Research 2: Influencing Change (2012) by The Power Is In People

Research number 2

www.oxfam.org.au

Credits Title >

Research number 2 Influencing Change

Published >

July 2012 by Oxfam

Author >

Matthew Phillips

Editor >

Jacquie Lee

Design >

LUMO (www.lumo.co.za)

Oxfam gives permission for excerpts from this book to be photocopied or reproduced provided that the source is clearly and properly acknowledged.

Contact Details >

Oxfam House 56 Clark Road Glenwood Durban 4001 South Africa Tel: +27 (0) 31 201 0865 infosouthafrica@oxfam.org.au

Disclaimer >

The views in this publication are those of the respective authors and do not necessarily represent those of Oxfam or any funding agency. The interview and review process was participatory and consent around content and inclusion of personal information was given to Oxfam by interviewees.

Matthew Phillips Policy and Community Engagement Coordinator - Africa Unit Oxfam Australia 132 Leicester Street Carlton VIC 3053 Australia Tel: +61 (0) 39 289 9444 www.oxfam.org.au

contents Executive Summary and Recommendations List of Acronyms

04 07

Section 1: Introduction The Oxfam HIV and AIDS Program (OHAP) Methodology and Objectives Literature Reviews Selection of Participating Partner Organisations Structure of Interviews and Workshops Limitations

09 09 10 11 12 12 13

Section 2: Context Analysis

Section 3: Findings and Case Studies Attitudinal Change: Stigma, discrimination, gender and culture Case Study A: Disclosure and access to VCT and/or treatment Case Study B: Access to communities Policy and Practice Changes: Engaging formal power structures Case Study C: Batho Pele audit Case Study D: Inter-sectoral working worum and governance programs Case Study E: Supporting community led activism Case Study F: Working in alliances

Section 4: Theories of Change The integral Framework Social Accountability

35 35 36

Section 5: Conclusion and Recommendations

References Acknowledgements

46 48

17 20

21 25 26 28 32

PHOTO ÂŠ Matthew Willman | Oxfam

Executive Summary and Recommendations The Oxfam HIV and AIDS Program (OHAP) in South Africa has worked with local partner organisations since 1998 to ensure communities are less vulnerable to HIV and AIDS and its impacts though the support of programs that enhance the quality and cohesion of the response to HIV and AIDS in South Africa. The program works towards strengthening approaches to HIV and STI prevention that effectively address gender, sexuality and diversity, with a particular focus on young people. It also supports the sustainable delivery and uptake of integrated HIV and AIDS programs at community level and aims to create and sustain enabling environments with a particular focus on the rights of people living with and affected by HIV and/or AIDS. While OHAP supports a range of local civil society organisations (CSOs) including national advocacy and campaign organisations, many of its partners identify their work as “service delivery”. This work comprises a range of interventions including HIV and STI prevention and awareness campaigns, supporting community access to—or in some circumstances direct provision of— voluntary counselling and testing (VCT) and treatment programs and the management of home-based care (HBC) networks. The OHAP management team have observed anecdotal evidence that suggests some service delivery CSOs have contributed in significant ways to policy and practice changes but have been unable to identify or articulate this work as “advocacy”. This research was commissioned to explore and document the strategies that OHAP partners employ to influence change and to position them in the context of other documented theories of change. The report finds that it is impossible to successfully deliver HIV prevention, treatment, care and support programs without engaging in advocacy work. For all OHAP partner organisations who participated in this research, advocacy has been essential in creating and maintaining the conditions for them to conduct

their work. In addition to this, all participating partners engage with power structures to influence change, the impacts of which reach beyond the realm of their direct activities. These range from engagement with formal institutions such as local, provincial and national government departments to working with more informal structures such as tribal and religious leadership. Many partners do not describe this work as “advocacy” and this means it can be difficult for them to identify and articulate examples of impact beyond their substantive service delivery work. This is particularly challenging when much of their work consists of engaging power at the localised and personal level to bring about changes in attitudes, beliefs and behaviour. As one participant explained “actually we weren’t advocating ... our main aim was to bridge the gap between us and them.” However, partners’ engagement with power at the informal and individual level—exemplified, for instance, by their work on gender norms, stigma and discrimination—provides the basis for developing a broader understanding of how power can be influenced at the formal and systemic level of governments and institutions. In some instances it is the language of advocacy, campaigning and policy engagement itself that is obstructive and misunderstood. Several of the report’s recommendations relate to the need for OHAP staff and partners to engage in a discussion about “power”, “influence” and “change” in order to enable the identification of advocacy as one of a range of strategies employed to influence change. In acknowledgement of the challenges faced by the South African government in addressing the gap between policy and implementation, the recommendations suggest that OHAP should continue to support the delivery and uptake of HIV and AIDS programs. However, given the relatively recent change in the political context in which HIV related policies are developed

and implemented in South Africa, it is timely for OHAP to be considering how the program may work to maximise the impact of all strategies employed by partners—including advocacy, campaigning and policy engagement. This is particularly pertinent given the current health policy debates in South Africa and the upcoming review of the HIV & AIDS and STI National Strategic Plan (NSP). Oxfam should continue to refine its overarching analysis of the political economy of HIV and AIDS in South Africa. In addition to developing a greater awareness by OHAP and partner organisation staff of the operation of power at all levels, this will enable OHAP to employ the most effective strategies to influence change at the right moment. Specific recommendations include:

Recommendation 1 > Continue to support the long-term and sustained engagement by partners in the delivery of services, the provision of information and in combating unequal gender power relations and other cultural norms that entrench inequality, vulnerability, stigma and discrimination.

Recommendation 2 > Advocacy training should continue to be provided to partner organisations and Oxfam’s program management staff. This training should be conducted in a way that acknowledges the existing experience and contextual knowledge of partners and staff. Examples of where partners have used strategies

to influence change should be used to develop a shared language of power, influence and change that demonstrates the mutually supportive relationship between “service delivery” and “advocacy” activities before engaging with technical jargon.

Recommendation 3 > In order to ensure that the influencing and advocacy work of OHAP partners is captured through regular reporting mechanisms, Oxfam’s program management tools should be reviewed to allow space for information on what challenges partners experience or have experienced in successfully implementing their programs, and how they sought to overcome these challenges. The current reporting requirements against the program’s policy and practice change objectives are difficult for partners to complete without prior knowledge of the language used to describe advocacy and policy engagement activities. If Oxfam’s proposal, appraisal and reporting documents allow partners and staff to think more about how they work to influence change and achieve planned outcomes then Oxfam and the organisations it supports would gain access to a greater depth of information.

Recommendation 4 > The existing influencing work conducted by OHAP partners with religious leadership, traditional leadership, and all levels of government should be resourced where appropriate. Relationship building and advocacy activities require resources and are often conducted in addition to a full workload. If sustained and concentrated engagement on a particular issue

Executive Summary and Recommendations . . . continued or set of issues is deemed a priority by a partner and Oxfam then resources should be requested through the proposal process and provided, funds permitting, to avoid ad hoc engagement.

Recommendation 8 > Continue to work with partners and allies to monitor political developments and opportunities.

Recommendation 5 > Continue to work with national advocacy organisations (as well as regional and international allies where appropriate) to escalate local issues to the national and international agenda.

Recommendation 6 > Resource organisations with expertise in particular thematic policy areas to participate actively in or lead an alliance of OHAP partners through the existing Communities of Practice model.

Recommendation 9 > Provide technical, legal, logistical and financial support (as required and available) to ensure that appropriate partners are able to engage in key moments of policy reform and to sustain that engagement in order to monitor policy implementation processes. Sustainability issues should be addressed by lobbying government to appropriately resource any ongoing partnership with local civil society groups.

Recommendation 10 > Recommendation 7 > The Community of Practice and Link-and-Learn models currently used by Oxfam in the management of OHAP should be continued and expanded, with an active role for Oxfam at a programmatic level to facilitate alliance building between partners working on similar issues along with advocacy and popular mobilisation training (see recommendation 3).

Where no single advocacy organisation or coalition is working on a particular issue of relevance to partners, Oxfam should considerâ&#x20AC;&#x201D;in consultation with its partnersâ&#x20AC;&#x201D;using its advocacy and campaigning resources and expertise to advance these issues at the national level or to open a space for partners to do so. These advocacy, campaigning or policy engagement activities by Oxfam should not be to the exclusion of South African civil society but, instead, should be complementary and mutually supportive.

List of Acronyms AIDS >

KZN > KwaZulu-Natal

PLWHA >

Acquired Immunodeficiency Syndrome

ANC >

M&E >

PMTCT >

African National Congress

Monitoring and Evaluation

ART >

MDR-TB >

Prevention of Mother to Child Transmission

Antiretroviral Therapy

Multi-Drug Resistant Tuberculosis

ARV >

MEC >

Antiretroviral

Office of the Member of the Executive Council

SGBV >

MOU >

STI >

Memorandum of Understanding

Sexually Transmitted Infection

MSF >

TAC >

Medicins Sans Frontiers

Treatment Action Campaign

NGO >

TB >

Non-Governmental Organisation

Tuberculosis

Department of Health and Social Development (Limpopo Province)

NPO >

TOC >

Non-Profit Organisation

Theory of Change

GNU >

NSP >

VCT >

Government of National Unity

The HIV & AIDS and STI National Strategic Plan for South Africa, 2007-2011

Voluntary Counselling and Testing

CCW > Community Care Worker

CSO > Civil Society Organisation

DoHA > Department of Home Affairs

DoHSD >

HBC > Home Based Care

HIV > Human Immunodeficiency Virus

IDP > Integrated Development Plan

OHAP > Oxfam HIV and AIDS Program

People Living with HIV/AIDS

SANAC > South African National AIDS Council Sexual and other gender based violence

The Comprehensive Plan > Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa, 2004.

PHCC >

The National Guidelines >

Primary Health Care Clinic

The South African Antiretroviral Treatment Guidelines, 2010

PHOTO ÂŠ Matthew Willman | Oxfam

SECTION 1: INTRODUCTION The purpose of this report is to document the strategies employed by a selection of partners supported by Oxfamâ&#x20AC;&#x2122;s HIV and AIDS Program (OHAP) in South Africa to influence social, political and behavioural change in their spheres of operation. It offers analysis of the changes in policy and practice that are relevant and related to the activities of one or more of these organisations and seeks to situate them within broader processes of change in South Africa. The report also provides a limited scan of current literature relating to processes of change, particularly as they are relevant to the context of South Africa, the prevention, control and management of HIV and AIDS and the delivery of and access to essential services. Finally, this research offers some recommendations on how Oxfam can best continue to support the influencing strategies of partners at a national, provincial and local level as part of a comprehensive advocacy strategy. This report is not intended to be an evaluation of the work of Oxfam or its partners in South Africa. Monitoring and evaluation of the impact and effectiveness of programs managed by Oxfam and the organisations it supports is conducted on a regular and ongoing basis through a variety of mechanisms built into program management and governance structures. Instead, this report documents the strategies employed by a select number of organisations supported by Oxfam and is intended to inform Oxfamâ&#x20AC;&#x2122;s analysis of change and the effective support and management of advocacy and community development programs. It is also designed to be of use to the organisations that Oxfam supports in South Africa by highlighting some of the strategies they already use to influence change and framing them in the language of advocacy and campaigning.

