Situating responsibility for the control of infectious disease: the work of lay HIV counsellors in South Africa Hayley MacGregor Dr Hayley MacGregor, 13 Dec 2011

The ESRC STEPS Centre S ocial T echnological and E nvironmental P athways to S ustainability

STEPS Challenges Understanding development-science interfaces in a highly dynamic world Linking environmental sustainability with poverty reduction and social justice Making science and technology work for the poor Across 3 domains: Health, Agriculture and Water Challenging conventional approaches of separate sectors and disciplinary silos Dr Hayley MacGregor, 13 Dec 2011

Key features of STEPS Approach Different FRAMINGS of systems: different ways of representing a system or problem A politicised view of ‘systems’ and their dynamic environments Acknowledging the politics of knowledge Addressing governance: power, politics and institutions Dr Hayley MacGregor, 13 Dec 2011

‘system’ environment System: Social, institutional, ecological and technological elements interacting In dynamic ways A systems perspective Dr Hayley MacGregor, 13 Dec 2011

Framings: Different ways of understanding or representing a system and its relevant environment Integrating knowledge and values: Framing Dimensions of framing - Scale - Boundaries - Key elements and relationships - Dynamics in play - Outputs -- Perspectives -- Interests -- Goals - Values -- Notions of relevant experience Dr Hayley MacGregor, 13 Dec 2011

Pathways Approach In a given situation we might ask: –Who are the actors? –How is the system and goals for change FRAMED? –How is the ‘public’ constructed? Identify PATHWAYS of response Pay attention to alternative and marginalised perspectives Constructing pathways to sustainability requires recognition and deliberation amongst multiple perspectives and possible pathways Dr Hayley MacGregor, 13 Dec 2011

Epidemics and policy Epidemics: Science, Governance and Social Justice Avian Influenza: Science, Policy and Politics Dr Hayley MacGregor, 13 Dec 2011

HIV: a chronic illness Different framings of the problem of disease control Different understandings of the role of lay HIV counsellors Shifting meanings of ‘counselling’ A case study in Khayelitsha, Cape Town Dr Hayley MacGregor, 13 Dec 2011

Qualitative Methodology In depth interviews with 20 facility-based lay counsellors Interviews with their supervisors in the contracting NGO Participant observation of their training Key informant interviews Background of a new policy framework Previous fieldwork in Khayelitsha Dr Hayley MacGregor, 13 Dec 2011

The perspective of lay counsellors: Hybrid notions of ‘counselling’ The importance of formal and informal care practices Perception of themselves as brokers between the clinic and the community Complex understandings of ‘responsibility’ for illness Dr Hayley MacGregor, 13 Dec 2011

Their working conditions Anxiety about task shifting and increasing responsibility Anxiety about associated risks The politics of professionalisation Concerns about targets: ‘the stats’ Concerns about reduced time with clients: shifts in their practice and the effect on the nature of care Dr Hayley MacGregor, 13 Dec 2011

Conclusions The importance of relationships with clients The dangers of managerialism Building on the idea of ‘brokers’: helping others negotiate the health system Adequate supervision A critical perspective on discourses of responsibility Dr Hayley MacGregor, 13 Dec 2011

A new policy framework Re-engineering Primary Health Care in SA: the role of community careworkers? UNAIDS/Cordaid cross-country study: case studies and identifying advocacy points with the help of an advisory board The value of different kinds of evidence Anthropology and interdisciplinarity The politics of policy processes Dr Hayley MacGregor, 13 Dec 2011

The STEPS Centre’s Approach Working papers and briefings free to download on