Shaped by interdependence: external influences on the INGO´s equity implementation in HIV/AIDS
The interdependencies of the INGO, government, and donors shaped the INGO´s implementation of equity principles. The INGO aligned its implementation of equity principles in its HIV/AIDS work to the agendas of the donors and Kenyan government. The INGO implemented initiatives and focused on certain populations based on this alignment.
Aligning with priorities of donors and Kenyan government
Many INGO staff stated that working with the Kenyan government, including adhering to its priorities and policies, had been key to the success of the INGO in implementing equity in its HIV/AIDS work.
"You´ll not hear the Ministry of Health saying that [the INGO] is implementing a project that doesn´t adhere to its rules and regulations or policies or guidelines... You need the government to be fully behind an initiative, and if they are not behind it, you find that it´s very difficult" (#16, internal staff).
The INGO´s community empowerment approach aligned well with the Kenyan government´s Community Strategy, which had as a major focus to empower communities in health related issues:
"The intention [of the Community Strategy] is to build the capacity of communities to assess, analyze, plan, implement and manage health and health related development issues" communities will thereby be empowered to demand their rights to seek accountability from the formal [health] system for the efficiency and effectiveness of health and other services" The goal of reducing health inequities can only be achieved effectively by involving the population in decisions and in the mobilization and allocation of resources, and thereby promoting community ownership and control in the context in which they live their lives"[
49]
, p. 2, 4.
Government staff confirmed the Kenyan government´s commitment to the Community Strategy:
"I think our interest is not to simply have community members as recipients of services and goods, our interest is to empower them, so that they make decisions, they help us in decision-making and sustainability of those programs... So an area of interest to us is empowerment, so that empowerment of communities to take part in decision-making and promote sustainability of programming, even in the absence of support that is external" (#603, government staff).
Hence, the INGO´s community empowerment approach aligned with the Kenyan government´s priorities.
The INGO´s work in gender empowerment in its HIV/AIDS programs aligned with donor agendas, as gender equity was an area of priority for donors and an explicit funding condition of some donors. A few interviewees identified donors as the impetus for the INGO´s focus on gender equity:
"In Kenya, we weren´t looking at an equity lens until donors came in and said `Women have rights too and they need to have equal chances""Now most programs look at gender issues" (#50, internal staff).
The INGO´s focus on gender equity also aligned with the Kenyan government´s equity work, including the government´s collection of HIV/AIDS data by sex. The Kenyan government required that the INGO (and all NGOs and civil society organizations working in HIV/AIDS) complete a quarterly report on activities, and all data had to be reported for males and females separately (e.g. number of people trained, number receiving food and nutrition support). Internal interviewees also identified disaggregation of data by sex as the primary way that equity was measured by the INGO: "In our reporting, we make sure that our data is disaggregated by gender" (#33, internal staff). Civil society organization clients funded by the INGO were also required to report data for males and females as part of their civil society organizations´ activities:
"[The INGO] wants to see the management of organizations. Is it dominated by men alone, or is it inclusive? Are ladies represented?" (#508, client).
The formal collection of data by sex illustrated how the donors´ and Kenyan government´s priority of gender equity filtered to the INGO, and down into the community.
Hence, two of the major ways that the INGO implemented equity in its HIV/AIDS work were through community empowerment and a gender equity focus, aligning with priority areas for the donors and the Kenyan government.
Aligning with donor funding: "He who pays the piper calls the tune"
Donors primarily influenced the INGO´s implementation of equity in its HIV/AIDS work through funding requirements: "He who pays the piper calls the tune" (#400 - government staff and #124 - internal staff). Since the INGO relied heavily on donor funding, this influence was strong:
"At the end of the day, [the donor] is only concerned with what´s in the proposal [in terms of whether or not equity is a focus]" (#205, Northern INGO staff).
Specific requirements for funding proposals meant that INGO staff often felt that they lacked the flexibility to insert their own ideas and principles, which could limit the opportunity to realize fully the INGO´s equity principles in its projects. For example, some interviewees observed that when the donor´s request for a proposal for an HIV/AIDS project was not oriented towards equity, if INGO staff included an equity focus, the INGO might not be awarded the funding.
