Marketization, Daily Life and HIV in South Africa: Request for Proposals Background The Municipal Services Project (MSP) (www.queensu.ca/msp) is a multi-partner research, policy and educational initiative examining the restructuring of municipal services in Southern Africa. Research partners are the International Labour Research and Information Group (Cape Town), the University of the Witwatersrand (Johannesburg), the Human Sciences Research Council (Durban), Equinet (Harare), the South African Municipal Workers Union, the Canadian Union of Public Employees, and Queen's University (Canada). The project is funded by the International Development Research Centre (IDRC) of Canada. During the first phase of the project (2000 - 2003), the primary focus of our research was on the impact of policy reforms such as privatization and cost recovery on the delivery of basic municipal services (specifically water, sanitation, waste management and electricity). Most of this research was conducted in South Africa. We are now entering a second phase, which will focus more specifically on the impact of policy ‘reform’ on health and will expand the research to include more countries in Southern Africa. HIV/AIDS and Water Services The extent of the devastation associated with the HIV epidemic in Africa is by now familiar. A growing body of research links the spread of HIV with the poverty, economic insecurity and social disorganization associated with the adoption of neoliberal social and economic policies (Buvé, Bishikwabo-Nsarhaza & Mutangadura 2002) . These policies are generically known as ‘structural adjustment,’ after the term used by the International Monetary Fund to describe programs of domestic policy reform demanded as conditions for access to IMF and World Bank financing, but in some cases have been adopted at the initiative of national governments in order to make their economies more attractive to investors (Bond 2001, Cheru 2001, Saul 2001). The connection between the impact of these policies and HIV is captured by the observation of medical anthropologist Brooke Grundfest Schoepf that, as long ago as 1988, people in Zaire (now the Democratic Republic of the Congo) “had another name for AIDS (SIDA in French) that encapsulated their understanding of its social epidemiology,” which included rapid social change, endemic economic insecurity and the subordination of women: “Salaire Insuffisant Depuis des Années” (Schoepf 1998: 110, emphasis in original; see also Mill & Anarfi 2002, Schoepf 2002, Schoepf, Schoepf & Millen 2000). In South Africa, an important element of the neoliberal economic policy package has been the marketization of essential public services, notably water and electricity (Bond 2001, McDonald & Smith 2002, Ruiters & Bond 2000). We use the term ‘marketization’ to describe the combination of several phenomena: &#9643; outright privatization of public services; &#9643; reorganization of publicly provided services along commercial lines, which emphasize criteria such as cost recovery and return on investment; &#9643; reliance for capital investment on public-private partnerships, in which the private investors must earn competitive returns on their investment; &#9643; contracting out the management of public services; and &#9643; a retreat in political discourse from public or collective responsibility for the provision of services that are essential to health and well being. Effects have included drastic increases in the cost of services and an associated rise in the number of households affected by cuts in services (Bond 2001, Pauw 2003). Research carried out by MSP (Fiil-Flynn 2001) found, for example, that 20,000 households per month in Soweto were being cut off from electrical services in early 2001; in a sample of households surveyed, 61 percent had been cut off at least once in the preceding year; 45 percent of those households had been without electricity for more than a month. Health and safety impacts include food spoilage, indoor air pollution from alternative cooking fuels, increases in women’s domestic work load, and local increases in crime and domestic violence. In the Cape Town area, more than 75,000 households had their water cut off in 1999 and 2000 alone (McDonald and Smith 2002). In KwaZulu Natal a cholera outbreak that followed the introduction of cost recovery for household water affected more than 100,000 people and killed more than 200. This is just one of many instances in which widespread hardship followed the marketization of water services (Pauw 2003). Such policies can have a disproportionate impact on low-income households. As part of the second phase of its research, MSP has a small amount of funding (up to R70,000) available for an initial field test that will investigate how the marketization of essential services such as water and electricity creates special problems for households in which one or more members is HIV-positive. The MSP will be seeking additional funding from the Canadian Institutes of Health Research (CIHR) to expand the work into a larger scale pilot study, but these resources cannot be guaranteed at the moment. Various qualitative methodologies (e.g. participant observation, open- or closed-ended interviews, focus groups) may be appropriate, individually or in combination. As illustrations, Mill & Anarfi (2002) used interviews to explore the effect of poverty and economic insecurity not only on the risk of HIV infection, but also on the difficulties of daily life of Ghanaian women once they had been infected. In the United States, many researchers have documented the consequences of that country’s uniquely market-oriented system of health and social welfare provision for people living with AIDS or other chronic illnesses. Notably, Abraham (1993) followed a single inner city US family for a year to document the obstacles to access to care and social services in a market-driven health system. Based on five years of fieldwork, Tourigny (1998, 2001) similarly describes extraordinary adversities that confront HIV-positive urban residents and their extended (not necessarily biological) families, forcing some into the drug economy as a survival strategy. Crane, Quirk & van der Straten (2002) interviewed low-income couples, one member of which was HIV-positive, to investigate how policy choices related to welfare ‘reform’ and the tightening of criteria for disability benefits “contributed to the creation of an economy of poverty in which the sick, needy, and addicted must compete against each other for scarce resources” (see also Tourigny, 1998). These are just a few examples of a larger body of urban ethnography that has emerged in the United States against a background of deindustrialization and social policy retrenchment (for other examples see e.g. Bourgois, 1995a, 1995b, 1998; Francis-Okongwu, 1995, 1996; Newman, 1999). Research Questions 1. What is the impact of marketization of key basic services (specifically water and electricity) on the ability of persons with HIV/AIDS, and other members of their households, to cope with the illness? 2. How does the stigma associated with HIV/AIDS affect the ability of households and communities to cope with the illness and mobilize for needed resources, including access to key basic services? 3. What is the potential for design of a broader survey study of the same questions that would yield quantitative comparisons of health status indicators for persons with HIV/AIDS, and members of their households, exposed and not exposed to marketization of basic services? Research Design Question 1 The first question is the key focus of the research. It will be answered through comparative qualitative case studies using: &#9643; Participant/observation (of household organization, service access, health status) &#9643; A structured interview designed to elicit information about key demographic, health and service access indicators (e.g. household income and size, other illnesses, HIV/AIDS history, service access history, employment history) &#9643; A semi-structured, life history interview (Bernard 1995; Kohler-Riessman 1993: 1-24, 54-70) designed to elicit information about experiences of coping with HIV as affected by service access, in conjunction with other socioeconomic factors. A purposive sample will be drawn from households with similar socioeconomic profiles, in a single community, that fall into three categories of service access: (i) Few or no services (specifically water and electricity, but also sanitation and waste management) for a prolonged period, or frequent interruptions in service, that are attributable to marketization. (ii) Intermittent service but with little serious disruption in access (iii) Little or no disruption in service access These service access problems can be due to issues of price (e.g. increases due to cost recovery), technology (e.g. the introduction of pre-paid meters or trickle meters that restrict service volumes), privatization (e.g. redlining of low-income areas or differentiated service levels) or some combination thereof. We are especially interested in service cutoffs and the introduction of pre-paid meters in water and electricity, but the research need not be confined to these areas. Because other household members are invariably involved with the care of HIV-positive individuals once symptoms and opportunistic illnesses become evident, in each household, interviews will include: &#9643; at least one person who is HIV-positive, and &#9643; where such a person is a member of the household, one ‘adult’ (i.e., someone capable of giving consent to an interview) who plays a caregiving role and can therefore provide information about the process of coping with HIV/AIDS. The intent of the narrow sample frame is to minimize the confounding influence of poverty, which is already known to affect the process of HIV/AIDS coping/survival. Since marketization of services has been shown to reduce access for people unable to afford user-charges, the only difference in income between categories 1 and 3 should be the income required to maintain access with little or no disruption. The initial field-test will involve a sample of at least 10 households in each of the three categories. Question 2 Within this question, there are two important sub-questions (a) What is the nature of the stigma associated with HIV/AIDS in the study community/ies? (b) Are informal patterns of resource sharing, social cohesion (at the local or neighbourhood level) or community solidarity – with respect to basic municipal services – disrupted by the stigma associated with HIV/AIDS? These sub-questions will be answered through using the same combination of participant observation and interviews used to address Question 1. Additional interviews with non-infected individuals who are not members of a household included in the primary sample, and with community leaders, will also be undertaken, as well as reviews of the relevant service delivery literature. Question 3 This question is intended to be suggestive and illustrative of possible research strategies and objectives for the second phase of the work. It need not be addressed in the initial field test that MSP will be supporting but would be an asset. It would include a review of existing data on HIV/AIDS, health status and service access that may be amenable to quantitative analysis (including sample sizes/sampling methods, services to be covered, demographic inclusion, questions to be asked, etc.). Research Outputs The following written products will be required as part of the research output from the field test: · brief progress reports describing research activities, to be submitted to the Project directors; · submission of a draft report for comment by Project staff; · submission of a publishable quality final research report detailing the findings of the research for possible publication as one of the Project’s