Aid Withdrawal and Health Care Sustainability

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Aid Withdrawal and Health Care Sustainability Shifting Mandates in Health Institutions and Hiv/Aids Programs in Tanzania
Marten, Meredith G
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University of Florida
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Doctorate ( Ph.D.)
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University of Florida
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AIDS ( jstor )
Funding ( jstor )
Health care industry ( jstor )
HIV ( jstor )
Hospitals ( jstor )
Lutheranism ( jstor )
Nonprofit organizations ( jstor )
Primary health care ( jstor )
Volunteerism ( jstor )
Women ( jstor )
Anthropology -- Dissertations, Academic -- UF
health -- hiv -- tanzania
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theses ( marcgt )
government publication (state, provincial, terriorial, dependent) ( marcgt )
born-digital ( sobekcm )
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Anthropology thesis, Ph.D.


This dissertation uses the concept of precarity to frame the lived experience of uncertainty among patients and caregivers whose lives and livelihoods depend on the volatile health system in Tanzania. The past decade was marked by dramatic increases in donor assistance and increased pressure on non-governmental organizations (NGOs) to roll out HIV/AIDS programs. After the 2008 financial crisis, donor funding was scaled back, resulting in significant changes in the services available to many people living with HIV, and in the salaries and availability of work for Tanzanian health care workers. This research explores how volatility in global health funding and policy is experienced by patients, health care workers and administrators across multiple levels, principally within the context of shifting HIV/AIDS policy objectives. The data for this project was collected in twenty non-contiguous months from 2008-2013 in two sites: Dar es Salaam and Haydom Tanzania. Dar es Salaam is the commercial capital of Tanzania, representing an area with a multitude of NGOs. Haydom hosts a small rural hospital in north-central Tanzania. Data collection in both sites employed ethnographic methods to understand individual experiences of fluctuations in services and employment opportunities associated with short-term, donor-funded initiatives implemented via NGOs. I use this ethnographic data to illustrate the contingent processes of aid withdrawal and efforts to create sustainable health care in Tanzania, and identify that health care is just one of many unpredictable factors that patients and caregivers experience. Results indicate that the proliferation of private and non-governmental organizations in Tanzania contributes to an increasingly fragmented health system, which threatens the efficiency of national health care. NGOs exacerbate the brain drain of health care workers by encouraging employee migration from the public sectors to the high paying private sectors. Second, rising patient fees implemented by some NGOs limit access to care. Third, cuts in donor funding and services is associated with patient attrition, declining HIV/AIDS program enrollment, and reduced salaries for Tanzanian health care workers. This dissertation concludes by identifying opportunities for health systems to provide sustainable and equitable care, and encourages the integration of disease-specific programs into the Tanzanian public health sector. ( en )
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Thesis (Ph.D.)--University of Florida, 2014.
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by Meredith G Marten.

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© 2014 Meredith Gretz Marten


To my Dad, to Sharon, and to Brenda


4 ACKNOWLEDGMENTS First and foremost, I would like to thank the many people in both Haydom and in Dar es Salaam who participated in this research, and tolerated the hours of questions , measurement s and my general hanging around. Your patience with me, your insightfulness, and your collective concern and genuine interest in working to improve the well being of people in your communities is impressive, nob le and humbling. I learned so much from your experiences, and I am forever grateful. At Haydom, many people were essential in helping me to get this research off the ground. In particular, Olav and Turid Espegren and Mama Mushi , without whom I would not h ave been able to do nearly as much research as I did with many of the mothers living with HIV/AIDS. Your help and guidance were critical, and your deep concern and caring for the well being of your patients above all was very inspiring and moving. Bodil B ø V å ga, thank you for taking me under your wing in my early days in the field and offering so many important insights! For their invaluable research assistance in Tanzania, I give many heartfelt thanks to Neema, Lucy, Sesilia , Flora and Deo. Your work extended beyond helping me to figure out the most interesting questions to ask and talking through how best to interpret the meaning of data; y ou were great friends and motivated me to keep going. I cannot thank you enough! Many in Dar your kindness, hospitality and friendship were exceptional. Brenda, I will never forget your immediate help and hugs (and a glass of wine on the beach) in my greatest mo ment of need you are the single biggest reason I was able to stay in Tanzania and keep going during a trying first few weeks. I will never be able to properly get across how thankful I am to you, but dedicating this dissertation to you is a reflection of how central you are to the stories I tell here , and how deeply grateful I am to you and your lovely children. Besides all that, you are also one


