Origins and Evolution of CHBC Groups

One of the important aspects the IAD framework seeks to explain regarding the life of a group is the transition a group goes through from its inception. For example, capturing of processes of CHBC group formation, group composition, group strategies, motivational

factors, resource use and subjects’ perceptions, as well as more outward looking interaction with other agents in the continuum of care and support for HIV/AIDS cases is important for the group’s ability to sustain itself. Tracing the origins and the composition of each group is also important for understanding aspirations and motivations that matter. Literature from path dependency tools of analysis, which seeks to explain a sequence of events as a function of a given unique beginning, should also have a role in explaining the evolutionary aspects of the CHBC structures and eventual institutions. In other words some of the outcomes in the CHBC set-up are a function of constraints and limits that were set by events at the outset of the initiative.

In light of this the study seeks to understand and explain how the origins of the groups (first initiatives) appear to motivate or place constraints on group progression, and group ‘ownership’ among other factors. It has been documented that group size may be as much an indicator of institutional success as a precondition for such success (Ostrom and Poteete, 2004:2).The section also highlights the changes in group sizes as an important factor that reveals the underlying realities of the CHBC groups.

6.5.1.3 Indicators of Group Formation and Evolution

Table 6.2 below presents factors of group formation that are important for understanding institutional and transaction arrangements which themselves impact on group performance. The table provides a snapshot of the CHBC groups in terms of how they were formed, and also presents a picture of how they have been progressing in terms of recruitment of human resources and persistence of membership on the one hand, and on the other provides a context for interpretation and analysis of the general behaviour of the participants, also referred to as actions, invoked and explained in terms of inter- relationships.

Table 6.2: Characteristics of the Origin and Evolution of CHBC Groups

CHBC ATT M F G_AGE AIM IPOP CPOP FI FSI

Lizulu 7 3 4 12 8 16 8 Community 4 Sharpevalle 6 2 4 9 7 75 - Community 1 Matchuana 10 8 2 10 7 22 10 RC Priest 2 Lupiya 6 3 3 10 8 25 17 RC Priest 1 Nansato 7 4 3 15 9 30 - CCAP - Mpando 8 2 6 10 9 30 15 Community 1 Njolomole 6 4 2 2 2 55 30 NGO 1

Nachipere 7 1 6 9 6 30 7 Govt. Nurse 4

Mikombe 7 0 7 6 4 15 7 NGO 2

Kwakwanjana 10 1 9 9 6 - - Govt. Nurse 2 Goliati 5 1 4 8 6 11 6 Govt. Nurse -

Senzani 7 4 3 6 4 40 19 NGO 4

Manjawira 6 3 3 3 2 40 14 Govt. HSA 4 Nchiramwera 10 3 7 10 6 10 23 RC Priest 1 Chimaliro 6 2 4 11 6 23 11 RC Priest 2

Mean 7 3 5 9 6 30 14

Source: Munthali (2007)

Notes:

ATT. = members in attendance at the focus group discussion

M = the number of male members that were present during the discussion

F = the female members present at the discussion

G_AGE = the numbers of years the group has been in existence

AIM = the average number of years individuals have been members of the group

IPOP = the initial population or group size at inception

CPOP = the population or group size at the time of research

FI = who took the first initiative to compose a given group

FSI = the frequency of scheduled meetings or interaction within a group per month

RC Priest = A Roman Catholic Priest working in the area

CCAP = Church of Central Africa Presbyterian

HSA = a government community health surveillance assistant

Table 6.2 shows that CHBC groups have been in existence in Malawi for more than a decade now. Captured in this study are groups with lifespans ranging from two years to

fifteen years. This shows that CHBC has been a growing phenomenon in the response to the HIV/AIDS pandemic. The variation in group ages indicates that over time new groups have been started in an increased rate. Research by Birdsall and Kelly in 2007 shows that civil society organizations in Malawi have been involved in AIDS related activities prior to 1991 but real growth in such organizations has been experienced from 1999. The transition in formation of such organizations has been duly accompanied by the transition in their membership. On average a member spends about six years serving as a volunteer on a CHBC group. This falls short of the average life span of the group which is nine years. This suggests that for every three years that a group exists it loses one year’s equivalent of its own volunteerism human capital. Volunteerism comes in many different forms such as time, monetary contributions, and labour, among others, depending on what each group has established as their working modes in the care and support activities.

Table 6.2 also clearly reveals that CHBC work is predominantly undertaken by women in the communities. Men have been noted to join and drop out more rapidly than female members because men are expected to devote their time to household bread winning activities. However, it must be observed that quitting group membership also includes women at a very high rate. The difference between group means of IPOP and CPOP, which are populations at the formation of the group and at time of research respectively, shows that 50% of membership was lost in the average span of the nine years they existed. Such high drop-out rates in group membership are explained primarily by a lack of monetary incentives in the CHBC structures. Individuals tend to quit CHBC in favor of other gainful activities, more evidence of this is discussed under perceptions of internal conditions below.

