The Incoherent State of HIV/AIDS Development Initiatives in South Africa

The National Development Plan: A vision for 2030; UNAIDS and the NSP all share the ambition to “end AIDS by 2030”. However, they fail to provide a clear epistemological pathway to achieve their ambitions. Traditional scientific inquiry has struggled to overcome the challenges of complex realities and change. This article discusses the shortcomings of the current developmental apparatus so we may begin to envisage complexity thinking as a genuine course that responds to the complex and nonlinear dynamics of the HIV/AIDS epidemic and our developmental goals. This will depend on our ability to recognise that there is a substantial disparity between our developmental plans and policies, and the realities on the ground.

The disconnect between our developmental plans and policies and the realities on the ground that are inhibiting our efforts towards developmental goals

With the current narrative of developmental management, we are unlikely to reach the shared vision to ending AIDS by 2030 because it is structurally inappropriate to tackle the complexities of the current social epistemology of the South African HIV/AIDS epidemic and its associated external drivers.

There is a growing consensus of the need for innovative biosocial responses that make sense to local communities (1). Multiple arguments and statements from professionals and scholars in public health have realised that aspects of the HIV/AIDS epidemic are characteristic of complex systems – a notable argument can be found in the UNAIDS 2014 document, The Gap Report, which details the complexities of the epidemic and highlights the importance of novel bio-social response if we are to end AIDS by 2030. Despite this compelling argument, complexity has yet to be widely integrated into development policies and community-based management strategies (2).

The pressure for development and social change to self identify as evidence-based fields with rigidity has meant the meticulous utilization of reductionist techniques/science in order to quantify links between causes and explicitly definable health outcomes (Rychetnik and Wise, 2004; Brownson et al., 2009) (3).

In a summary of four generations of dominant community-based HIV management strategies, (Campbell & Cornish 2010) argued that the reason ‘first and second-generation’ interventions failed to achieve the goals they had set out was because they were often developed by external experts and imposed on communities in a ‘top-down’ fashion (4). These ‘one-size-fits-all’ interventions were ill-suited to resonate with local sentiments, perspectives, sensori-memorbilia, and the perceived needs and interests of the target communities (3). These interventions were insufficiently concerned about the complex social relations in which the programmes were implemented in (1).

“Complex adaptive systems are created and owned” by the agents who make up the system, yet Burman et al. (2013) argues that developmental initiatives are usually found at the periphery of the historically entangled and self-organising communities that they are implemented in (5). In addition to being distanced from the core of the complex adaptive system, the development initiative is restricted by its own internal logic - technical and linear forms of social theorising, driven by processes of path dependence and entrained thinking. This internal logic does not fit in neatly with the ‘causal thicket’ that characterises HIV/AIDS epidemiology, and consequently, the developmental capacity is restricted by the structural constrains of technical development paradigms. These paradigms are inadequate to respond to contemporary emergent problems and the “social dynamics” mentioned by the NDP. This has been partially responsible for sustaining – or even reducing - the “glass ceiling of developmental impact” (5).

The internal logic of current technical developmental policies and public health practitioners

Three centuries of social normalcy, informed by Descartes and Newtonian logic, have accustomed a method of thinking that seeks and prioritizes a distinctive and clear truth, regardless of the context. Through reductive thinking patterns, society has become inhospitable to any form of integration, ambiguity, or paradox. Accepted logic requires an understanding of systems in such a way that they are broken down or reduced into their simplest components and scrutinized separately. Further, these separable and independent components are assumed to follow a linear cause and effect relationship and that these relationships can be reversible. A system and its parts are therefore completely knowable with a future that can be determined, and from a decision-making perspective where it is possible to “get it right” and “reverse it” in case of an error. This implies that the decision-making process can be directly or indirectly controlled. The implications for problem-solving mean that if “getting it right” in theory is achievable, then stakeholders will rightfully look to policy makers and implementers to do so (6).

Most South African development initiatives currently operate with the presumption that citizens will act as neat and tidy variables in a linear equation responding to external inputs in expected ways, with no consideration of the context that the development initiative is implemented in. Burman et al. (2013) asserts that public health practitioners seem to have an attitude that suggest communities will remain static while they probe, diagnose, assess, plan and attempt to implement activities designed to fundamentally change people’s behaviours in complex landscapes (5).

The traditional approach of prevention programmes disseminating information were based on the assumption that individual knowledge can result in behaviour change because individuals are rational agents who will always behave in their best interest. These approaches emphasised improving individual’s levels of self-efficacy while not considering the social complexity of the HIV epidemiology that individuals are in (7).

The difficulty in confronting the “causal thicket” of CAS and the lack of clear methodology from the social sciences have seen public health practitioners disregard the complex epidemiology of HIV. While the frustrations can be understandable, this disregard does not make complexity and uncertainty go away (8) (5).

How have communities made sense of this today?