Occasional Papers or in some other format to be determined by the Project directors (in consultation with the researcher(s)); · preparation of popular article(s) on research findings for publication in the Project’s newsletter Expressions of Interest Researchers interested in undertaking this initial field test, or supervising students doing so as part of their studies, should contact Dr David McDonald <dm23@post.queensu.ca>, co-director of the Municipal Services Project, before preparing a detailed proposal for the field test. At the same time, they should contact Dr Ted Schrecker <schrecker@sask.usask.ca> at the Saskatchewan Population Health and Evaluation Unit (Canada), in order to discuss expanding the proposal for purposes of CIHR. However, because additional resources cannot be guaranteed, researchers submitting expressions of interest should keep in mind the need to deliver a research product within the confines of the R70,000 budget, plus whatever resources they themselves can mobilize. “Researchers” includes university faculty, students, and professionals working in other contexts (e.g. as independent consultants or staff of non-governmental organizations). Preference will be given to African-based researchers, including African students completing degree requirements in Canada. At the stage of expressions of interest with regard to the initial field test, we would like to encourage creativity with respect to methodology. The researcher(s) undertaking the field test will need to know, and have the trust of, the community where they are conducting the work. This will probably mean that they are already working in some area of health care or social services, as well as having some research training. For the larger pilot study – that is, the one that will be proposed to CIHR – we are considering building in a training component that will provide research skills for health workers and home visitors who are already with HIV-positive individuals and their families Copies of many periodical references cited in this call for proposals can be obtained from Ted Schrecker <schrecker@sask.usask.ca>, who is a member of the MSP Health Advisory Board. References Abraham, L.K. 1993. Mama Might Be Better Off Dead: The Failure of Health Care in Urban America. Chicago: University of Chicago Press. Bernard, H.R. 1995. Research Methods in Anthropology: Qualitative and Quantitative Approaches, 2nd edition. Walnut Creek, CA: Altamira Press. Bond, P. 2001. Against Apartheid: South Africa Meets the World Bank, IMF and International Finance. Cape Town: UCT Press. Bourgois, P. 1995a. In Search of Respect: Selling Crack in El Barrio. Cambridge: Cambridge University Press. Bourgois, P. 1995b. The Political Economy of Resistance and Self-Destruction in the Crack Economy: An Ethnographic Perspective. Annals of the New York Academy of Sciences 749: 97-118. Bourgois, P. 1998. Families and Children in Pain in the U.S. Inner City. In N. Scheper-Hughes and C. Sargent (eds)., Small Wars: The Cultural Politics of Childhood (pp. 331-351). Berkeley: University of California Press. Buvé, A., Bishikwabo-Nsarhaza, K., Mutangadura, G. 2002. The spread and effect of HIV-1 infection in sub-Saharan Africa. Lancet 359: 2011–2017 Cheru, F. 2001. Overcoming apartheid’s legacy: the ascendancy of neoliberalism in South Africa’s anti-poverty strategy. Third World Quarterly 22: 505–527. Crane, J., Quirk, K., van der Straten, A. 2002. ‘Come back when you’re dying: the commodification of AIDS among California’s urban poor. Social Science & Medicine 55: 1115-1127. Fiil-Flynn, M. 2001. The Electricity Crisis in Soweto, Occasional Paper No. 4 (Cape Town: Municipal Services Project, 2001) Francis-Okongwu, A. 1995. Looking up from the bottom to the ceiling of the basement floor: female single-parent families surviving on $22,000 or less a year. Urban Anthropology 24: 313-362. Francis-Okongwu, A. 1996. Keeping the show on the road: female-headed families surviving on $22,000 a year or less in New York City. Urban Anthropology 25: 115-163. Kohler Riessman, C. 1993. Narrative Analysis. Qualitative Research Methods Series, 30. Newbury Park, CA: Sage. McDonald, D., Smith, L. 2002. Privatizing Cape Town: Service Delivery and Policy Reforms since 1996, Occasional Paper no. 7. Cape Town: Municipal Services Project Mill, J., Anarfi, J. 2002. HIV risk environment for Ghanaian women: challenges to prevention. Social Science & Medicine 54: 325-337. Newman, K. 1999. No Shame in My Game: The Working Poor in the Inner City. New York: A.A. Knopf & Russell Sage Foundation. Pauw, J. 2003. Metered to Death : How a Water Experiment Caused Riots and a Cholera Epidemic. Washington, DC: Center for Public Integrity, February 5 Ruiters, G., Bond, P. 2000. Contradictions in Municipal Transformation from Apartheid to Democracy: The Battle over Local Water Privatization in South Africa, Background Research Series. Cape Town: Municipal Services Project Saul, J. S. 2001. Cry for the Beloved Country: The Post-apartheid Denouement. Review of African Political Economy No. 89: 429-460. Schoepf, B. 1998. Inscribing the body politic: AIDS in Africa. In M. Lock and P. Kaufert (eds.), Pragmatic Women and Body Politics (pp 98-126). Cambridge: Cambridge University Press. Schoepf, B. 2002. ‘Mobutu’s Disease’: A Social History of AIDS in Kinshasa. Review of African Political Economy No. 93/94: 561-573. Schoepf, B., Schoepf, C., & Millen, J. 2000. Theoretical Therapies, Remote Remedies: SAPs and the Political Ecology of Poverty and Health in Africa. In J. Yong Kim, J. Millen, A. Irwin & J. Gershman (eds.), Dying for Growth: Global Inequality and the Health of the Poor (pp 91-126). Monroe, Maine: Common Courage Press. Tourigny, S.C. 1988. Some New Dying Trick: African American Youths ‘Choosing’ HIV/AIDS. Qualitative Health Research 8: 149-167. Tourigny, S.C. 2001. Some new killing trick: Welfare reform and drug markets in a U.S. urban ghetto. Social Justice 28 (4, Winter): 49-72.