5 of the most dedicated, caring, and motivated health care workers I have seen anywhere, and I look up to you so th and health care in Tanzania. Thanks also to Annike for putting me up for a few weeks, great conversations and making delicious espresso! Mama Neema, Stephano, Neema, Lucy, Kiri, Linda, Upendo, Wesley and Mary thank you for welcoming me into your home and treating me like a family member, you were wonderfully kind and so very helpful. To many of the other wonderful peopl e I met along the way Ingeborg , Britt, Linn, Kjartan, Joany, Anette tusen tak k for your friendship, your insights, for adventuring together, and for teaching me a handful of Norwegian words! To Ingeborg and Cathy in particular, talking through many of my research questions with you both was enormously helpful, the outcomes of those conversations are scattered throughout these pages. I wrote them with you in mind, and I am so very thankful. Many thanks as well to Sode Matiku, who helped me to negotiate t he labyrinthine DSM health care system and work through many fundamental questions about health care delivery. I hope to work with you again! And to Sheila Makindara , Timah Twalipo and Mihayo Bupamba as well my first work in D ar was made possible by you all thank you for being wonderful and supportive friends and mentors ! Additionally, thank you to the Tanzania National Institute for Medical Research, the Commission for Science and Technology, Haydom Lutheran Hospital, and the numerous NGOs I wandered around and pestered people with endless questions (especially ICAP). My w ork would have been impossible without your support thanks to all the organizations who work tirelessly to advance science and medical research and practice to benefit the health and well being of Tanzanians.


6 In Florida, thanks to Alyson Young a wonde rful ad visor and supportive friend, who devoted many hours to listening to me work through problems and helping me to figure out how best to address them. Thank you as well for being a fantastic fieldwork companion and introducing me to Haydom. I would lik e to thank my dissertation committee Clarence (Lance) Gravlee, Maria Stoilkova, and Suzanna Smith, as well as Peter Collings, Sharon Abramowitz, Sarah Szurek and Marit Ø stebo for providing much needed assistance in the field and during data analysis writ e up stages. Pete thanks so much for reading and commenting on hundreds of pages, and for helping me figure out what ethnography means! I look forward to learning more from you as we venture north this summer. M any thanks as well to All ison Salinger and Shreya Patel two very intelligent and motivated undergrads at UF for their help in transcribing interviews. Many fellow students and friends at UF helped me immensely during the proposal, research and writing processes, including Noelle Sullivan, Clau dine Valli è res, Gypsy Price, Tess Ryley, Sarah Szurek , Alan Schultz, Brian Tyler, David Dillon Alon dra Laguer Diaz, Val Solomon, Zack Gilmore and Ben Burgen . To Alison Montgomery, I rt has meant to me throughout this whole process . Being in the field at the same time and sharing our stories and worries were so comforting when I was most uncomfortable. Karen Jones was invaluable (and somehow always smiling and cheerful!) , as were Pam, Pat, and Nita . Thank you all for your help! Cor rina, Todd, Abe and Ike a t the Center for African Studies were wonderful help as well , many thanks for all that you do to keep us in line. To Beth Chambless thank you so much for your support and a much needed visit toward the end of fieldwork. You are always a breath of fresh air and the funniest person I know


7 perfect for injecting humor into a fieldwork experience that was often sad. Also many thanks to Cheryl Ward for advising me during my early, formative years you made me the anthropologist I am today, and ten years later I continue to be very grateful. Ben , thank you so much for brainstorming with me for hours on end how to work through, think abo ut, and write up this work. Your kindness, interest, intelligence and helpfulness were critical for this dissertation getting done, and making it a less lonely experience than it so often is. Dad , thanks for always encouraging me to do the interesting thi ngs that I was passionate about Your sunny outlook on life, and your grit, are exceptional and coaching me over the phone to be that myself during tough times in the field was essential. Many thanks also to Mike, Melissa and A ndrew for your love and support! Finally, many heartfelt thanks to Sharon Jablonski, a wonderful role model who encouraged me to do a PhD in the first place, and to keep searching for the rese arch that interested and inspired me the most. That encouragement continued to keep me going through the difficult return shock phase, and through data analysis and writing stages . You are always o n my mind, and are dearly missed. Funding for this researc h was made possible by many generous sources, principally the US Fulbright Hays Doctoral Dissertation Research Abroad program, funding thro ugh the Madelyn Lockhart Dissertation Fellowship . Funding for data analysis and dissertation writing also helped enormously, through the John M . Goggin Award and the Elizabeth