Burman et al. (2013) argues that the repeated implementation of ‘more of the same’ type of development approach in hopes of improved outcomes, has seen an elevated sense of “emancipatory entitlement” from communities who are becoming increasingly more vocal to see meaningful changes in their immediate settings after many years of democratic rule. The recent historical failures and disappointments of development initiatives since 1994 has seen dwindling confidence in positive developmental outcomes that make sense in terms of their “social imaginary” with regards to democratic equity and redress (5). Most of these communities lie at the periphery of prosperity and are faced with modern and traditional forms of chronic poverty and a deep discontentment that permeates their daily routines. Despite the frustrations endured during this extensive perceived failure, the developmental landscape is still entrenched in “anticipatory expectations” from development that is based on the “histories of the democratic transition” (5).

A phenomenon that happens with some regularity and is completely unforeseen by decision-makers/planners, is for “community members to mobilise themselves and their networks around the goal of securing something from the development initiative” (5). Swidler and Watkins (2009) explain how donor’s insistence that CBO initiatives be self-sustainable has had the unintended affect of creating an irrationalizing environment that reinforces “a contingent, opportunist orientation among recipients” and encourages “hunting and gathering in [the] terrain of AIDS NGO projects” (9). Additionally, they reveal how during requests for resources in Malawi, it was found that there was “substantial slippage” between what was initially requested and what could be approved, undermining a core assumption of community mobilization - communities are better placed to know their needs and interests than national or international experts (9). Burchardt et al. (2013) also describe how the dependence of non-state actors on international resources (and the associated norms and institutions) has profoundly impacted on their accountability and developmental responsiveness to local populations (10).

A pivotal “tipping point” facing South Africa today is the manner in which development policy reacts to intrinsic frustrations while dealing with external influences and delivering to the populace (5). The insistence to apply more rigorous measures of efficiency and productivity on agents with regards to development, without engaging with the fundamental epistemological shortcomings of the current developmental approach may result in attempts to alleviate the situation, exacerbating the populations’ frustrations.

It then seems logical to find innovative ways to be freed from such an inappropriate “approach to development before the existing developmental apparatus inadvertently fuels further dissatisfaction” (5). This will be difficult to accomplish with out the decision to shift towards a more reflexive manner of development planning that allows for the questioning of epistemology and empowers development planners and practitioners to take up complexity rather than deny it.

Conclusion

Traditional and reductionist assumptions have been the dominant mental model for developmental policy makers and planners even when the situation does not fit the presumptions of these linear models. This paradigm has acted as a latent guiding principle in the top-down decision-making process. And while it is being gradually challenged for contributing towards developmental bottle necks or glass ceilings when applied inappropriately to complex situations, we need to find substantive strategies to account for the uncertain and nonlinear dynamics and HIV/AIDS related behaviours of discontented population.

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Work Cited

1. Burman CJ. The Taming Wicked Problems Framework: A plausible biosocial contribution to ‘ending AIDS by 2030’. TD: The Journal for Transdisciplinary Research in Southern Africa. 2018;14(1):1-12.

2. Burman CJ, Aphane M. Complex HIV/AIDS landscapes: reflections on how ‘path creation’influenced an action-oriented intervention. Systemic Practice and Action Research. 2017;30(1):45-66.

3. Van Beurden EK, Kia AM, Zask A, Dietrich U, Rose L. Making sense in a complex landscape: how the Cynefin Framework from Complex Adaptive Systems Theory can inform health promotion practice. Health promotion international. 2013;28(1):73-83.

4. Campbell C, Cornish F. Towards a “fourth generation” of approaches to HIV/AIDS management: creating contexts for effective community mobilisation. AIDS care. 2010;22(sup2):1569-79.

5. Burman C, Mamabolo R, Aphane M, Lebese P, Delobelle P. The South African developmental landscape: restricted potentials or expansive, complex adaptive opportunities? TD: The Journal for Transdisciplinary Research in Southern Africa. 2013;9(1):17-37.

6. Rogers KH, Luton R, Biggs H, Biggs R, Blignaut S, Choles AG, et al. Fostering complexity thinking in action research for change in social–ecological systems. Ecology and Society. 2013;18(2).

7. Burman CJ, Moerschell L, Mamabolo R, Aphane M, Delobelle P. Re-imagining decision making: addressing a discrete social driver of HIV/AIDS through the lens of complexity science. African Journal of AIDS Research. 2015;14(1):75-84.

8. Auerbach JD, Parkhurst JO, Cáceres CF. Addressing social drivers of HIV/AIDS for the long-term response: conceptual and methodological considerations. Global public health. 2011;6(sup3):S293-S309.

9. Swidler A, Watkins SC. “Teach a man to fish”: the sustainability doctrine and its social consequences. World development. 2009;37(7):1182-96.
   

10. Burchardt M, Patterson AS, Rasmussen LM. The politics and anti-politics of social movements: religion and HIV/AIDS in Africa. Taylor & Francis; 2013. p. 171-85.