The Oxfam HIV and AIDS Program (OHAP) The Oxfam HIV and AIDS Program (OHAP) in South Africa was established in 1998. Initially referred to as the Joint Oxfam HIV and AIDS Program, OHAP is currently in its fourth management phase. Each phase spans three years and is guided by priorities outlined in the program strategic plan. The first phase of OHAP was designed as a pilot program working through local civil society organisations and focused on improving HIV and AIDS service delivery, building the organisational capacity of South African CSOs and advocating for an improved HIV and AIDS response. The second phase built on the achievements of the first and focused more specifically on supporting partners in the development, documentation and dissemination of good practice and the creation of an enabling environment for the civil society response to HIV and AIDS. The third phase identified and focused on a number of specific thematic issues and programming challenges including gender, monitoring and evaluation, advocacy, antiretroviral therapy, and organisational development. OHAP is managed by the Oxfam Australia office in Durban, South Africa, and is guided by a Program Committee (PC) comprising Oxfams Hong Kong, Novib, Germany, Ireland and Australia. OHAP works with nearly 30 local civil society organisations and aims to ensure communities are less vulnerable to HIV and AIDS and their impacts through the support of programs that enhance the quality and cohesion of the response to HIV and AIDS in South Africa. At a programmatic level OHAP works towards strengthening approaches to HIV and STI prevention work that effectively address gender, sexuality and diversity, with a particular focus

SECTION 1: INTRODUCTION . . . continued on young people; supports the sustainable delivery and uptake of integrated HIV and AIDS programs at community level; and aims to create and sustain enabling environments with a particular focus on the rights of people living with and affected by HIV and/or AIDS.

Methodology and Objectives The objectives of this research exercise are: 1) 2) 3) 4) 5)

To understand the dynamics between power bearers (at the international, national, district, provincial and local levels) that impact upon the work of OHAP, its partner organisations and people (particularly women, orphans and other vulnerable children) living with, or affected by HIV and AIDS in South Africa; To understand how OHAP and its partner organisations have previously articulated their efforts to influence change for people living with or affected by HIV and AIDS; To learn from a sample of OHAP partners about when change has occurred at the local and/or provincial level, what they perceive to have contributed to these changes, and what role, if any, they played in the change; To situate the influencing strategies articulated by participating partners in the context of other documented theories of change; To understand how Oxfam, through OHAP, may best support partners’ local and provincial level influencing activities as part of a comprehensive advocacy strategy.

Given the centrality of gender justice to Oxfam’s approach to programming and the particular importance of gender as a power relation shaping the capability of women and men to exercise choice and ability to access information, goods and services

in the context of HIV, the author has endeavoured to employ a gendered methodology in the design of the research project as well as in the collection and analysis of data. Design In designing the terms of reference, gender was taken into account in a number of ways. Firstly, in commissioning the contextual analysis contained in the literature review of the role of duty bearers in the prevention, control and management of HIV and AIDS in South Africa, the researchers expanded the scope of enquiry beyond the formal power structures traditionally considered to occupy the “public sphere”. Rather than focussing solely on an analysis of the power of governments to influence change through formal institutions, the report acknowledged that many of the factors that influence an individual’s vulnerability to HIV infection and ability to access treatment, care and support depend on “informal” power structures that exist within the domestic space and within cultural and religious institutions. In agreeing on the selection of partner organisations to participate, it was acknowledged that many of OHAP’s partners identify their core business as service delivery and operate within domestic spaces traditionally regarded as being within the “private sphere”. For this reason the researchers deliberately focused on these organisations for the collection of the majority of the data and altered the language used to explain the terms of inquiry to allow participants to include interactions with power structures in any of the realms in which they operate. Data Collection In acknowledgement of the depth and diversity of local knowledge and experience the approach to qualitative data collection involved open-ended interviews with small groups of staff, both women and men, from participating partner

organisations. Rather than following a script of questions, this technique allowed the researchers to follow the lead of participants in exploring their perceptions of the context in which they work and how change has occurred. The interviews and workshops did not start from a predetermined definition of “advocacy”. As previously mentioned, staff from participating organisations identify their core work as service delivery, much of it centred around treatment, care and support within the domestic context. For this reason the researchers introduced the objectives of the exercise in broader terms of understanding change, power and influence then extrapolated these concepts to apply to the context in which partners work. Participants were then invited to consider how their work interacts with the power structures that permeate all spheres of life rather than regarding power as merely present in formal institutions. Analysis Finally, the approach has sought to interrogate the conventional separation of the public/political sphere on the one hand from the private/domestic sphere on the other. This decision reflects an assertion that, in the context of HIV and AIDS, the divide between the public sphere—the realm of politics and advocacy—and private sphere—the realm of individual behaviour, attitudes and beliefs—is collapsed and does not provide a useful theoretical starting point with which to think about inequality and people’s access to goods and information. This approach regards gender as a power relation and as a set of cultural norms that are present in all realms of existence. This power relation is articulated just as intricately in the home as it is within a “traditional” court or government department. For instance, the prevention of HIV transmission requires that

a woman be able to negotiate the use of a condom with her partner or partners. As feminist literature regarding women’s citizenship in South Africa suggests, this occurs outside the reach of formal politics and the law, although it can and should be supported by legislation (see for example Gouws (ed), 2005). Likewise, access to treatment does not only rely on the stable supply of affordable therapies by the state, but also on a woman’s ability to disclose to her family and medical professional without fear of violence or social isolation. Given the focus of this report on strategies employed by service delivery organisations, this approach has also proved useful in that it allowed the staff of participating civil society organisations (CSOs) to speak about their engagement with power at the micro level of individual advocacy before broadening the scope of enquiry to include more formal structures. The researchers have deliberately included examples that fall along a continuum of power structures; from micro to macro and from informal to formal. These categories have proved useful tools as they allow diverse examples to be compared and analysed.

Literature Reviews The data relating to objectives 1, 2 and 4 above was sourced through desk based research. The report by Iyinoluwa O. Ologe was prepared in March 2010 to provide the author of this report with a broad contextual analysis of current literature relating to HIV prevention, control and management in South Africa. A summary of this analysis, and other findings that guided the direction of this research, are included in section 2 of this report. The material related to objective 4 represents a limited scan of current literature relating to theories of change relevant to the context of South Africa, the HIV and AIDS epidemics and the provision of, and access to, essential services.

SECTION 1: INTRODUCTION . . . continued Selection of Participating Partner Organisations The data relating to objective 2 was collected through a series of interviews and workshops with staff from six CSOs supported by Oxfam in South Africa through OHAP. Due to limited time and resources, not all OHAP partner organisations could be interviewed. Instead, organisations were selected according to criteria agreed prior to the commencement of the research. As the aim of this document is to describe the influencing strategies employed by organisations that do not necessarily identify their core work as “advocacy”, the following criteria reflect the assumption that larger organisations engaging in formal advocacy work may easily articulate their model of change in conversation and publications and would therefore not require face-to-face interviews. The six organisations invited to participate in facilitated workshops and interviews were selected using the following criteria. The organisations: 1) 2) 3) 4) 5) 6)

include a mix of those with an urban and rural focus; are representative of the geographical spread for the program [OHAP]; work at a local and/or provincial level; identify the main focus of their work to be “service delivery”; form their program priorities by responding to a particular need identified by the community with which they work; and either influence change on behalf of the community and/ or support and enable the community members to influence change themselves.

While OHAP has partner organisations that operate nationally, the researchers did not meet in person with CSOs outside of KwaZulu-Natal (KZN) and Limpopo for two reasons. Upon charting OHAP partner organisations according to the six criteria, it was found that the majority of partner organisations that met criteria 3-6 were based in KZN and Limpopo. A partial explanation for

this is that most CSOs supported by Oxfam through OHAP based outside of these two provinces are advocacy organisations that operate on a national scale. While this is not the case for all organisations outside of KZN and Limpopo, the data-gathering phase of the research had to be conducted in a shorter than anticipated time frame meaning that the researchers were unable to travel to other provinces to speak with partners. This constraint was discussed with the management team of OHAP and it was decided that it would not adversely affect the outcome of the research project and, if thought necessary, an additional piece of work could be conducted which would include a broader range of CSO partners.

Structure of Interviews and Workshops The purpose of the interviews and workshops was to gather data from CSOs supported through OHAP regarding their perceptions of social, political, attitudinal and behavioural change and to document the strategies the organisations employ to influence. OHAP management staff noted that anecdotal evidence suggests partner organisations have contributed in significant ways to policy and practise changes at local, provincial and national levels, however, some of these partners have not been able to identify or articulate the processes and actions that have resulted in those changes as advocacy. It was noted from the outset of the research design that many OHAP partners have expressed resistance to using the word “advocacy” to define their work. Previous OHAP research has indicated that individual and organisational knowledge of advocacy is patchy across the program (Moodley, 2004). This could provide one explanation for this resistance, as service delivery-focused organisations are at times intimidated or confused by the discourse employed to describe advocacy, campaigning and policy engagement activities. For this reason

the authors of this report chose to explore this assumption with the partner organisations who agreed to participate in the workshops and interviews. Meetings were held in three formats. The researchers visited three organisations on site to engage in loosely structured interviews with staff. A workshop involving representatives from three organisations was also held at the Oxfam office in Durban. While the workshop was conducted in a more formal manner, the method of enquiry and content of discussion were similar and informed by the outcomes of previous interviews. All meetings were recorded and transcribed for subsequent analysis. An additional phone interview was conducted with a senior government official who has responsibilities in the areas of HIV and tuberculosis prevention and treatment in South Africa. This interview served to verify information gathered that related to a third party and to gain an alternative perspective of the role of civil society—particularly community based service delivery organisations—in bringing about change in South Africa.

Participants then discussed the perception that advocacy only occurs when trying to influence formal power structures such as national governments. By referring to their examples, they identified and grouped power structures into “formal”— being district, local, provincial and national government and multilateral organisations—and “informal”—being traditional councils and courts, churches and other organisations. Several participants also identified the family and home as a power structure citing their work on gender, stigma and access to resources such as the child support grant as examples of where unequal power relations have effects. Participants then offered further examples of how they have engaged with these power structures to bring about change. Comparisons were made between different situations and further clarification sought on why a particular set of activities were conducted in one context while, in another context, a different strategy was employed.