"Because the other thing that has to be kept in the forefront, is that the RFA [request for applications] has very specific outputs. And it is only those outputs that you are allowed to respond to, in response to that RFA. And so, for example, if there isn´t anything in there about equity, and then you put specific programmatic things around, you´re going to add that, you are not responsive to the RFA. And you are automatically denied" (#201, Northern INGO staff).
"Why struggle to suggest something in the proposal when, first of all, the instructions for doing the proposal are very rigid. You are told exactly then how to write each paragraph and what to say, what targets to meet... But indeed sometimes they say suggest other innovative ideas. And if equity is one of them, it might fit. Or if a disadvantaged region of the country or communities or groups are, then that´s when you might have scope" (#3, internal staff).
However, some INGO staff felt that many donors facilitated the INGO´s implementation of equity in HIV/AIDS, since equity was often a focus of donor funding.
"I´d say that donors facilitate [equity] more than anything else. I mean, after all, their funds come from them, but also... the donors are coming from countries where equity probably is more advanced. To them, it´s also of key interest that we demonstrate that whatever we´re implementing [in HIV/AIDS] is addressing equity, that it is basically making the lives of communities better. So, donors actually facilitate [equity]" (#1, internal staff).
As one interviewee noted, equity as a whole may be a donor-driven concept: "everyone is moving on equity because this is all Western driven, the labels are Western, they are part of donor conditionalities"(#124, internal staff).
Donors had particular political ideologies and values that defined what they wanted to focus on, and fund, in terms of HIV/AIDS programs. Donors´ requests for proposals were based on the priorities and agenda of the Northern country first and foremost.
"As a development agency [from Northern country], we have our global policy that guides the overall development. This comes from external research, evidence, and our experience in development work in countries" (#607, donor).
Many interviewees noted that certain donors, in particular those from European countries, were more likely to include an equity focus in their requests for proposals for HIV/AIDS projects.
"The proposals [for funding of HIV/AIDS initiatives] originating from Europe tend to embrace equity in this broader sense as in pro-poor, explicitly, as compared to... the American [proposals]" (#3, internal staff).
By contrast, the U.S. was identified as one donor that, in the past, had deliberately excluded certain projects that facilitated equity. The HIV/AIDS funding under the Bush Jr. administration had criteria that some interviewees felt negatively affected the implementation of equity principles.
"We´ve had a long period where [for U.S.´s PEPFAR funding] family planning has been off the agenda...which doesn´t help in any way, because the well-off people - they are always getting access to family planning, the ones that are well-educated and know what to do. The poor people with less education, with poorer access, they are then the ones that are marginalized in this case, right? So, some donors, because of their policy, are limiting the ability to have a proper equity, or fully, fully focus on equity... and some are very supportive" (#2, internal staff).
This same senior staff person noted that donors´ priorities, and the resulting requests for proposals, changed depending on the donor country´s current political climate:
"USA, especially PEPFAR... moves with the wind depending on who is in power and the government system" (#2, internal staff).
The U.S. was viewed as having increased its focus on equity under the Obama administration, and following the development of the Global Health Initiative (from PEPFAR).
"Increasingly, even the American proposals you see that they want that you target the most vulnerable in society" (#3, internal staff).
This shift was identified in interviews, and verified in participant observation and in the review of proposals for new HIV/AIDS projects, in which the U.S. recently added equity as one of its focus areas.
Because donors´ requests for proposals reflected their Northern country´s political ideologies and values, a few interviewees, both external and internal, acknowledged that donors had the potential to override what Kenya had identified as priorities by prescribing projects in requests for proposals:
"So you might find that if a [donor] doesn´t really care about gender or maybe with MARPs [most-at risk-populations] or anything else, it´s very difficult for us...Those are decisions made already in Washington. It´s very difficult for us to say, `No, we have a gap addressing girls in school´ [or] `you need some equity element to that´. They´ll tell you `No, but it´s not in our plans so we won´t do it´" (#400, government staff).
Even with formal mechanisms to encourage alignment of donor funding with Kenyan government priorities in HIV/AIDS (including the Paris Declaration [
50], the Action Framework for HIV/AIDS [
51], and the Kenyan Health Sector Wide Approach - Code of Conduct [
52]), equity elements of HIV/AIDS programs were particularly susceptible to donor influence.