Nchiramwera, a group found in Thyolo district, is the only group which grew between its formation in 1996 and 2006. Having formed under the auspices of the Catholic Church priest, this group undertook volunteerism as a function of the church’s outreach programme. When an NGO called MSF Belgium came into Thyolo communities to start supporting them in fighting against HIV/AIDS, expectations of possible monetary rewards set in and the group grew much bigger before some dropped out again. This

group still remains larger than when it started. This is an example of the importance of socio-cultural perspectives held by the subjects. Monetary considerations which have been observed to have strong influential effects on individuals are found to be weaker than the galvanizing effects of religious beliefs of the community members. This then suggests that the origins of the group do matter when it comes to its persistence.

The national response to HIV/AIDS has obviously provided the drive to start CHBC groups in the villages. The multiple partnerships at higher organizational levels are also manifest at the community level. This is exhibited in the manner these groups started. The study sought to find out who provided the most initial impetus for the group to be created, and the results of this question are summarized as indicator FI. This indicator shows that a variety of individuals have been responsible for initiating CHBC groups in the communities. The range includes government community nurses and health surveillance assistants, church leaders, NGOs and in some respect community members themselves.

Despite the standardized methods documented by the NAC and its partners designed to guide training of CHBC volunteers, variations in channels of passing this information down to the actors have resulted in groups being organized and operating differently. For example one indicator, on the basis of which groups differ, is that despite all of them having steering committees, there is a variation in the composition of the committees and the number of times they are scheduled to have meetings in a period of one month.

Group meetings, to plan and share responsibilities, are scheduled to be conducted on a regular monthly basis, and these range from once in some groups, to two, three and even four times per month in others. This shows how the different forms of training and guidance has influenced the actors, but it also is a reflection of the variations that result from how the same information is amenable to widely varied interpretations due to differences in cognitive capacities and a perception of one’s own situation. An aspect of a group’s own situation in this case would suggest that groups with fewer meetings per

month are exhibiting economising behaviour in organizing their activities in the most plausible way.

6.5.1.4 Perceptions of Partners External to CHBC Groups

This section shows that various agents have different roles to play in the continuum of care and support for HIV/AIDS. Roles include facilitating, coordinating, financing and in some cases making critical decisions involving other agents in the matrix. One factor that is important for carrying out roles in such a scenario rests with expectations an agent has of another. In light of this, arguments from resource dependence theories suggest that between two parties who are employing strategic responses to each other, individual behaviour will be manifest in the form of compromise, avoidance, defiance, compliance and manipulation among others.

On the other hand we need to account for institutional incentives and explain what is undergirded by actors’ own orientations and perceptions. These orientations and perceptions are a function of access to information and cognitive capacities, what is normally referred to as rational consumerism. To explore these notions we must seek empirical information on the actual preferences and perceptions of those involved which will give a reflection of how they understand the presence and roles played by their partners. This must also unveil misperceptions and normative (ideological) orientations that are responsible for ways in which they tend to do things amongst themselves and how they interface their partners.

Using this sort of logic influential impacts emanating from engaging other partners, such as facilitation, capacity building, and other forms of reinforcements are analyzed. In other words, as CHBCs face their counterpart organizations, which of the elements of these partnerships (institutional factors) manifest themselves in their day to day behaviour? Perceptions of those partners immediate to CHBC groups are summarized in Table 6.3 below.

Table 6.3: How CHBC Groups Perceive Other Partners and External Conditions Response AES % (n) STL % (n) SFBO % (n) SPL % (n) EID % (n) ECA % (n) No 88 (7) 43 (6) 7 (1) 73 (11) 8 (1) 29 (2) Yes 13 (1) 57 (8) 93 (14) 27 (4) 92 (11) 71 (5) N1 100 (8) 100 (14) 100 (15) 100 (15) 100 (12) 100 (7) Source: Munthali (2007) Notes:

i) Yes = presence of the specified ‘perception’

ii) AES = satisfactory or adequate external support to the group.

iii) STL = satisfactory support from traditional leadership to CHBC activities. iv) SFBO = satisfactory support from faith-based organizations to the groups. v) SPL = satisfactory support from political leadership to CHBCs.

vi) EID = external support to CHBCs irregular or declining.

vii) ECA = an indication of the presence of critical external authority or decision making institutions have in the running of the CHBCs (equivalent of property rights, laws and constitutions).

The main finding in this table is that the recipients of external assistance perceive assistance to be irregular and in some cases declining. While this is happening it has also been reported that a lot of these groups do not have the capacities to meet the basic nutritional and hygiene needs of their patients (Conroy et al, 2006:144; Birdsall and Kelly, 2007:141). The irregularity of funding has two faces. On the one side, it gives a reflection of the competitive nature of obtaining funding from the NAC via the Umbrella Organizations. CHBCs have to and do write proposals to the NAC and other funding organizations for their care and support services. There is ample evidence that there have been excessive delays in processing these proposals at the NAC (Birdsall and Kelly, 2007:141). The NAC’s ability to disburse is hampered by capacity concerns both at the central office as well as the implementing agents. The capacity is also limited by the inadequacy of resources to meet the increasing demands funding care and treatment. The

resources going to support households with chronically ill persons were documented by the NAC to have been on the decline (GOM, 2007:51).