Limitations While the main objective of the meetings was to identify and understand instances in which the participating organisations engaged in activities to bring about change, the first section of all interviews comprised a discussion to establish a common language of power, change and influence in the context of the partner organisations’ work. Participants were first asked to describe what they regard as the core work of the organisation. After establishing this context, participants discussed instances in which they had met resistance to their work by individuals or organisations and then to describe what they had done in order to counter that resistance thereby creating and maintaining the space for their work. Through this process participants recognised the presence of power relations in a particular context and, in turn, identified the strategies they had employed to negotiate the relationship and influence the situation.

The main limitation of this research is that it is difficult to verify the impact of the influencing strategies discussed with partners. Due to time and resource constraints, the researcher was unable to speak with advocacy targets or community members affected or involved and only qualitative data was able to be collected for inclusion in this document. For this reason the perceptions of workshop and interview participants have been privileged, meaning that some contextual analysis of broader trends and events that may have influenced change might have been overlooked. However the purpose of this exercise was not to evaluate the effectiveness and impact of Oxfam or its partners. The focus has, instead, been on the perceptions of OHAP partner organisations of how change has occurred in a particular context.

PHOTO ÂŠ Matthew Willman | Oxfam

SECTION 2: CONTEXT ANALYSIS The approach adopted during the data gathering phase was informed, in part, by a contextual analysis of current literature on HIV and AIDS in South Africa. The following is a summary of the reportâ&#x20AC;&#x2122;s key findings and a discussion of how these findings informed the methodology and focus of the workshop and interviews. The literature review highlighted the factors that affect the susceptibility of individuals to HIV infection. Those factors include: opportunities for sexual networking; the age of sexual debut; infection with other diseases; exposure to violence and gender-based abuse; exposure to alcohol; economic opportunities for women; and individual behaviour. The literature review also discussed the factors that affect community vulnerability to the impacts of HIV and AIDS. Of those factors, poverty was highlighted as the most crucial. The level of social cohesion, and the presence of negative cultural beliefs and practices were also cited as important factors.

focuses on four priority areas: prevention; treatment, care and support; research, monitoring and surveillance; and human rights and access to justice. Local and provincial governments were also said to play important roles in implementing the national governmentâ&#x20AC;&#x2122;s HIV and AIDS strategic plan. In addition, the literature review discussed the roles of non-governmental actors such as the private sector, non-governmental organisations, human rights groups, religious organisations, and traditional leaders. The literature review concluded that the South African government is responsive to the HIV and AIDS epidemic and supports proven intervention strategies. Therefore, advocacy groups should make known to the government the challenges and achievements of various organisations working to combat HIV and AIDS. It was recommended that advocacy groups should utilise the platforms of AIDS Councils (national, provincial, local and district) which are comprised of both government officials and members of civil society, to influence power bearers.

The literature review identified the government as the primary duty bearer and discussed its role in the prevention, control and management of HIV and AIDS. The national government

PHOTO ÂŠ Matthew Willman | Oxfam

SECTION 3: Findings and Case Studies As outlined in the methodology, for the purposes of this research exercise there has been no distinction made between the operation of power relations at a micro, individual level and those that operate on a formal, institutional level. The decision has allowed the author and research participants to chart the interaction of participating CSOs with power structures as diverse as the South African National AIDS Council (SANAC), the family, traditional courts and tribal councils. It has also allowed a focus on the process and strategy employed to influence change rather than the scale, impact or significance of the change in policy or practice itself. Examples of how OHAP partner organisations have engaged with these power structures have been divided into two sections below. The first is a description of how various partners have sought to bring about change in attitudes, beliefs and cultural norms. This is in acknowledgement that many partners regard their efforts to combat stigma and discrimination as the foundation of the campaign to bring about change in their communities. Partners report that stigma and negative discrimination have been institutionalised within the church, traditional structures and government. The inclusion of examples of CSO efforts to combat stigma at every level of society reflects the assertion that the beliefs informing negative discrimination are a product of culture and subject to change. The second section maps ways that partners have engagedâ&#x20AC;&#x201D;by themselves or through alliances and coalitionsâ&#x20AC;&#x201D;with formalised power structures. During the data collection phase, the researcher and participants built upon the earlier identification of strategies used to influence informal power structures and alter beliefs. This understanding of change and influence was then expanded to include interactions with government departments and other institutions. Specific case studies have been provided that relate to both sections.

Attitudinal Change: stigma, discrimination, gender and culture Stigma and discrimination towards people living with HIV was reported by all participating CSOs to be the most pervasive negative force shaping resistance to the implementation of HIV programs. It is also at the heart of political and social obstructions to the ability of individuals to access testing as well as treatment, care and support when required (Deacon, Uys & Mohlahlane, 2005). These issues are well documented in the literature but the case studies below outline the way participating partner organisations perceive the problem, how it affects women and men as gendered actors and inhibits the effective implementation of HIV programming. They also outline some of the strategies employed by participating CSOs to address these issues, document any challenges experienced and provide an indication of the impact of those efforts. Impact of stigma and discrimination on women and men Some cultural and religious beliefs operate to establish and support stigma and discrimination toward people living with HIV. All participating organisations reported that they have had to overcome the dominant teaching in the Christian church that infection with HIV is punishment for sinful behaviour. Likewise, all participants confirmed that the traditional cultural beliefs of many South Africans attribute HIV to a curse or being bewitched. These beliefs cause many people to fear attending a Voluntary Counselling and Testing (VCT) clinic or an event to raise awareness of issues relating to HIV. While the rights of people living with HIV are upheld in South African legislation, the impact of these beliefs on those living with (or suspected to be living with) or affected by HIV is often felt in very personal ways by people who have little opportunity for recourse.

SECTION 3: Findings and Case Studies . . . continued All participating CSOs agreed that stigma and discrimination are gendered phenomena and that prevailing gender norms play a particularly key role in defining an individual’s vulnerability to infection, and their ability to access testing and treatment. Participants in workshops and interviews frequently cited the following as examples of the impact of gender norms: • • • • •

women are unable to negotiate condom use with their partner or partners; men refuse to be tested for HIV and other Sexually Transmitted Infections (STIs); men refuse to allow their wives to be tested for HIV and other STIs; women are afraid to disclose their HIV status to their family for fear of being ostracised or the victim of violence; women—many of whom may be themselves sick—often shoulder a disproportionate burden of care within the home and broader community.

These issues are also identified in literature relating to gender norms and vulnerability to infection. For instance, the South African Health Review 2010 (Mullick, Teffo-Menziwa, Williams, & Jina, 2010) published by Health Systems Trust refers specifically to the role of gender power relations in sexual and gender based violence (SGBV), arguing that the “underlying gender power imbalance affects women’s ability to protect themselves and... limits a woman’s ability to effectively negotiate preventative behaviours such as the use of condoms.” (2010: 50). Likewise the report refers to violence “occurring in a broader context of relationships marked by controlling behaviours by men and a pervasive sense of fear among women, limited freedom of choice and access to services.” (2010: 50).

Impact on the implementation of HIV prevention, care and support programs Just as stigma and discrimination impact on a woman, man, girl or boy’s ability to access knowledge about HIV, VCT and treatment, they also impact on the ability of individuals and groups to disseminate information about prevention and treatment or provide services to a community. The obstructive effect of the beliefs and policies of the Mbeki administration on the implementation of HIV prevention and care programs in South Africa is well documented (Natrass, 2007 and Geffen, 2009). However, local, provincial and national governments are not the only institutions capable of supporting or impeding community action. The HIV & AIDS and STI National Strategic Plan for South Africa, 2007–2011 (NSP) recognises “traditional” leaders as key implementing partners in the fight against HIV and AIDS acknowledging their unique position of trust and respect amongst the community (Ologe, 2010: 24). All participating CSOs emphasised the importance of working with not only traditional leaders, but also representatives of other informal power structures such as religious institutions, or individuals such as traditional healers, who occupy positions of influence within the community. Gendered power relations are also of relevance here as participating CSOs frequently noted that traditional power structures are highly patriarchal, with tribal leadership and church leadership dominated by men. As traditional and church leadership act as “gatekeepers” to the community, this requires organisations to negotiate these relations in order to gain access to communities to run awareness campaigns, promote VCT, or to provide treatment, care and support.

Strategies All participating partner organisations assert that working with traditional and religious leaders and structures is vital to the success of a program for a number of reasons. Individual leaders have the ability to influence changes in attitudes and behaviour through the content of their sermons, discussions at community meetings and consultations and through modelling good behaviour. They also have the ability to block or facilitate access to communities by partner organisations. In addition to working with traditional and religious leaders to gain access to communities and to influence the content of public messaging, participating CSOs employed a range of other strategies to combat stigma and discrimination. These included: creating a safe space in which people can share their experience, ask questions or seek assistance if required; encouraging public disclosure of HIV status; and using culturally appropriate and accessible communication methods to deliver accurate information and stimulate debate. These forms of media included popular theatre, local papers and radio stations, literacy classes, songs, church sermons and meetings of traditional councils. Many people living with HIV/AIDS (PLWHA) who participated in this research referred to this process of ‘testifying’ as a powerful tool against stigma due to its effect of ‘putting a human face to HIV’ or ‘making it real.’

“Actually we weren’t advocating—we were trying to get something across… to the community we were working in, to understand more about HIV/AIDS, stigma and discrimination. Our main aim was really to bridge the gap between us and them.”

Risks and Challenges Working with and within institutions such the church or tribal councils also involves some risks and challenges. One common challenge is that some churches, religious leaders and traditional leaders refuse to talk about condom use as a prevention measure. In the case of churches, condom use is regarded as sinful and encouraging promiscuity, but some cultural systems also do not allow a woman to request condom use within marriage as it is perceived as disrespectful to the husband. There is a strong gender dynamic at play, as one research participant explained:

“[T]he woman cannot suggest that the man go for VCT and cannot suggest that they use [a] condom because... she will be sent home to come back with the cow to ‘clean’ the family because she has said something that is not supposed to be said to the husband.” Partners also reported that traditional leaders are prepared to be flexible on some issues, such as the referral of rape cases to the courts, but may resist change in other areas. One partner cited the tradition of bride price as something that traditional leaders are resistant to giving up because they feel that “there are no benefits” for them in doing so. While this may not be a problem in itself, if a leader feels like the CSO is attempting to undermine his authority by suggesting changes in traditional practice, then the relationship may be compromised.

