Letting them Die – Why Programs Fail

Saturday, 09 July 2016

"In the old South Africa we killed people. Now we're just letting them die." – Pieter-Dirk Uys

In her 2003 book, 'Letting them Die': Why HIV/AIDS Prevention Programmes Fail, Catherine Campbell describes how "the best-intentioned programmes, even when they achieve high levels of mobilization of the least-powerful sectors of small local communities, may have less than optimal results." (p. 19). Because the project took place in the late 90s and the book was published in 2003, I will not focus on some of the time-specific issues raised by the author, rather upon the broader issues that continue to inform programming, and analysis of it.

What is quite unique about this book is its openness to explore failure, and its explicit exploration of failures from the perspective of a critical insider (as opposed to a critical outsider who may not have all the details or be aware of the historical nuances). For example: "The second shortcoming in project design that emerges was the way in which the project planners were over-optimistic and somewhat simplistic in assuming that diverse stakeholders would be equally committed to participating in partnerships in the interests of supporting the Project's proposed activities. It was also over-optimistic in assuming that the more powerful groupings would be motivated to collaborate in projects designed to promote the interests of marginalized constituencies with little social power or influence" (p. 60). And, "rather than working together to develop new frameworks of understanding and action, they simply continued to implement the approaches they had used before the Project… with little attempt to bring these activities into the Project's integrative framework, or to develop new forms of collaboration with new and non-traditional partners" (p. 152). "Somewhat ironically, despite its well-intentioned conceptual origins, in practice the 'stakeholder' concept is often used in a way that masks how these unequal power relations between stakeholders have the power to undermine community development goals" (p. 181). Although the activities analyzed are time, place and sector bound, the approach to understanding failure offers insight into how programming can learn from what did not work well. An example of what tends to be missed by critical outsiders is that of staff related challenges and conflict, which in this project played a crucial role in creating barriers for collaboration (see pages 160-162).

Readers will appreciate the dynamic conversation woven throughout this book that explores institutional factors affecting the community that are beyond it, while engaging in very localized activities. Poverty, migrant labor systems, all-male hostels, and the selective neglect of laws (e.g. on pages 64 and 105), are a few of the contextual factors Campbell is cognizant of, while making a case for the importance of localized activities that did not address these factors directly.

Reading parts of Campbell's book I had to remind myself that it was written about a project that took place in the late 90s, not 2016. For example, she writes "Clearly, such outcome measures are vital for measuring whether or not interventions have had their desired effects. However, they often contribute little to understandings of the processes whereby programmes do or do not succeed in having an impact" (p. 9). Which is a point I've made in a recent article looking at the Safety Net program in Ethiopia. Campbell concludes: "The history of the late twentieth century is replete with examples of failed but well-meaning attempts by countries in the North to 'help' countries in the South (it is not for nothing that Africa is sometimes referred to as the 'graveyard of development projects'). Yet, these same mistakes are made again and again" (p. 193).

On social capital and participation:

"Concern has been expressed that concepts such as social capital and participation are dangerously ambiguous. On the one hand, they serve as potential tools for critical social theorists who argue that it is only through grassroots participation in strong community-based organizations that socially excluded people will gain the power to lobby governments and other powerful bodies to recognize and meet their needs. On the other hand, such concepts have the potential to be 'hijacked' by neo-liberal, free-market theorists, who argue that grassroots organizations and networks have the power to take over many functions (e.g. welfare) previously assigned to governments or international development agencies. Such arrangements can serve as justifications for cuts in welfare spending in the more affluent countries of the North, and reduced development aid to poorer countries in the South. In order to avoid this perversion of the radical potential of the concept of social capital, it is vitally important that critical social scientists locate conceptualizations of social capital, participation and community development against the backdrop of wider conceptualizations of politics and power." (p. 52-53)

"…evidence suggests that not all forms of local participation have equally positive benefits for participants. Furthermore, there is much evidence that social capital is often unequally distributed in particular contexts. Thus, for example, research has shown that effective participation in local networks is most likely to take place among the wealthiest and the most educated members of a community. Furthermore, social capital may often serve as a source of social exclusion and disadvantage, in contexts where opportunities for creating, sustaining and accessing beneficial social capital are constrained by poverty, or other forms of social inequality, such as caste or gender." (p. 53)

"…in setting up projects of this nature, much more work need to be done in clarifying the boundaries and constituencies of different stakeholder groups. There must be clarity around exactly which people and which interests are represented by each stakeholder group. It is also vitally important for each stakeholder group to provide clear and transparent procedures for ensuring that appropriately representative figures are nominated to act or speak on its behalf. It is also important for particular stakeholder groups to establish transparent mechanisms whereby their representatives are seen to consult and report back to their constituencies, and to be fully accountable to the people they represent." (p. 180)

"The research also suggested that grassroots participation is by no means a 'magic bullet'. The potential for local participation to have positive health benefits depends very heavily on the extent to which local attempts by marginalized groups are supported and enabled by efforts of more powerful constituencies, at the regional, national and international levels, and the development of health systems and organizational infrastructure to co-ordinate joint efforts. Participation has the potential to create networks of bonding social capital within marginalized communities, which is a very important component of the possibility of change. Yet such change cannot happen with the parallel efforts of more powerful groups." (p. 196)