8 TABLE OF CONTE NTS page ACKNOWLEDGMENTS ................................ ................................ ................................ ............... 4 LIST OF TABLES ................................ ................................ ................................ ......................... 11 LIST OF FIGURES ................................ ................................ ................................ ....................... 12 LIST OF ABBREVIATIONS ................................ ................................ ................................ ........ 13 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .................. 17 The Golden Age of Global Health ................................ ................................ .......................... 18 Precariousness and Precarity ................................ ................................ ................................ .. 20 Sustainability ................................ ................................ ................................ .......................... 22 Methods ................................ ................................ ................................ ................................ .. 25 Summer 2009 Field Season ................................ ................................ ................................ .... 27 2011 2012 Field Season ................................ ................................ ................................ ....... 31 Sustainability in Policy and Practice ................................ ................................ ...................... 35 Organization of the Dissertation ................................ ................................ ............................. 40 2 GLOBAL HEALTH AND ETHNOGRAPHIC CONTEXT ................................ .................. 44 Historical Roots of Global Health and Development ................................ ............................. 45 IDS 2008) ................................ ...... 48 ................................ ........ 50 Primary Health Care and Health Systems Strengthening ................................ ................ 57 History of Aid in Tanzania ................................ ................................ ................................ ..... 60 The Health Sector in Tanzania ................................ ................................ ............................... 62 Introduction to Fieldwork ................................ ................................ ................................ ....... 65 Fieldwork Setting ................................ ................................ ................................ .................... 67 Haydom, (Mbulu, Manyara, Tanzania) ................................ ................................ ........... 68 Haydom Lutheran Hospital ................................ ................................ ...................... 72 HIV and PMTCT at Haydom Lutheran Hospital ................................ ..................... 76 Dar es Salaam ................................ ................................ ................................ .................. 78 Key Informants ................................ ................................ ................................ ................ 82 Conclusion ................................ ................................ ................................ .............................. 87 3 THEORETICAL CONTEXT ................................ ................................ ................................ . 88 Global Health Inequalities ................................ ................................ ................................ ...... 88 Neoliberalism, Globalization and Health ................................ ................................ ........ 91 Biopower and Biopolitics ................................ ................................ ................................ 97 Biological Citizenship ................................ ................................ ................................ ... 100


9 ................................ ................................ ............................... 102 Precariousness and Precarity ................................ ................................ ................................ 105 Precarity ................................ ................................ ................................ ......................... 107 Precarity in HIV/AIDS Programs in Tanzania ................................ .............................. 111 Sustainability and Sustainable Development in Health ................................ ........................ 114 Conclusion ................................ ................................ ................................ ............................ 120 4 ................................ ................................ ................................ ............... 121 Fieldnotes, 12 March, 2011 (Dar es Salaam) ................................ ................................ ....... 121 Precariousness ................................ ................................ ................................ ....................... 124 Methods ................................ ................................ ................................ ................................ 127 Semi structured Interviews: Haydom Town and Villages (92 total) ............................. 128 Cultural Consensus Anal ysis ................................ ................................ ......................... 130 Results ................................ ................................ ................................ ........................... 134 Discussion of Cultural Consensus and Interview Data ................................ ......................... 134 The Shift to Market Economy ................................ ................................ .............................. 140 ................................ ................................ . 141 Education and Employment ................................ ................................ ................................ .. 145 ................................ ................................ ................................ ......................... 149 Joyce ................................ ................................ ................................ .............................. 151 Asha ................................ ................................ ................................ ............................... 153 George ................................ ................................ ................................ ........................... 156 Gideon ................................ ................................ ................................ ........................... 160 Tumaini ................................ ................................ ................................ .......................... 162 5 AID WITHDRAWAL: PRECARIOUSNESS IN HEALTH CARE ................................ .... 171 Aid Exit ................................ ................................ ................................ ................................ . 176 Case Studies of Aid Withdrawal ................................ ................................ ........................... 179 #1: Bilateral and Multilateral Aid in Tanzania: Rapidly Shifting Do nor Funding and Policy ................................ ................................ ................................ ......................... 180 #2: Haydom Lutheran Hospital Funded Hospital ................................ ................................ ................................ ......... 186 Corruption at HLH ................................ ................................ ................................ . 191 Aid withdrawal and moral obligations ................................ ................................ ... 196 #3: Millennium Development Goals 4 and 5 Program: The Tail End of a Vertical Program ................................ ................................ ................................ ...................... 200 #4: PEPFA R in Tanzania: Fueling the Golden Age of Global Health .......................... 204 #5: PMTCT at HLH: Decreasing Enrollment and Loss to Follow Up After Funding Rolls Back ................................ ................................ ................................ .................. 207 Conclusion ................................ ................................ ................................ ............................ 214 6 HEALTH CARE SUSTAINABILITY: PRIVATE ORGANIZATIONS AND HEALTH SYST EM STRENGTHENING IN TANZANIA ................................ ................ 215