SECTION 3: Findings and Case Studies . . . continued Case Study A: Disclosure and access to VCT and/or treatment One workshop participant shared a story that demonstrates the power of cultural and religious beliefs about HIV in generating fear of stigma and discrimination and how these are experienced by women and men. The story accords broadly with the experiences of all participating partner organisations and demonstrates several of the innovative strategies employed by CSOs in combating the effects of stigma, while also addressing its cultural and/or religious foundations. The story involves a woman who came to a six-monthly meeting of community members run by their organisation to discuss experiences and stories relating to HIV. The woman shared that she was the most recent of four wives in her marriage. She had witnessed that the most senior wife in the family was sick and after three months she herself became ill and had accessed VCT. Her test came back positive but she felt unable to disclose her status to her husband and family for fear of losing her husband, being ostracised or punished by the other wives and expelled from the family. The organisation responded to her request for assistance and spoke to the ward councillor in the area to receive permission to hold an HIV awareness-raising event using popular theatre at the local clinic. As the workshop participant explained, “We could not just come into an area and start solving problems without approaching the local councillor or the local induna1. We have to get permission.” Once attaining the councillor’s permission, the organisation arranged with the clinic sister

1. Induna is a Zulu word referring to a leader

[nurse] to close the clinic so everyone could attend the performance in which the woman and the theatre group acted out her story using pseudonyms. As is their practice the organisation then provided catering and facilitated a conversation with the audience about the issues raised in the performance. The workshop participant explained,

“We normally sit and talk and form a relationship between us and the sister… we wanted to hear the comments of the sister at the hospital. After she commented we said, ‘Okay, we have a lady who has the same problem’ and [the sister] took it from there.” Following the performance and discussion the staff of the organisation was confident that the sister would not negatively discriminate against the woman concerned. Once the woman felt comfortable to disclose, the clinic sister arranged ongoing support for the woman, her husband and family. This included the provision of counselling and antiretroviral therapy (ART), calling the husband into the clinic and assisting the woman in disclosing her status to him, providing him with accurate information about what this meant, offering and providing him with VCT. Sadly the first wife died of an AIDS related illness soon after as she was unable to commence ART in time. The husband also tested positive, but he and the remaining family members are alive, the marriage is intact and all those requiring treatment, care and support are now able to access it without fear of discrimination.

While the partner organisation involved in the example above did not think about their activities as advocacy, it could be argued that by interceding with a third-party duty bearer to assist an individual to claim their right to health without fear of recrimination, the organisation was advocating on her behalf. The example is of interest because it demonstrates several strategies employed by a number of organisations in their work to combat the effects of stigma and its foundation.

Case Study B: Access to communities One organisation that runs HIV and AIDS prevention programs, trains home based carers and manages a large home based care (HBC) network across several municipalities reported that they frequently alter their approach according to the context in which they work. In one particular area, the delivery of prevention programs was inhibited by lack of interest from the community. After conducting a focus group the organisation decided to engage local traditional leaders. A staff member explained that “approaching the traditional leaders was a way of trying to get to the root because as Africans when you go to the head you stand a change of being heard by everybody.” After approaching the traditional leaders, the organisation was endorsed and many people attended the training. Accessing traditional leaders is not always so straightforward. The same staff member explained that it is “very difficult, not easy because there is a lot of protocol in doing it... As a woman you cannot walk into the kraal2 and start talking and... presenting your view and everything. It has to go through [the right] people.” In one instance the organisation formed an alliance with a group of men that had participated in one of their “men as carers” programs. The interview participant explained that:

2. While the original meaning of kraal refers to an enclosure for cattle within a homestead, the term is commonly used to refer to an entire homestead complex. PHOTO © Matthew Willman | Oxfam

SECTION 3: Findings and Case Studies . . . continued “we started off by training them and thereafter meeting those men... and getting them to get us closer to the traditional leaders. We use the same men to try and mobilise people through the instructions of the traditional leaders now because they were our link.” In another community the organisation encountered resistance to talking about modes of transmission and prevention as the issues of sex, sexuality and gender are regarded as taboo. They worked with a group of youth to write and produce a play about HIV-related issues and performed it for the tribal council instead. The staff member involved quoted one chief who reacted by standing up saying “good Lord this is what we have been needing!”. He has since called public meetings at which the youth group perform the play then assist the organisation in facilitating a conversation about the issues contained in the drama. The outcomes of these efforts have included an increase in the number of people accessing VCT and increasing cooperation between the OHAP partner organisation and other stakeholders such as the local clinic, traditional healers and traditional leaders. Despite initial resistance several traditional healers now refer people to the clinic for VCT. As one participant explained, “Traditional healers play an important role when it comes to the influence they have in the community. You will be surprised that the traditional healer can have influence over the traditional leader.”

Policy and Practice Changes Engaging formal power structures Most partners who participated in this study have done some work in assisting people to gain access to the identification documents necessary to attain social grants and services. The Department of Home Affairs (DoHA) is responsible for the processing of applications for identity documents. Issues around the timely and transparent consideration of applications are well documented and consistent with the reports of partner organisations. Workshop and interview participants identified a variety of problems with DoHA. These ranged from the rejection of applications en masse with no substantive reason given, unreasonably slow processing of applications with inadequate communication of progress, failure of department staff to attend appointments and convoluted, poorly communicated or inconsistent application guidelines and requirements. Strategies As service delivery organisations, many partners work with applicants to assist them in filling out application forms, liaising with DoHA, and arranging transportation to the department’s office. However, the multiple and ongoing systemic challenges have meant that partners have also employed a wide range of strategies to bring about improvements in service delivery. Some of the strategies used by partners include: • •

establishing and maintaining working relationships with local staff and high-level officials from DoHA in their local area; establishing an inter-sectoral working forum including representatives from tribal councils, religious institutions, local CSOs and staff from a range of government departments including Health, Home Affairs, Social

• •

Development, Justice and Correctional Services (see next case study); conducting community surveys based on the Batho Pele principles3 and measuring client satisfaction with various government departments, sharing these with local government representatives and publishing in local newspapers when necessary; and monitoring the political context for opportunities to influence.

It was recognised by all organisations that in each example it had been important to establish a constructive relationship with local representatives of the relevant government department. Participants frequently observed that this was made possible due to the credibility their organisation had previously established among the community and with local government through the effective delivery of long-term development programs that respond to community needs. However, in some cases government officials, tribal or church leaders regarded the CSOs with suspicion. The strategies that they employed to overcome this resistance are discussed below. It was also acknowledged that the timing of some efforts to improve the performance of DoHA coincided with the election of the Zuma administration and the appointment of a new Minister for Home Affairs. According to one workshop participant, the “new administration [appointed] the new minister to literally clean out home affairs so all the officials were no longer

sleeping on duty”. Partners noted the importance of monitoring the political environment and being prepared to “take the opportunity” if or when it arises. Risks and Challenges Many participating CSOs identified the management of relationships with government departments, traditional councils and church leadership as a challenge when engaging in influencing activities. While in some instances having a strong relationship has proved beneficial in giving the CSO credibility and a respected voice to criticise the other party, in other situations organisations have been unsure of whether the risk of engaging an advocacy target will result in losing credibility. As one workshop participant explained:

“We strive to try and get relationships going, link communities with relevant stakeholders; service providers like [the Department of] Social Development, local government, traditional councils because we believe that is how you facilitate development. But then you see what happens in that relationship is that sometimes you need to advocate or influence changes and so end up in a situation where you are not sure:

3. In his 2001 article concerning public sector reform in South Africa, Erwin Schwella explains that “Project Batho Pele” emerged from the ideals outlined in the Republic of South Africa’s constitution drafted in the years following independence and “made concrete” in the White Paper on the Transformation of the Public Service drafted in 1995 (the White Paper). Batho Pele (People First) comprises eight principles consistent with the mission statement proposed in the White Paper which refers to “a people centred and people driven public service” (cited in Schwella, 2001: 374). The project, initiated in 1997, is aimed at achieving improvements in service delivery through reform of institutions and their management structures.

SECTION 3: Findings and Case Studies . . . continued ‘Do I have a relationship with this traditional council and cannot challenge them?’ We have a relationship with local government or a particular municipality and as a consequence they see us as friends—this kind of pseudo relationship when you cannot challenge.”

In this instance the partner organisation has employed a number of strategies to work with traditional leadership in a nonthreatening way, some of which are detailed in Case Study D below.

One participating CSO pointed out that in the context in which they work, many people are fearful of engaging with “political issues” because they are worried about the result of being perceived as partisan or going against the political allegiances of their family or the traditional leadership in the region. This hesitance is, according the partner, also present amongst some traditional and religious leaders, although for different reasons.

“[P]eople have read bibles… out of context so where the bible is not explicit about the involvement of the people of cloth in the issues of governance so now they start doing that like it’s wrong so they find it even difficult to separate between politics in general and party politics where people go for a particular political party.”

In the case of traditional leadership, the partner explained;

“There is a general fear that such human rights movements or organisations or Chapter 9 institutions4… are there to erode the culture of black people so now people want to get that assurance that their comfort zones won’t be interfered with.”

Similarly, the partner pointed out that some church leaders also do not believe in getting involved in democratic processes. As the partner explained;

The organisation concerned works specifically with church leadership on matters of governance and democracy, and have found creative and culturally appropriate ways to engage churches, some of which are also detailed in Case Study D. Another challenge frequently cited by participating CSOs is the general lack of knowledge in some communities regarding their constitutional and human rights. In some instances people

4. Chapter 9 institutions are independent bodies, subject only to the Constitution of the Republic of South Africa, and were established under the 1996 Constitution to “strengthen constitutional democracy in the Republic.” They comprise the Public Protector, the South African Human Rights Commission, the Commission for the Promotion and Protection of the Rights of Cultural, Religious and Linguistic Communities, the Commission for Gender Equality, the Auditor-General and the Electoral Commission (www.info.gov.za, accessed April 2011).

were unaware that they were entitled to access information relating to government budgets and expenditure, and in others people were unaware that it was the duty of DoHA to process their application for identity documents. The Batho Pele audit detailed in Case Study C is one example of how partner activities have increased the level of awareness of rights amongst the community at the same time as evaluating the performance of respective government departments in the delivery of services. In addition, many organisations reported using various methods of explaining rights and duties to community members including popular theatre, workshops and working with traditional and church leaders to explain these to their constituencies.

PHOTO ÂŠ Matthew Willman | Oxfam

Case Study C: Batho Pele audit One CSO that participated in this study had been conducting public education sessions on human rights within the framework of the Batho Pele principles prior to the election of the Zuma administration. The organisation had reached agreements with DoHA, along with the departments of Social Development and Health to produce, fund and conduct a community survey based on the Batho Pele principles and to share the results with each department, offering them the opportunity to participate in a repeat survey to verify the results. The survey results demonstrated widespread dissatisfaction with DoHA in particular, but the officials involved demonstrated no willingness to participate in a repeat survey or implement changes to address the problems identified. At this stage the partner organisation published the results in the local newspaper. While these activities were not deliberately coordinated with the change in administration, the survey and its publication in local media provided the local DoHA branch with a pre-existing measure of their performance highlighting areas for improvement. The partner reported significant improvement in the delivery of services by the department in their area since the publication of the survey. Applicants are now also able to track the progress of their application online and more people are being assisted. It was noted that the relationship of the organisation with DoHA officials has also markedly improved. One staff member explained that:

â&#x20AC;&#x153;they are now clear of our intentionsâ&#x20AC;&#x201D;that we are not there to compete with them. We are actually there to make their job easier. Firstly, 25

SECTION 3: Findings and Case Studies . . . continued we are going to make sure that people have the required papers so they don’t have to turn them away because if they turn people back today the very same people will be back tomorrow.” As outlined in the risks and challenges section above, many CSOs that participated in this research report that some government departments, churches or traditional leaders are suspicious of the activities and intentions of their organisation. As the quote from the participant above demonstrates, the organisation struggled to get an appointment or make any headway with the staff of DoHA due to uncertainty regarding the intentions of the organisation concerned. In this instance, printing the results of the survey in local media was a strategic decision based on the partner’s analysis of the political environment. Such public campaigning has inherent risks but the case study demonstrates that the end result was beneficial to the organisation, the communities affected and DoHA as they realised the value of the CSO’s activities and network in assisting them to implement and monitor reform.