"There are some [donors] that look at what they need to get out of [funding a project on HIV/AIDS in Kenya] and they give their resources to that. The [government] doesn´t control resources... The best we can do as [government agency] is to provide the best guidance, and say, `Okay, fine. This is the minimum package, this is the policy, this is what you need to do, this is how you get consent, this is how it happens´... We can try and tell them, `Okay fine, I think you need to work in this particular region´, but we are not always successful to tell them that we need to work in this particular region, because the mechanisms that these partners and the donors have... we may not have total control for that" (#400, government staff).
Hence, donors had the ability to direct local implementation decisions that influenced equity. This included decisions on whether vulnerable groups, including those in certain remote geographic areas, were a focus for HIV/AIDS interventions.
Interviewees also noted that donors influenced the INGO´s implementation of equity principles in its HIV/AIDS work via the duration of funding. Project funding was typically short-term (between three and five years), which was not viewed as conducive to fostering equity:
"Donors´ cycles are insufficient for addressing equity issues... Donors just want to provide services" (#41, internal staff).
Providing short-term services may address immediate needs, but it is inadequate to shift structural determinants, including cultural changes. These short-term agendas were often a result of the Northern country´s political cycle of four or five years, but, as noted by interviewees, making a difference in terms of equity, including empowering communities, can take many years (#201, Northern government staff).
"If you would have a program that would last, let´s say six years, then it would be more meaningful in terms of [equity] outcomes, `cause we´re really based on outputs, `cause it´s really ... it´s changing perceptions and building that capacity that we have been building" (#85, internal staff).
Hence, a disconnect existed between the donors´ needs (to focus on short-term outputs to report to constituents) and development needs (which would include long-term equity outcomes).
Aligning with Kenyan government´s legislation and donor countries´ policies
The Kenyan government and donors also shaped the INGO´s implementation of its equity principles in terms of where the INGO did not focus. Senior managers noted that the INGO did not advocate legislative changes to address human rights for most-at-risk populationsd, including men who have sex with men and sex workers.
The INGO had an excellent reputation, built on its history of work in the communities and its positive relationships with donors and the Kenyan government. The INGO wanted to maintain this reputation and therefore avoided advocating on issues that would be perceived as highly controversial or out of step with Kenyan legislation.
"So we push for the whole area of equity and address vulnerability and marginalization as much as we can, especially in the areas that are not political controversial" (#2, internal staff).
Senior management staff of the Kenyan INGO said in interviews and in participant observation that if these parameters were not respected, the INGO risked a number of consequences that would have a direct and deleterious impact on their work in the country. These included being banned from Kenya if it were to implement its equity principles through advocating certain controversial legal changes, such as legislation to legalize homosexuality:
"If you want, as an organization, to go out and advocate for legalization of homosexuality, then you would be in trouble... Well, if we did, it would have serious consequences for us; or it could have... I mean, in the most extreme cases, we would be deregistered as an NGO, right, and not be allowed in the country. That would be on the extreme, but you know, it could be more control [over] what we´re doing, lobbying donors for not giving us money, us in our ability to do policy influence in our other areas...and, [the INGO] wouldn´t go that way because it has never been the way we have been working, trying to be confrontational" (#2, internal staff).
For this reason, the INGO worked within the system in ways that avoided potentially serious repercussions. For example, in Kenya, homosexuality, sex work, and drug use are illegal. Advocating the legalization of homosexuality or sex work, or providing harm reduction services to injecting drug users, were viewed as contentious given legal frameworks and socio-cultural norms in Kenya. As one partner NGO interviewee noted, in order to maintain positive relationships with the Kenyan government, many NGOs avoided advocating changes to legislation in these highly contentious areas.
"[Some NGOs] are looking at their relationship with the government and they realize that issues of homosexuality are criminalized in this country and so they realize that to maintain a good relationship with the government, they don´t want to be talking about [legalization]. Sex work again is criminalized and therefore organizations are cautious to look at [legalization]" (#602, partner NGO).
The case INGO was one of these NGOs that worked within the Kenyan legal framework to maintain these relationships:
"So we try and find ways of working within the present legal framework [of the country], whether we agree to it or not" (#2, internal staff).
