Adolescent girls are at the center of many health development interventions. Based on ethnographic research in rural Malawi, I analyze the design, implementation, and reception of an international non-government organization's project aiming to reduce teenage pregnancies by keeping girls in school. Drawing on Fassin's theorization of culturalism as ideology, I analyze how a tendency to overemphasize culture is inherent to the project's behavior change approach, but is reinforced locally by class-shaped notions of development, and plays out through reinforcing ethnic stereotypes. I argue that culturalism builds upon previous health development initiatives that dichotomized modernity and tradition, and is strengthened by shortterm donor funding. KEYWORDS Malawi; behavioral change; culturalism; harmful cultural practices; teenage pregnancies Currently, adolescent girls are a major target group of global health and development interventions. In line with the interconnected nature of the Sustainable Development Goals, the Global Strategy on Women's, Children's and Adolescents' Health and a Lancet Commission on Adolescent Health and Wellbeing suggest multisectoral policies with a strong link between adolescent (reproductive) health and education, including comprehensive sexuality education (Patton et al. 2016; WHO 2015). The prevailing development discourse depicts girls as the greatest investment for economic development; an empowerment discourse which, according to Hickel (2014:1355), "has become popular because it taps into ideals of individual freedom that are central to the Western liberal tradition." In the case of maternal health, this pairing of health and economic arguments resulted in part from a deliberate rebranding by advocates who felt that the message "saving women's lives" did not resonate with neoliberal or businessoriented donors (Storeng and Behague 2014). The framing of teenage pregnancies is related not only to adverse health outcomes, but also to the interruption of schooling and girls' developmental potential (Patton et al. 2016). In wider development discourse, education, gender equality, human rights, delaying marriage, and reducing fertility are constructed as reciprocal causal aims, characteristic of modern societies, and capable of catalyzing economic development (Thornton, Dorius and Swindle 2015).This particular focus on girls has been criticized for its neoliberal underpinnings. Girls are simultaneously constructed as vulnerable and responsible for development, presented as culturally constrained and sexually oppressed; individual personhood and kinship are overemphasized as drivers of poverty, whereas structural factors at communal, national, and global levels are ignored (Hickel 2014;Shain 2013;Switzer 2013;Switzer, Bent and Endsley 2016). Empirical research shows that "empowered" girls struggle to overcome structural barriers (Hayhurst 2013) and draws attention to the creation of new subjectivities and relationships (Classen 2013). Interventions that appear to be morally neutral and ev...
International non-governmental organisations (INGOs) play an increasingly prominent and multifaceted role in the field of global healthas policy advocates, recipients of donor funds, and implementers of donor-funded programmes. Many such NGOs and their local affiliates have become highly professionalized and oriented towards the priorities of global-level actors, with potential negative consequences for their ability to represent the grassroots and to challenge structures of power and inequality. In this thesis, I examine the dynamics around INGO project implementation in Malawi, within the broader context of overlapping development initiatives, shifting priorities, conditions of scarcity and donor dependence, and poor health outcomes. I draw on ethnographic research conducted in rural Malawi between May 2015 and August 2016, which focused on the implementation of a Save the Children project that aimed to improve maternal health by reducing teenage pregnancies, primarily by keeping girls in school and increasing their use of reproductive health services, notably contraceptives. My ethnographic gaze is on the individuals who serve as intermediaries between donors, northern (I)NGOs and local recipients, who I conceptualise as brokers. They include INGO district staff, primary school teachers, health workers, village heads, and community representatives. Through a focus on their practices, I examine how they translate global norms and aims into programmatic practice. The thesis brings together three peerreviewed articles. The first (in Forum for Development Studies) discusses how primary school teachers deal with, and implement, various overlapping NGO initiatives targeting girls, and the implications for public sector institutions. The second article (in Medical Anthropology) examines how INGOs' programmatic focus on behaviour change interventions inadvertently results in staff blaming culture for teenage pregnancies and school dropout, reinforcing ethnic stereotypes originating in historical inequalities and previous health development initiatives which targeted harmful cultural practices. The third article (in Reproductive Health Matters) analyses the responses of village heads, midwives and women to the reintroduction of userfees for maternal health services resulting from donors' suspension of budget support, shifting national priorities, and unstable service delivery contracts. Overall, I argue that examining the practices of the brokers who implement and reshape health development initiatives can shed light on policy-to-practice gaps and how unintended consequences occur. My ethnographic research thus helps to explain why initiatives might not be sustainable despite the intention of donors and INGOs to strengthen existing public and community structures. 1 This research is led by Professor Sidsel Roalkvam, Co-Investigator Katerini Storeng, and senior researchers at the University of Malawi-Professor Blessings Chinsinga, Peter Mvula and Joseph Chunga. Fieldwork in Malawi has been carried out by three Universit...
Despite the strong global focus on improving maternal health during past decades, there is still a long way to go to ensure equitable access to services and quality of care for women and girls around the world. To understand widely acknowledged inequities and policy-to-practice gaps in maternal health, we must critically analyse the workings of power in policy and health systems. This paper analyses power dynamics at play in the implementation of maternal health policies in rural Malawi, a country with one of the world's highest burdens of maternal mortality. Specifically, we analyse Malawi's recent experience with the temporary reintroduction of user-fees for maternity services as a response to the suspension of donor funding, a shift in political leadership and priorities, and unstable service contracts between the government and its implementing partner, the Christian Health Association of Malawi. Based on ethnographic research conducted in 2015/16, the article describes the perceptions and experiences of policy implementation among various local actors (health workers, village heads and women). The way in which maternity services "fall apart" and are "fixed" is the result of dynamic interactions between policy and webs of accountability. Policies meet with a cascade of dynamic responses, which ultimately result in the exclusion of the most vulnerable rural women from maternity care services, against the aims of global and national safe motherhood policies.
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