Case Study D:

Inter-sectoral working forum and governance programs

One faith-based partner organisation interviewed for this study works in a rural context and runs programs addressing HIV and AIDS, poverty, gender based violence and promoting good governance and democratic participation. They work with a range of actors, including religious and traditional leadership and youth groups through a variety of modalities. These range from service delivery functions—such as VCT promotion programs, awareness programs around HIV and gender, and the provision of home based care and market garden programs — to partnering with universities in urban centres to conduct courses for local religious leaders on democracy, gender and theology. According to one representative, the organisation’s purpose is to “create a space for the church and community at large to respond to social ills” including the “ignorance which comes in the form of… people not [being] willing to participate in democracy issues because they perceive that [it] is a sin especially if you are talking about things relating to government”.

PHOTO © Matthew Willman | Oxfam

As part of a suite of activities relating to governance and democracy, the organisation facilitates a multi-stakeholder working forum including local officials from the provincial departments of Health, Agriculture, Correctional Services, Justice, Home Affairs and Social Development as well as traditional and religious leaders from the area and representatives of the partner organisation. The meetings are coordinated by the organisation concerned and some meetings are open to the public to discuss issues of concern to the community. The working forum has dealt with issues as diverse as: • • • • •

the response of authorities and the community to the incidence of rape and gender based violence in the area; the inefficiency and lack of transparency in the processing of identity documents by DoHA; the monitoring of progress against the local Integrated Development Plan (IDP)5; difficulties experienced by those on ART in obtaining a constant supply of medication or ensuring they have food to take with the medication; and difficulties experienced by people gaining access (and transport) to local markets to sell excess produce.

The meetings have resulted in the relevant parties sharing information, coordinating responses to particular problems and negotiating the division of responsibilities. According to the staff interviewed for this research, some of the outcomes of the working forum include:

• • • • •

coordinated approaches to dealing with particular cases of violence. For instance, after the death of a man in the community allegedly murdered in an instance of politically motivated violence, the CSO provided food parcels, provisional and “pastoral” care to the orphaned children and referred the case to the police for investigation; DoHA worked to arrange a death certificate for the parent and ID documents for the orphans (necessary for them to access social grants); and social workers linked the children to the relevant social grants; increases in the efficiency and transparency of DoHA and the number of people attaining identification documents. It was acknowledged also that the change in administration was a major influence in this area; greater numbers of people accessing VCT; arrangements made with the Department of Agriculture to provide transport to local markets so that people living in remote rural areas are able to sell excess produce from their gardens as an income generating activity; relationship building between the community and police. For one community event organised by the working forum, the traditional leadership provided the venue, the CSO organised the event and the Department of Correctional Services provided the catering. The staff of the organisation believe that by establishing trust between community members and police more cases of gender-based violence and rape are likely to be reported.

Outcomes of other initiatives under the organisation’s governance program have included an increasing consensus between the police and some traditional leaders regarding their respective roles in bringing perpetrators of SGBV to justice. It

5. An Integrated Development Plan is an overarching framework for the development of an area which is required to be produced, through a series of consultations, by each municipality. IDPs are intended to take into account both economic and social development. (www.etu.org.za, accessed April 2011)

SECTION 3: Findings and Case Studies . . . continued is the practice of some tribal councils and chiefs to deal with allegations of rape through the exchange of goods from the alleged perpetrator to the victim’s family and to the chief. The partner organisation has done a significant amount of work to educate traditional leaders about rape and gender-based violence as crimes. Some of this work has occurred within the context of the cross-sectoral working forum and some in separate processes. For instance, the organisation has facilitated forums with tribal leaders, police and an external expert—such as the district prosecutor—to encourage the referral of cases to the appropriate authorities. The observation of a staff member interviewed is that there has been an increase in the percentage of rape cases reported to the police in the “areas that we have been focussing on since we started” and a reduction in the number of cases reported to the traditional court. The organisation has also run community forums on rights, duties and accountability with a particular focus on “the types of information [the community] are entitled to access”. One staff member explained that many people “didn’t know they have the right to ask about the [government’s] budget, to know about the budget—it was something in the possession of the officials and not supposed to be seen”. The CSO reported that community members are now able to be more confident in holding politicians and officials to account regarding the costing of election promises or proposals contained in the IDP for the area. The staff member also observed that community members are also more active in holding their CSO to account.

Case Study E: Supporting community led activism Staff of one organisation who participated in this study described an example of change that not only demonstrates the potential impact of sustained engagement with the community through the delivery of services, but also the interaction of power relations in multiple spheres of existence. The organisation has been active in a Limpopo township with a population of approximately 45,000 since the pre-democracy era, but began doing work relating to HIV in 1996. Its activities include running awareness campaigns, setting up support groups for people living with HIV, providing home based care for the sick and providing VCT for community members. The organisation was one of a few to begin providing ART prior to 2004 when, following the court case discussed below, the South African cabinet introduced the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa (hereinafter the Comprehensive Plan) requiring government provision of ART and Prevention of Mother to Child Transmission (PMTCT) through the public system6. Following the introduction of the Comprehensive Plan, the organisation established a “Wellness Clinic” that worked alongside the town clinic to provide sustained treatment, care and support (including ART and PMTCT) to those living with HIV and AIDS as well as integrating treatment for TB co-infection. Data collected at the clinic demonstrates significant impact, with up to 98 percent of pregnant women referred to the clinic taking up triple therapy7 in 2008-2009—all of whom delivered babies with negative HIV status8.

6. The organisation’s collection and dissemination of data to support the Treatment Action Campaign’s (TAC) case against the government is discussed in “Case Study E”. 7. Triple therapy refers to any 3-agent antiretroviral regimen. Evidence suggests that the use of multiple agents of different classes is thought to improve the probability of a positive outcome. 8. Proposal to Oxfam Australia, 19 July 2009, pg. 1.

In the aftermath of the global financial crisis, funding for the Wellness Clinic was reduced and the organisation met with the Limpopo Provincial Government’s Department of Health and Social Development (DoHSD) who indicated that the clients of the Wellness Clinic would be transferred to the provincial hospital system. The organisation convened a meeting to communicate the news to the community and many of the township residents—particularly those living with HIV and accessing services at the clinic—protested the move. Many people began to contact the doctor in charge of the province’s antiretroviral (ARV) program. He was unable to influence the decision and some community members asked the staff of the OHAP partner organisation to advocate on their behalf. The staff agreed that this was a matter for the community and that they were unable to interfere, however they did refer the community to the appropriate complaints mechanisms for the Premier’s office, the office of the members of the executive council (MEC) and the Batho Pele process. The community commenced with a number of campaigning activities including a letter writing campaign to the Premier’s office, calling the provincial government’s “ombuds-phone line” and staging protest actions and toyi-toyis9. The messages called for the provincial government to fund the Wellness Clinic and for it to remain under the administration of the CSO. These messages were eventually delivered to the doctor in charge of the province’s ART program by way of his seniors. He then contacted the organisation to arrange a meeting with staff and community members. As one staff member explained he “had all those letters and didn’t know what to do… he felt that the community needed to be helped, but he didn’t know how until he came here and we said that we can do our part.”

While the organisation concerned did not initiate the protests or letter writing campaign, they provided a viable alternative to the provincial government at the right time. The government had responded to the protesters’ demands and seemingly recognised the claims by community members that the standard of care provided to clients at the Wellness Clinic could drop significantly if their cases were absorbed into the state run hospital system. However, the provincial government was not in a financial position to provide full funding to the clinic, nor was it capable of administering the clinic separately from the hospital system. The participating CSO was able to negotiate a Memorandum of Understanding (MOU) outlining the terms of the partnership between the Limpopo Provincial Government and their organisation in order to keep the Wellness Clinic functioning under the administration of the organisation. In April 2010, the clinic was “handed back” to the community and the cases restored to the participating partner organisation by the government hospital. Put simply, the terms of the agreement require that the Government will: • • •

provide ARVs according to provisions made in the South African National Antiretroviral Treatment Guidelines 2010 (the National Guidelines); cover all the costs of blood collections to be done (according to the National Guidelines) for patients; and provide treatments for opportunistic infections through the Primary Health Care Clinic (PHCC).

9. Toyi-toyi is a southern African dance accompanying protest chants. It was used also used as a form of protest against apartheid in South Africa.

SECTION 3: Findings and Case Studies . . . continued In turn, the obligations of the CSO concerned are to: • • •

see patients and treat them according to the National Guidelines; pay the doctors whom it contracts to work at the Wellness Clinic; work together with the local clinic and provide the government with statistics and Monitoring and Evaluation (M&E) of the program.

The costs of any additional treatments provided outside those stipulated in the Guidelines will be incurred by the CSO, but outcomes of any importance will be shared with government if they are of enough significance to influence government policies and shape further iterations of the National Guidelines. This approach is consistent with the desire expressed in the Guidelines for local CSOs and government to conduct joint research projects and to share significant findings. While the outcomes of current trials will not become clear until trends emerge in the data gathered at the Wellness Centre, this set of clauses included in the MOU formalises, at least in theory, a partnership with the Provincial Government. The CSO is subsidised by Government to conduct its core work in alignment with national standards but is also allowed the space in which to trial innovative treatments and treatment combinations. This result is important for a number of reasons: Active Citizenship: Some conservative commentators claim that South African society has recently become characterised by a disengaged and apathetic citizenry (Geffen, 2010: 194), unprepared or unable to assert claims to their rights. However,

in this instance the community mobilised in an organised and appropriate manner to protest the removal of a service, an act that many claim would compromise not only the health of those living with HIV, but the wellbeing of the community more broadly. As one interview participant explained:

“So this is the community [that got the Wellness Clinic back], it is not us. We tried but it didn’t work with negotiation and talk. But once the community took it up it just came off.” This example of community action to influence change seems to contradict the assertions of those who claim that many South Africans are politically disengaged. While it is not within the remit of this report to assess whether this is or is not the case, it is interesting to note the observations of the organization involved in this regard. When asked whether the community had always had such confidence to initiate a campaign asserting their right to health, one staff member (who is also a resident of the local township) responded that the community:

“have that confidence because when we talk about the health of the community the community stand up and fight for themselves, for their rights. They confront everybody to talk about their health and to assist themselves… I think [this has come about] because we conduct awareness everyday and we give the information to the community.”

