Situating responsibility for the control of infectious disease: the work of lay HIV counsellors in South Africa Hayley MacGregor Dr Hayley MacGregor, 13

Dr Hayley MacGregor, 13 Dec 2011

Situating responsibility for the control of infectious disease:

the work of lay HIV counsellors in South Africa

Hayley MacGregor

The ESRC STEPS CentreSocialTechnological andEnvironmentalPathways to

Sustainability


STEPS Challenges

• Understanding development-science interfaces in a highly dynamic world

• Linking environmental sustainability with poverty reduction and social justice

• Making science and technology work for the poor• Across 3 domains: Health, Agriculture and Water• Challenging conventional approaches of separate

sectors and disciplinary silos

www.steps-centre.org


Key features of STEPS Approach

• Different FRAMINGS of systems: different ways of representing a system or problem

• A politicised view of ‘systems’ and their dynamic environments

• Acknowledging the politics of knowledge• Addressing governance: power, politics and institutions

www.steps-centre.org


‘system’

environment

System:Social, institutional, ecological and technological elements interactingIn dynamic ways

A systems perspective


Framings: Different ways of understanding or representing a system

and its relevant environment

Integrating knowledge and values: Framing

Dimensions of framing

- Scale- Boundaries

- Key elements and relationships

- Dynamics in play- Outputs

- - Perspectives- - Interests- - Goals- Values- - Notions of relevant

experience


Pathways Approach

• In a given situation we might ask:– Who are the actors?– How is the system and goals for change FRAMED?– How is the ‘public’ constructed?

• Identify PATHWAYS of response• Pay attention to alternative and marginalised

perspectives• Constructing pathways to sustainability requires

recognition and deliberation amongst multiple perspectives and possible pathways


Epidemics and policy

• Epidemics: Science, Governance and Social Justice

• Avian Influenza: Science, Policy and Politics


HIV: a chronic illness

• Different framings of the problem of disease control

• Different understandings of the role of lay HIV counsellors

• Shifting meanings of ‘counselling’• A case study in Khayelitsha, Cape Town




Qualitative Methodology

• In depth interviews with 20 facility-based lay counsellors

• Interviews with their supervisors in the contracting NGO

• Participant observation of their training• Key informant interviews • Background of a new policy framework• Previous fieldwork in Khayelitsha


The perspective of lay counsellors:

• Hybrid notions of ‘counselling’• The importance of formal and informal

care practices• Perception of themselves as brokers

between the clinic and the community• Complex understandings of ‘responsibility’

for illness


Their working conditions

• Anxiety about task shifting and increasing responsibility

• Anxiety about associated risks• The politics of professionalisation• Concerns about targets: ‘the stats’• Concerns about reduced time with clients:

shifts in their practice and the effect on the nature of care


Conclusions

• The importance of relationships with clients

• The dangers of managerialism• Building on the idea of ‘brokers’: helping

others negotiate the health system• Adequate supervision• A critical perspective on discourses of

responsibility


A new policy framework

• Re-engineering Primary Health Care in SA: the role of community careworkers?

• UNAIDS/Cordaid cross-country study: case studies and identifying advocacy points with the help of an advisory board

• The value of different kinds of evidence• Anthropology and interdisciplinarity• The politics of policy processes

The STEPS Centre’s Approach

Working papers and briefings free to download on www.steps-centre.org

http://www.steps-centre.org/

Documents

Situating responsibility for the control of infectious disease: the work of lay HIV counsellors in South Africa Hayley MacGregor Dr Hayley MacGregor, 13