreeing to carryout SMC [21, 24]. Both MH and DPs felt pressured by the donors and WHO to fulfil the target hence they compromised genuine consultation with communities (which takes time). But it was in the MH’s power to lead the implementation in a way that represented community views. It seems negotiations with WHO are possible [42]. Lesotho is one example of a country that prioritised its traditional views regarding SMC instead of rushing to sign an agreement with WHO when not prepared to reach target. Nonetheless, Lesotho was seen by UNAIDS as non-compliant, against universality and “recalcitrant” [50:766]. What is known is the new global health agenda allows renegotiations and compromise [50]

The nature of antagony in the SMC program in Botswana has implications for North-South health partnerships theory and practice. As to theory development, the findings of this study suggest roots of antagony that partnership planners and managers should be alert to. As to practice, evidence for iatrogenic violence has highlighted the need for partnership interventions to prevent partners’ good intentions accidentally producing bad outcomes. The metaphors of the Trojan horse and therapeutic domination have highlighted the need for vigilance and rigour at the stage of establishing a partnership, for the local partners to take responsibility and prevent more powerful partners from developing and taking over local implementation. As an appeal, researchers should consider exploring measurement of antagony in partnerships just as they have done for synergy.