It is difficult not to attribute—at least in part—the confidence evident in the community to the activities of the organisation concerned. As suggested by the interview participant, the delivery of accurate information about HIV, AIDS, STIs and TB specifically, and related issues such as nutrition has provided the community with the information necessary for them to be confident in making decisions about their health. The value placed in the Wellness Centre by the community members serves to demonstrate the degree of trust that the organisation has established in all sections of the community since forming in 1984 as a support agency for democracy activists imprisoned under the apartheid regime. Further, as an annual report10 by the organisation points out:

“the work carried out in the community over the past years has brought the levels of stigma and discrimination down in the community. This has become very visible in the way PLWHA have come forward to express their feelings about the way the handover of the Wellness Clinic was handled by the Department. There was no fear at all to stage protest actions and toyi-toying.”

Stigma and Discrimination: This quote neatly summarises much of the content of the interview with staff from the CSO concerned. It demonstrates that in combating stigma and discrimination through the strategies discussed in “Attitudinal Change: stigma, discrimination, gender and culture” above, many CSOs supported through OHAP engage with power relations articulated in a spectrum of structures—from formal institutions such as the provincial DoHSD through to those that find expression at the most personal level; impeding, for instance, an HIV positive woman or man’s freedom of expression or movement. Even in situations where the CSO or members of the community in which it works seek to influence change through engaging the most formal of structures, this work is supported and enabled by the previous and sustained engagement with the informal power structures that determine and protect cultural and religious beliefs resulting in stigma and negative discrimination against those living with, thought to be living with, or affected by HIV.

10. Proposal to Oxfam Australia, 19 July 2009, pg. 18.

SECTION 3: Findings and Case Studies . . . continued

Case Study F: Working in alliances

The National Director of Multi-Drug Resistant (MDR)-TB, TB and HIV in the National Department of Health (TB Cluster) has a longstanding connection to the work of the organisation discussed above. He has previously been employed by the DoHSD in Limpopo province as a medical officer then superintendant of the hospital closest to where the CSO operates. He became a board member of the CSO and subsequently became involved in the organisation’s activities. These included seeing patients on a weekly basis, travelling to other community based treatment programs with senior staff to learn from the practice of other NGOs implementing ARV (including PMTCT) treatment prior to the introduction of the Comprehensive Plan in 2004. He has coauthored, with the Director of the participating organisation, a number of journal articles presented at conferences in the region and globally. The interview with a government official provided the opportunity to clarify the subtleties and details of the complex and multiple processes of change described in a relatively short meeting with CSO staff. It also provided a high level perspective of how the national government may view the role of civil society actors such as large advocacy groups like the Treatment Action Campaign (TAC) and small service-delivery organisations such as the one discussed in the previous case study. The line of questioning focussed firstly on his perspective on the key challenges experienced between 1994 and 2007 in the fight against HIV, AIDS and TB in South Africa, then tried to characterise the role of civil society in addressing these challenges. Secondly the questions focussed on the period of the current NSP and asked identical questions about the role of CSOs.

The key challenges in the fight against HIV and AIDS in the period from 1994 to 2007 were identified, at first, as a “lack of direction” under the first Government of National Unity (GNU) in relation to the HIV/AIDS epidemic. This has been publicly acknowledged by former President, Nelson Mandela, who has since provided strong support to the cause. Following Mbeki’s rise to power in 1999 challenges of a different nature became obstructive to the implementation of the new HIV/AIDS and STD Strategic Plan 2000-2005. The most substantial of these obstacles was the continual denial by Mbeki that HIV causes AIDS and his then Minister for Health’s refusal to design and adopt a public sector plan for the treatment of HIV/AIDS with ARVs. The Minister, Dr Tshabalala-Msimang cited the toxicity of the drugs and instead promoted the efficacy of treatments including the consumption of beetroot, garlic, lemons and other nutritional interventions (Geffen, 2010: 70-72). The introduction of a policy establishing the national government as the primary duty bearer for the delivery of ARV treatments to people living with HIV and AIDS was eventually forced by a campaign of mass mobilisation, civil disobedience and, importantly, a successful court case brought by TAC against the government arguing that ARVs should be provided to pregnant women through the public sector for PMTCT. According to the interviewee, service-delivery organisations of all sizes were able to play a significant role in bringing about this change as they supported TAC in a number of ways. These included publicising the activities of TAC amongst the communities in which they worked, facilitating popular mobilisation, data collection and the sharing and dissemination of this information. For instance, the ground-breaking Medicins Sans Frontiers (MSF) project in Khayelitsha, Western Cape began providing ART in 2001. The director of the organisation that participated in this research visited the project with the interviewee in 2003

and soon began providing ART and PMTCT in their own context, collecting data on its impacts and sharing these with TAC, officials within the health department and other organisations. In his opinion, “TAC managed to win the case because smaller NGOs collected data and published evidence. This supported TAC in winning the case.” The current NSP is widely regarded with general acclaim however, in the interviewee’s opinion, it never articulated a clear direction of how ARV treatment could be integrated with primary health care service delivery. Likewise, although the plan states that testing and care for TB should be integrated with HIV and primary health care, there remains a tendency to over-centralise and separate testing and treatment of HIV and TB within the hospital system. In his opinion this is at odds with best practice as TB treatment is best located within local PHCCs which are able to effectively provide tracking services and adherence support. Again, organisations such as the one that participated in this research provide models for this type of integrated, community level care. Data collected by this organisation and others doing similar work is shared with individuals within the national Department of Health and these directly and indirectly influence recommendations for changes in policies and treatment guidelines.

participated in this research had, through information sharing with influential individuals, larger campaign organisations and various government departments, indirect influence over the development of evidence-based treatment and PMTCT guidelines. In more general terms this case study also implies that civil society plays a vital role in influencing reform of government policy. Relationships with allies within government structures are often undervalued; however, this example demonstrates that they can be key to bringing about changes with broad-reaching impacts.

Within the new political context, brought about by the replacement of the previous health minister, CSOs are also able to influence change through more formal processes of partnership with government departments. This is exemplified in the 2010 review of the National Guidelines. The Department of Health consulted with civil society on the draft guidelines and inputs were in many cases incorporated. According to the interviewee the Government “relies on technical input from small organisations”. This suggests the CSO that

PHOTO ÂŠ Matthew Willman | Oxfam

SECTION 4: Theories of Change The case studies above provide some examples of how OHAP partner organisations that identify their core work as service delivery have employed strategies to influence change. This report has tried to place the examples in the context of the other work of the participating CSOs in an effort to demonstrate how “advocacy” activities are related to, support, and are supported by the delivery of other program activities. In analytical and abstract terms these activities, the assumptions underpinning a theory of how power operates and how change occurs in a particular context represents a “theory of change” (TOC). Most organisations who participated in this research reported that they were not trying to do advocacy work so it is unlikely that they explicitly think about their work in the abstract terms of the TOC approach. However it is obvious from the examples that, in many instances, the staff of partner organisations negotiated complex power relations in order to create the space in which they could do their work.

Rao and David Kelleher of Gender at Work in their 2005 article “Is There Life After Gender Mainstreaming?”. This framework has also been adopted in a similar form by Oxfam Canada to form the conceptual basis of their analysis of gender inequality. The assumption shaping Rao and Kelleher’s “integral framework” (see Figure 1) is that in order to effect long term, sustainable and real change in the lives of women and men, the social systems and institutions—which they define as the social and political rules dictating “who gets what, who does what and who decides” (2005: 59)—must be transformed. The framework presents a model of the various spheres in which change needs to occur in order to achieve this transformation.

Figure 1: The Integral Framework INDIVIDUAL LEVEL

The section below outlines some theories of change that seem applicable to the context in which OHAP partners operate, and bear some resemblance to those implicit in the examples offered by the organisations that participated in this research.

The Integral Framework The examples identified by participants in this research demonstrate that although the core work of their organisation is the delivery of services to communities with which they work, they regularly engage with power structures at various levels to influence change. What is referred to in this document as “informal” and “formal” power structures broadly aligns with part of a more comprehensive theory of change articulated by Aruna

INFORMAL

WOMEN & MEN’S CONSCIOUSNESS

WOMEN & MEN’S ACCESS TO RESOURCES

NORMS & EXCLUSIONARY PRACTICES

FORMAL INSTITUTIONS, LAWS & POLICIES

FORMAL

SYSTEMIC LEVEL

SECTION 4: Theories of Change . . . continued One strength of this approach is that it questions assumptions that change in one area, such as the formal/systemic arena of health policy reform, necessarily results in improvements in the ability of individuals to access services. Likewise, “it is possible to have material resources, but no influence… [or] to be ‘economically empowered’ but not be free from violence” (Rao & Kelleher, 2005: 61). In the context of South Africa the disconnect between policy and practice is well documented (Wouters, van Rensburg & Meulemans, 2009) and the effects of this disconnect, as it impacts on those living with or affected by HIV, were identified by all research participants as one of the most significant challenges their programs seek to overcome. While the integral framework was developed by Gender at Work specifically in relation to gender equality and women’s empowerment, the model is useful beyond gender specific work and has particular relevance to programming in the area of HIV and AIDS. As the examples identified by participating partner organisations demonstrate, in addition to the substantive work of service delivery—which effects change in the objective conditions of the individuals they work with—their organisations frequently influence informal power relations at the individual level of knowledge and the systemic structures of the home and community. Running door-to-door awareness campaigns, or integrating HIV and AIDS or gender awareness messages into adult literacy programs builds women’s and men’s awareness of their rights and supports their capacity to make informed choices around HIV prevention, testing, treatment and care. But the power relations constraining the ability of individuals, particularly women and children, to claim and protect their rights, negotiate condom use or access health services are not only evident in

the formal arena of policy and legislation. They are expressed through informal cultural and religious norms produced and protected by systemic structures such as the church and tribal leadership and articulated in the gendered relations of the home. Theorists and practitioners have argued that the weakness of traditional management theory and organisational development thinking and practice (when applied to organisations working within Southern contexts toward social change) “is that it does not explicitly deal with power dynamics or cultural change” (Rao & Kelleher, 2005: 58). For this reason, the integral framework provides a useful analytical tool to interrogate the distinction between the “public sphere”—in which activities such as advocacy and campaigning can influence changes in policy and legislation—and the “private sphere” of individual behaviour. Just as work on gender inequality and women’s empowerment engages with power relations that run through structures as diverse as the home, community, organisations, market and states, so too does work relating to HIV and AIDS prevention and care.