From an equity perspective, working within the legal framework limited the programming and advocacy approaches that the INGO could take with most-at-risk populations, including men who have sex with men and sex workers. As one interviewee explained in speaking about one of Kenya´s neighbouring countries:
"It means we can´t make statements on the issue [of legalizing homosexuality]. And we did not make statements about Uganda-the penalties [death penalty] for being gay, the legislation that was pending recently. And... that´s because the countries in which we work, it´s illegal. So, we try to be very neutral as an organization and I regret that" (#204, Northern INGO staff).
The INGO refrained from advocating controversial issues, opting instead to remain "neutral" (i.e., silent) in order to continue working closely with Southern country governments. The quote above from a Northern INGO staff member also highlights the challenge when legal frameworks in Southern countries contradict equity values of Northern donor countries. As a Kenyan INGO staff member noted:
"You will have some of the offices that... would try and push issues that are difficult for us to address, again homosexuality. Some of the national [Northern] offices will say, "You must fight for [legalizing homosexuality]"{. [Interviewer: And how does that play out?] "We will say what we can do [in Kenya] and what we can´t do, so they have not pushed us on areas where we just can´t implement it. So they [Northern offices] might have a strong desire, but so far they have listened to us and then agreed to disagree, when we have said, `We can´t move on that´" (#2, internal staff).
This illustrates the tension between the Northern INGO and Kenyan INGO staff who had different perceptions about how equity could be implemented and the risks involved. While the Northern INGO staff may have sought to advocate on these issues, the Kenyan INGO continued to priorize aligning with the Kenyan government to maintain positive relationships, avoid negative repercussions, and continue its work.
Contradictory directives within Kenya existed as well. While the Kenyan government identified the importance of working with most-at-risk populations in the Kenyan National AIDS Strategic Plan III (KNASP), there was incongruence between these statements and the legislation Kenya has in place. This challenge was directly acknowledged in the KNASP:
"A series of difficult legal issues arise from attempts to programme more directly for the MARPs (sex workers, IDUs, MSM), and to take these programmes to scale. Sex work, homosexuality and drug use are all illegal in Kenya. Programmes have been working with all these groups for many years, but under constraints. There is a need to come up with policies that will facilitate scaling up access to services by the different groups clustered under the term MARPs"[
48].
A few interviewees indicated that the Kenyan government and the case INGO focused on public health advocacy, as outlined in the KNASP, including reaching vulnerable groups with health services. Another tactic would have been to advocate equity through an overall human rights approach, including advocating for changes in legal frameworks for most-at-risk populations. However, a few interviewees noted that the Kenyan government focused on a public health approach, which included health care access, rather than a human rights approach that would involve addressing human rights issues for most-at-risk populations by changing legislation. As one interviewee explained:
"There is the public health [approach] which is what the KNASP looks at. Then there is the human rights approach, which is what some organizations want to look at... The KNASP is really talking about prevention and care for these populations [which is a public health approach], but we have some organizations also that are going into- issues of legislation like having them not criminalized [which is a human rights approach]" (#602, partner NGO).
Hence, providing health services to various groups, including most-at-risk populations, would fall under what was deemed acceptable under the KNASP and permissible within the legislative framework in Kenya. However, the INGO did not move beyond this to focus on a more human rights approach given potential repercussions.
A donor country´s policies could also influence the INGO in its implementation of equity principles. An instance was cited where the donor country´s policies had the potential to negatively influence the INGO´s implementation of its equity principles in its HIV/AIDS work. In order to be eligible to receive U.S. funding, the INGO agreed to the U.S.´s policy forbidding its funding recipients to advocate the legalization of sex work. By agreeing to this policy, the INGO could not advocate any change to the legal framework in Kenya while holding this U.S. funding. One of the Northern INGO staff identified this as a limitation to the INGO´s right to advocate on issues that might influence equity:
"This type of thing [signing this agreement] can be a challenge though as what if we wanted to advocate for a change in law in the country we are working in? There was some contention since we had to have this policy if we wanted the grant, but we might want to support the legalization of prostitution at some point, so this encroaches on freedom of speech" (#200, Northern INGO staff).
Thus, the INGO´s reliance on donor funding could also place a limit on the potential advocacy levers that the INGO could use in implementing its equity principles in its HIV/AIDS work.
Hence, legislation and policies from other players in the interdependent system within which the INGO worked influenced the INGO´s advocacy work or the potential areas for the INGO´s advocacy. In particular, the INGO was constrained in its human rights efforts.