The second is that the community members have very limited capacities to write up proposals. When they do, the quality of the proposals is usually below the standards expected by the NAC. This engages the two sides in an exchange process which aims to clarify and improve the technicalities in the proposals. This process has often led to most proposals not getting funded. Failure and delays in getting funding through these channels contribute to the CHBCs claims of irregular and falling funding levels. It must be noted that on occasion villagers have also benefited from sporadic project assistance in the form of relief. However, the negative dependency effects are revealed by projects that are scaling down. For example, the World Vision International has had a massive presence in Thyolo distributing food to households with chronically ill individuals and also implementing food for assets work in the communities called C-SAFE. This project is no longer running in Thyolo, and the negative effects of this phase out are felt by the communities as they appear to be continually on the losing side of the battle against poverty.

Table 6.3 also shows that support for community care from other organizations is considered inadequate as indicated by 88% (AES) of the groups. This also confirms the irregularity of the assistance. Here it is likely that the actors’ perception of assistance takes a narrow definition of material and financial support which often comes from external donors. The Table appears to show that support from FBOs and traditional leaders is almost satisfactory. These were observed in the preceding sections to be limited to channeling of information through meetings. But the overall indicator for external support (AES) shows that there is very little coming through, and is thus a cause for dissatisfaction. In essence what the reflections of the actors point to the fact that they do not expect much from the traditional and political leaders, so for that reason they do not see them as a major source of frustration. In other words, these leaderships are outside the structures of CHBC as it were, and whatever form of help they chip in is appreciated. While this is partly a result of some critical bottlenecks existing at higher levels, as

discussed in earlier sections, it is worth noting that there are inherent weaknesses in the coordination structures at the lowest levels as well. In particular there are gaps in human resources and institutional structures crucial for mobilizing resources.

The findings also suggest that there are relatively stronger linkages with faith based organizations, which appear to be working more closely with the groups than traditional leaders. Sidelining of traditional leaders in operations of care giving and support for HIV/AIDS was also observed by Birdsall and Kelly (2007) in a study of Bangwe community in Blantyre district. This brings into question the integrative nature of the approach to development and responding to HIV/AIDS in particular. This situation also applies to perceptions of the political structures in the communities. Just about 27% of the CHBC initiatives indicated that they received supportive contributions from political structures. This is too low considering that there are claims of promoting an all inclusive approach to the National Response.

An all inclusive approach needs to start with the traditional and political figures because these live within the communities, and they often have important social roles to play there. Typically, in situations where there is a serious illness or a funeral, the first point of call is that traditional leader and the political leaders are often expected to contribute resources towards the funeral. The findings, however, suggest that integration of these structures in the communities has been limited to HIV/AIDS information dissemination during meetings. By its nature, CHBC service delivery in these rural areas fits in more with the structures of religious work, than the routine traditional leader’s work. For this reason, more effort is needed to get the traditional leaders and political leaders to get more closely involved.

One other important aspect reflecting transaction costs is the extent to which their actions are dictated by external authority or the degree of autonomy exercised by the actors in their day to day decisions. In this regard, the actors were asked to discuss who made the critical decisions regarding their daily routines. While the responses indicate that there is a considerable degree of independence in some areas, the groups still consider that

decisions are made by those who supervise them. This point is strongly tied to the assistance they get from their partners and the semi-formal structures in which they operate. CHBCs see themselves almost as part of the civil structures (hierarchy) that connects government and non government bodies. The groups call themselves names that associate them with the parent organization such as Malawi Social Action Fund (MASAF) group or Medicines’ San Frontier (MSF) groups depending on who gives them most of the external assistance. Two concepts found in transaction costs economics, namely ‘autonomy’ and ‘coherence’ can be used to interpret this situation.

Peters (2000:8) observes that autonomy shows the degree to which an organization is institutionalized. Autonomy represents a concern with the capacity of institutions to make and implement their own decisions. Arguably, the extent to which they are not dependent upon another organization or institution, determines whether they can be said to be institutionalized. The more institutionalized the better because this implies that the members have experimented and learnt how to work around obstacles to achieve their objectives in the most efficient manner. On the other hand, coherence represents the capacity of the institution to manage its own workload and to develop procedures to process tasks in a timely and reasonable manner. This also represents a capacity of the institution to make decisions about its core tasks and beliefs and to filter out diversions from those. If the CHBC groups have to wait for initiatives that originate from the higher level agents it must be seen to have negative implications on the costs of transacting.

The perceptions discussed in the above paragraph explain why CHBC members ask to be considered for some token allowances because those working for NGOs and government always receive large sums of money in the form of allowances for supervisory visits they make to the communities. The perception portrays that the community members feel the unevenness of the playing field; they consider themselves fully deserving as they are now an integral part of the health delivery structure. At the same time they face high transaction costs on the basis of which they would like to be compensated. In institutional economics literature, this is essentially what Israel (1987: 66) refers to as ‘job interpretation’ which results from motivational forces that are determined by personal

interests as well as from some automatic inducements of the activities in which you engage. Individuals interpret their own roles alongside others with whom they connect as they perform their activities, and build expectations on such relational linkages.

The influence of other social protection mechanisms also has a part to play in explaining