Social Accountability The current literature on accountability and public sector reform offers suggestions for the engagement of civil society to maximise accountability of duty bearers to poor people for the delivery of services. In an article entitled “Producing Social Accountability? The Impact of Service Delivery Reforms”, Anuradha Joshi asserts that “[w]hen collective actors participate in service delivery reforms, they are more likely to engage in social accountability actions that monitor reform implementation as well as increase the uptake of reforms by

people” (2008: 10). In the context of HIV and AIDS in South Africa, the “social accountability” approach may be of interest given the relatively recent changes in the political context in which HIV policy is generated and implemented. Joshi defines the polity as “the space within which political struggles across the public-private divide take place and through which both state and societal capacities and natures are shaped” (2008: 15). This implies that the polity is shaped not only by the arrangement of government institutions and the content of its policies, but is both shaped and determined by the arrangement and style of engagement of other collective actors such as civil society. For this reason, according to Joshi, “formative moments of reforms matter. Collective actors who are able to engage in the reform process are able to ‘engineer fit’ between the reforms and their own capacities” (2008: 15). In other words, if a government is inclusive and open to the input of civil society and communities, groups and individuals can participate in shaping reform, monitor its implementation and increase people’s capability to access the related services. In the context of HIV and AIDS in South Africa the government has not always been a partner in reform and program implementation. A brief look at the relationship of civil society to government in the recent past illustrates how collective actors can organise in particular ways in response to the context in which they operate. This is also useful in helping to illustrate the risks and benefits of engaging with government in a different way given the current arrangement of the polity. Despite a relatively progressive policy framework relating to the prevention, treatment and management of HIV in South Africa, the stance of the then President Thabo Mbeki and his Minister of Health regarding the cause of AIDS and the efficacy of ART resulted in the state eschewing its responsibility to

deliver treatment to people living with HIV, or medication for the prevention of mother to child transmission. In order to bring about change in this environment, civil society adopted an oppositional stance most visible in the campaign of mass mobilisation, civil disobedience and litigation spearheaded by TAC. Using the judiciary to force government to adopt legislation represents a victory in bottom-up policy making. It can be argued that it also forced a change in the arrangement of government and that this presents an opportunity for civil society to influence and engage with government in a different manner. Wouters, van Rensburg and Meulemans argue that the schism between civil society and the state during the term of Mbeki’s leadership;

“ruled out any broad-based social response to the epidemic. The process of policy making was overshadowed by increasingly antagonistic and intransigent positions for the Government and civil society, which made successful policy implementation virtually impossible” E. Wouters, HCJ van Rensburg & H. Meulemans, 2009: 176 The authors suggest that the subsequent revival of the Inter-Ministerial AIDS Council, the restructuring of SANAC and extensive consultation relating to the NSP reorientated the relationship of government and civil society groups in South Africa (2010: 178). This change of dynamic is interesting for a number of reasons. Firstly, it may help in demonstrating why participating OHAP partner organisations employed particular

SECTION 4: Theories of Change . . . continued influencing strategies in a particular context. It could also indicate ways for OHAP and its partners to arrange themselves and plan strategically for ongoing and sustained engagement with government in relation to health systems policy more broadly as well as those directly pertaining to HIV. One influencing strategy employed by most organisations that participated in this study involves establishing informal alliances with key actors within institutions. Joshi claims that:

“[a]t the heart of social accountability strategies are alliances formed across the public-private divide, which enable societal actors to gain leverage (through information, access etc.) vis-a-vis the state. These can occur through societal actors occupying [positions within] the state over time... [o]r they can occur through the forging of alliances between societal actors representing the poor and sympathetic reformists/groups with the state.” Joshi, 2008: 14 This strategy is evident within examples cited in this research. Several organisations referred to alliances formed with strategic members of traditional leadership and the church; “gatekeepers” that, for instance, facilitated access to communities and incorporated accurate messages relating to HIV and helpful information regarding gender, sex and sexuality when

addressing their constituency. In one example, the organisation used their professional association with a senior government employee to ensure that data and evidence collected from their HIV/TB co-infection, ART and PMTCT programs was channelled through the correct channels to ensure it informed—and potentially influenced—the review of the National Guidelines. Several organisations also cited social audits of community satisfaction with public sector service delivery as a strategy to bring about increased accountability by government departments to rights holders. The Batho Pele audit not only presents a culturally appropriate and accessible way to educate people of their rights in the South African context, it also provides a mechanism whereby community members are able to monitor the performance of duty bearers in delivering on their obligations. In the example outlined in the case study above, the use of media to publicise the results of the survey represents a strategic decision to engage with government in a particular way. The partner reported that the strategy—and a number of external political factors—not only resulted in better outcomes for community members, but forced the government to engage in a more constructive way with civil society. The organisation claims that they now have a more inclusive and responsive working relationship with government. It was also noted that community members report a greater level of transparency at DoHA and have noticed improvements in the efficiency with which applications for identity documents are processed. This example demonstrates that, in the context of a nonresponsive and obstructive government, a public campaign of naming-and-shaming the relevant duty-bearer can be the most effective mechanism to bring about change. In this instance, civil society adopted an oppositional stance to bring about change; however, this tactic did not occur in isolation.

The careful collection of data and the willingness to engage constructively with government also allowed the organisation to capitalise on the moment of reform. They now partner with government in the implementation of the changes in policy by assisting communities in accessing government services properly. The continued use of the Batho Pele framework also operates as a tool to assess community satisfaction with services, allowing both the organisation and government to monitor the implementation of the changes and to continually build awareness amongst community members of the services available to them. Budget tracking is another social accountability mechanism discussed by Joshi that was cited as an influencing strategy by OHAP partners participating in this research. According to Wouters, van Rensburg and Meulemans, it is an important factor in the successful implementation of the NSP. They write that “[i]ncreased monitoring of budget spending and the corresponding strengthening of the provincial health care systems are required to bridge the gap between the ambitious policy document [the Comprehensive Plan] and the reality in the field” (2010: 178). In the context in which many OHAP participants work, facilitating this kind of work is not a simple matter, with one partner organisation reporting that many community members were surprised to learn that they have the right to access information about the budget and expenditure allocated to the IDP, particular government departments or to request information on what resources have been allocated by politicians to deliver on their election promises. The organisation concerned argues that this is part of a related group of challenges in encouraging community members to engage in democratic processes addressed through their governance program outlined in Case Study D.

Joshi refers to social accountability mechanisms as strategies to achieve “long route accountability” vis-a-vis the “short route accountability” exercised through the ballot box. Several characteristics of the South African political context indicate that favouring non-electoral accountability mechanisms— such as those identified by Joshi and OHAP partners who have participated in this study—may be effective ways of engaging government and other actors on policy and practice reform relating to HIV and AIDS. Most obviously, the ongoing domination of the African National Congress (ANC) in electoral polls does not establish an environment whereby politicians have strong electoral based incentives to improve service delivery systems. Joshi also cites “lack of information on the performance of politicians, social fragmentation along religious and ethnic lines and a lack of credibility among the population about political promises” (2008: 12) as factors that contribute to a climate in which vertical accountability mechanisms such as elections are not, in isolation, the most effective ways for citizens to hold duty bearers to account. While using the judicial system to effect change has resulted in significant changes in the South African context, the high risk and resource intensive nature of litigation can be prohibitive in many instances. When considered in light of Rao and Kelleher’s Integral Framework, it is clear that several examples of OHAP partner influencing strategies demonstrate that efforts by partners to effect change within the individual and systemic spheres of “informal” power structures paid dividends when opportunities for partners or community members to influence change in the formal systemic sphere of policies, laws and institutions arose. For instance, when women and men living with or affected by

SECTION 4: Theories of Change . . . continued HIV found out that the government would be incorporating the patients from the Wellness Clinic into the provincial hospital system, they felt comfortable and confident to speak out, protest and negotiate with government. Not only had long term, sustained efforts made to combat stigma and discrimination resulted in a public sphere in which women and men could publically express their views without fear, the dissemination of accurate information about HIV and AIDS and related issues gave the community members the confidence to do so.

service delivery and awareness raising campaigns etc) by the CSOs concerned appears to have armed communities with the information necessary to confidently speak out. In the terms of the Integral Framework, ongoing work conducted by the partner organisations that focussed on the individual and systemic spheres of informal power structures assisted in creating a space in which peopleâ&#x20AC;&#x201D;particularly women and people living with HIVâ&#x20AC;&#x201D;were able to engage in political struggles without fear of violence or other kinds of abuse founded on stigma.

As Case Study D demonstrates, some individuals in particular contexts in which OHAP partner organisations work are hesitant to engage in political processes for fear of being perceived to be partisan or disloyal to family, religious or tribal allegiances. This hesitation presents a challenge to implementation of the social accountability measures discussed above. However, examples such as the grassroots campaign to have the Wellness Clinic returned to the community, the Batho Pele audit and the inter-sectoral governance forum suggest that this is not always the case. Access to information through awareness and sustained engagement with communities (by way of

If indeed the political context in which policy reform and program implementation relating to HIV and AIDS is occurring is conducive to sustained engagement by civil society and communities through social accountability mechanisms, it is essential to continue work in all spheres where unequal power relations exist. By working with communities to increase awareness of their rights, information about their health, transforming gender relations and reducing the effect of stigma and discrimination, people can have the confidence to more effectively engage in actively holding duty bearers to account.

PHOTO ÂŠ Matthew Willman | Oxfam

SECTION 5: Conclusion and Recommendations “[T]he Government alone, and especially the national Department of Health on its own, is unable to develop and implement a comprehensive and successful strategy against HIV/AIDS” E. Wouters, HCJ van Rensburg & H. Meulemans, 2009: 179 It is impossible to successfully deliver HIV prevention, treatment, care and support programs without engaging in advocacy work. For all the OHAP partner organisations that participated in this research, advocacy has been essential in creating and protecting the space and conditions for them to carry out their work. Engaging with government and other bearers of power such as traditional leaders and religious institutions has also been important in addressing systemic and ideological structures that increase women’s and men’s vulnerability to HIV and its impacts as well as their ability to access the knowledge, resources, goods and services required to bring about sustainable change. The substantive service delivery and behaviour change work of partners working in the arena of access to resources and changing women’s and men’s consciousness is acknowledged and articulated through the appraisal and reporting tools used by Oxfam. However, the work of “service delivery” organisations is not confined to activities targeted at individuals. While the development of individual knowledge, skills and the transformation of consciousness to reduce vulnerability and encourage behaviour change on the one hand, and the delivery of services and programs to ensure equitable access to resources, safety and voice on the other are important aspects of their work, they are not the sum of it.

Thinking in terms of Rao and Kelleher’s Integral Framework (Figure 1), all partners explicitly engage with and negotiate power relations in three of the four quadrants. Their service delivery work occurs in the individual/formal arena of changing the material conditions of people living with or affected by HIV. What has been referred to broadly as “behaviour change” encompasses prevention efforts and the associated work by partners to transform individual beliefs and practices relating to gender, sex, sexuality and stigma and discrimination. All this work can be considered to operate in the individual/informal arena of women and men’s consciousness and intersects with efforts to change these beliefs as they manifest as norms and cultural practices in the informal/systemic arena of institutions such as the church and tribal councils. Advocacy and policy related activities were believed by many participating CSOs to consist of high-level engagement with (usually the national) government and to involve highly publicised campaigns. For this reason, some partners did not realise that they also work within the formal/systemic sphere of policies, laws and institutions to influence change. These activities, some of which are featured in the case studies above, are closely related to, support and are supported by partner activities in the other three quadrants. This could be one reason why participants did not explicitly identify them as advocacy—they were just doing what they needed to do to make change happen. In the terms of “social accountability” as outlined by Joshi, the examples of social audits framed around the Batho Pele principles, inter-sectoral governance forums, budget monitoring and engaging in public-private alliances (with allies inside or close to government) are all advocacy strategies to achieve

SECTION 5: Conclusion and Recommendations . . . continued “long-route accountability” and to engage in policy reform and implementation. This report argues that given the stance of the South African government to implement evidencebased prevention and treatment measures and to work with civil society in partnership, these strategies are appropriate in the current political context. This is of significance given the upcoming review of the NSP and processes such as the stalled consultation on the proposed Community Care Worker Management Policy Framework11. However, the engagement of OHAP partner organisations who participated in this research with government seems to occur largely on an ad hoc basis. The 2004 mapping of OHAP partner advocacy activities also found that advocacy occurred on a reactive basis with little strategic or coordinated thinking (Moodley, 2004). Figure 2 summarises the levels in which advocacy activities occur within OHAP. The mechanisms and forums in which these occur are discussed below (corresponding to groups A, B and C in Figure 2) and recommendations made on how to capitalise on existing capacity to influence change within Oxfam and its partners. Recommendations are also made for policy and advocacy engagement by Oxfam in South Africa (D).

A. “Service Delivery” Organisations Supported by Oxfam Partners supported through OHAP to provide services to people living with or affected by HIV frequently engage in influencing activities in a number of realms. In some contexts, there may be value in differentiating between strategies to influence change

at the individual/informal, systemic/informal and individual/ formal levels from those that seek to use advocacy and policy engagement activities to influence policy and practice at the formal/systemic level. However, in many contexts it is also helpful to demystify the technical language used to discuss these activities and to consider the interrelated nature of different strategies in addressing problems. If unequal power relations are at the heart of challenges to bring about sustainable change at all levels, then an integrated theory of change is required to ensure that Oxfam and its partners are most effectively addressing these challenges in a sustainable way.

“immediately when you explained that advocacy is not only at the high level, I mean it was like an eye opener for me because after all these years I did not know that. So maybe that is something we can get some training on from Oxfam to make people aware that we are doing something in advocacy.”

11. In 2009, the national Department of Health conducted a brief consultation on the proposed Community Care Worker Management Policy Framework (draft version 6) which intends to address the implicit and explicit responsibilities of the departments of Health and Social Development to community care workers (CCWs) funded by nonprofit organisations (NPOs). Seven OHAP partner organisations contributed to a joint submission to the Department. The process was facilitated by Oxfam in South Africa.

Recommendation 2 >

Recommendation 4 >

Advocacy training should continue to be provided to partner organisations and Oxfam’s program management staff. This training should be conducted in a way that acknowledges the existing experience and contextual knowledge of partners and staff. Examples of where partners have used strategies to influence change should be used to develop a shared language of power, influence and change that demonstrates the mutually supportive relationship between “service delivery” and “advocacy” activities before engaging with technical jargon.

The existing influencing work conducted by OHAP partners with religious leadership, traditional leadership, and all levels of government should be resourced where appropriate. Relationship building and advocacy activities require resources and are often conducted in addition to a full workload. If sustained and concentrated engagement on a particular issue or set of issues is deemed a priority by a partner and Oxfam then resources should be requested through the proposal process and provided, funds permitting, to avoid ad hoc engagement.

Recommendation 3 >

B. Advocacy and Campaign Organisations Supported by Oxfam

In order to ensure that the influencing and advocacy work of OHAP partners is captured through regular reporting mechanisms, Oxfam’s program management tools should be reviewed to allow space for information on what challenges partners experience or have experienced in successfully implementing their programs, and how they sought to overcome these challenges. The current reporting requirements against the program’s policy and practice change objectives are difficult for partners to complete without prior knowledge of the language used to describe advocacy and policy engagement activities. If Oxfam’s proposal, appraisal and reporting documents allow partners and staff to think more about how they work to influence change and achieve planned outcomes then Oxfam and the organisations it supports would gain access to a greater depth of information.

The work of national level advocacy and campaigning organisations has value in and of itself. However, as the work of the TAC and the discussion contained in this document regarding working in alliances demonstrates, there is significant value in locally based “service delivery” organisations and national level advocacy organisations working together.

SECTION 5: Conclusion and Recommendations . . . continued Recommendation 6 > Resource organisations with expertise in particular thematic policy areas to participate actively in or lead an alliance of OHAP partners through the existing Communities of Practice model.

C. Communities of Practice When providing feedback on the usefulness of the joint workshop conducted for this research, partners expressed that the main benefit was to hear what other groups were doing to deal with similar issues. Interventions by particular partners may be context specific, however, sharing of ideas and experiences can result in alternative strategies being employed if success has not been forthcoming. Many local problems are related to national, regional or international processes and communicating with CSOs operating in different locations and/ or engaging at these different levels can result in powerful alliances linking organisations with local experience to national or global campaigns. As the examples in this research suggest, relationships between civil society groups, CSOs and communities, and between partner organisations and allies within government are important factors in bringing about change. The Community of Practice model demonstrates some potential in this regard.

Recommendation 7 > The Community of Practice and Link-and-Learn models currently used by Oxfam in the management of OHAP should be continued and expanded, with an active role for Oxfam at a programmatic

level to facilitate alliance building between partners working on similar issues along with advocacy and popular mobilisation training (see recommendation 3).

D. Oxfam Advocacy and Campaign Activities Oxfam Australia has been responsible for the management of OHAP for over ten years. Historically, it has not engaged directly with government on South African policy matters, opting instead to support the work of partner organisations in this regard. There is no doubt that supporting South African organisations to engage with their own government has value and that these efforts have been noted by partners to be an empowering experience. However, the political context is constantly changing and there may be some instances where it is appropriate and strategic for Oxfam to act in its own capacity. As demonstrated in the Theory of Change section of this document, engagement with moments of reform such as consultation processes can prove to be valuable as long as the conditions for sustained engagement are in place. If OHAP is considered to be an alliance of South African civil society groups working on HIV and AIDS related issues, then Oxfamâ&#x20AC;&#x201D;with its access to knowledge of trends occurring at the national and international level, its resources and expertise in advocacy and campaigningâ&#x20AC;&#x201D;plays a key role in that alliance.

Recommendation 8 > Continue to work with partners and allies to monitor political developments and opportunities.

Recommendation 9 >

Recommendation 10 >

Provide technical, legal, logistical and financial support (as required and available) to ensure that appropriate partners are able to engage in key moments of policy reform and to sustain that engagement in order to monitor policy implementation processes. Sustainability issues should be addressed by lobbying government to appropriately resource any ongoing partnership with local civil society groups.

Where no single advocacy organisation or coalition is working on a particular issue of relevance to partners, Oxfam should consider— in consultation with its partners—using its advocacy and campaigning resources and expertise to advance these issues at the national level or to open a space for partners to do so. These advocacy, campaigning or policy engagement activities by Oxfam should not be to the exclusion of South African civil society but, instead, should be complementary and mutually supportive.

Figure 2: Levels of engagement with institutions by Oxfam and partners

Oxfam HIV and AIDS Program

B. Advocacy and campaign orginisations supported by Oxfam

GOVERNMENT NATIONAL

PROVINCIAL C. Communities of Practice

A. “Service delivery” orginisations supported by Oxfam

MUNICIPALITY

RELIGIOUS ORGINISATIONS TRADITIONAL LEADERSHIP

REFERENCES Department of Health, 2009, Community Care Worker Management Policy Framework 2009 (Draft Version 6.0), Department of Health, South Africa.

Mullick, S. Teffo-Menziwa, M. Williams, E. & Jina, R. 2010, “Women and Sexual Violence”, South African Health Review 2010, Health Systems Trust, South Africa.

Deacon, H. Uys, L. & Mohlahlane, R. 2009, “HIV and Stigma in South Africa”, in P. Rohleder et al. (eds), HIV/AIDS in South Africa 25 Years On: Psychosocial Perspectives, Springer.

Nattrass, N. Mortal Combat: AIDS Denialism and the Struggle for Antiretrovirals in South Africa, 2007, UKZN Press, Durban.

Geffen, N. 2009, “Justice After AIDS Denialism: Should there be prosecutions and compensation?”, Journal of Acquired Immune Deficiency Syndromes, Volume 51, No. 4, August, pp. 454–455. Geffen, N. 2010, Debunking Delusions: The Inside Story of the Treatment Action Campaign, Jacana Media, Johannesburg. Gouws, A. (ed), 2005, (Un)thinking Citizenship: Feminist Debates in Contemporary South Africa, Aldershot, Ashgate. Joshi, A. 2008, “Producing Social Accountability? The Impact of Service Delivery Reforms”, IDS Bulletin, Vol. 38, No. 6, pp. 10–17. Ologe, I. 2010, The Roles of Power Bearers in the Prevention, Control and Management of HIV and AIDS, internal Oxfam literature review. Moodley, P. 2004, Advocacy Mapping of JOHAP Partners in Limpopo and Kwa-Zulu Natal, Oxfam Australia.

Rao, A., & Kelleher, D. 2005, “Is There Life After Gender Mainstreaming?”, Gender and Development, Volume 13, No. 2, July, pp. 57–69. Schwella, E. 2001, “Public Sector Policy in the New South Africa: A Critical Review”, Public Performance & Management Review, Vol. 24, No. 4, June, pp. 367–388. Wouters, E. van Rensburg, HCJ. & Meulemans, H. 2010, “The National Strategic Plan of South Africa: what are the prospects of success after the repeated failure of previous AIDS policy?”, Health Policy and Planning: A journal on health in development, Volume 25, No. 3, May, pp. 171–185.

Web-based References: http://www.info.gov.za/documents/ constitution/1996/96cons9.htm (accessed April 2011) http://www.etu.org.za/toolbox/docs/localgov/webidp.htm (accessed April 2011)

PHOTO ÂŠ Matthew Willman | Oxfam

Acknowledgements The author would like to acknowledge the input and support of the individuals and organisations listed in alphabetical order below:

> Angela Smith > Bridgette Thorold > Chrisanta Muli > Comprehensive Health Care (CHoiCe Trust) > HIV and AIDS Prevention Group (HAPG), Bela Bela > Iyinoluwa O. Ologe > Jacquie Lee > Justice and Women (JAW) > Josef Gardiner > Kate Simpson > KwaZulu Regional Christian Council (KRCC) > Dr Norbert Ndjeka > Operation Upgrade > Sinani > Staff of Oxfam in South Africa > Tholuwazi Uzivikele (TU)

PHOTO ÂŠ Matthew Willman | Oxfam

www.oxfam.org.au

2012