10 Methods ................................ ................................ ................................ ................................ 217 Human Resources, Capacity Building and Health System Strengthening: Fundamental Barriers to Building Sustainable Health Care in Tanzania ................................ ............... 218 ................................ ................................ ...... 219 Health System Strengthening ................................ ................................ ........................ 222 Internal Brain Drain ................................ ................................ ................................ ....... 224 Medical Education And Accreditation ................................ ................................ .......... 226 Trainings ................................ ................................ ................................ ........................ 228 Salaries ................................ ................................ ................................ .......................... 232 Uzembe and Rushwa ................................ ................................ ................................ ..... 237 User Fees ................................ ................................ ................................ ....................... 241 Sustainability at Haydom Lutheran Hospital ................................ ................................ ........ 243 Discussion ................................ ................................ ................................ ............................. 245 PEPFAR and Sustainability ................................ ................................ ................................ .. 251 Conclusion ................................ ................................ ................................ ............................ 253 7 DISCUSSION AND CONCLUSION ................................ ................................ .................. 255 Privatization, Time, and the Humanitarian Mission ................................ ............................. 257 Privatization and Global Health in Tanzania ................................ ................................ ........ 258 Power at the Almost Exit ................................ ................................ ................................ ...... 263 A Look Ahead ................................ ................................ ................................ ....................... 273 Contributions of the Dissertation ................................ ................................ .......................... 275 APPENDIX A SEMI STRUCTURED INTERVIEW QUESTIONS FO R WOMEN IN PMTCT .............. 279 B SEMI STRUCTURED INTERVIEWS, HAYDOM ................................ ............................ 282 C SEMI STRUCTURED INTERVIEW QUESTIONS, HEALTH CARE WORKERS AT HAYDOM LUTHERAN HOSPITAL ................................ ................................ ................. 285 LIST OF REFERENCES ................................ ................................ ................................ ............. 286 BIOGRAPHICAL SKETCH ................................ ................................ ................................ ....... 314


11 LIST OF TABLES Table page 3 1 Health related sustainable development goals, from "The Future We Want" (UN 2012). ................................ ................................ ................................ ............................... 117 4 1 Consensus analysis answer key, Haydom town ................................ ............................... 136 4 2 Consensus analysis answer key, villages surrounding Haydom ................................ ...... 138 5 1 Changes in contributi KEPA, Policy Brief 03:2012 ................................ ................................ ............................ 184


12 LIST OF FIGURES Figure page 1 1 Public health students at SAIDIA Health Clinic, Samburu District, Kenya (2007) .......... 23 1 2 Samburu women waiting with their children to see the traveling nurse (200 7). ............... 24 2 1 Shops along the road near the entrance gate to Haydom Lutheran Hospital (2009). ........ 71 2 2 Entrance gate to Haydom Lutheran Hospital (2012). ................................ ........................ 72 2 3 Haydom Lutheran Hospital (2012). ................................ ................................ ................... 73 2 4 ................................ ................................ ..... 74 2 5 HIV Clinic at Haydom Lutheran Hospital (2012). ................................ ............................ 76 2 6 Fish market and air traffic control center, downtown Dar es Salaam (2011). ................... 79 4 1 ................................ .................... 157 5 1 Official development assistance to Tanzania. World Bank (2013e) ................................ 180 5 2 Number of women enrolled in PMTCT, 2008 2012. ................................ .................... 213 6 1 Tanzania consumer pri ce index (CPI), January 2000 January 2014 (NBS 2013) ........ 234 6 2 Percent of donor funds bypassing the state. From Mbacke (2013). ................................ . 252


13 LIST OF ABBREVIATIONS AMO Assistant Medical Officer ART Anti retroviral therapy (HIV/AIDS treatment) ARVs Anti retrovirals CCM Chama cha Mapinduzi Tanzanian political party CHBC Community Home Based Care Worker CMI Christen Michelsen Institute COs Clinical Officers CTC Care and Treatment Center acronym for the HIV/AIDS clinic at the hospital DFID Department for International Development (United Kingdom) DMO District Medical Officer FBOs Faith Based Organizations GBS General Budget Support GFATM Global Fund for AIDS, Tuberculosis and Malaria GHI Services HAART Highly Active Anti Ret r oviral Therapy Health Care Worker HCW HLH Haydom Lutheran Hospital HRH Human Resources for Health HSSP Health Sector Strategic Plan MDGs Millennium Development Goals MMD Managing Medical Director MOHSW Ministry of Health and Social Welfare (Tanzania) NACP National AIDS Control Programme


14 NGO Non Governmental Organization NORAD Norwegian Agency for Development Cooperation OECD Organization for Economic Cooperation and Development PEPFAR PF Partnership Framework PHC Primary Health Care PLHIVs People Living with HIV PMTCT Prevention of Mother to Child Transmission (of HIV) PRSPs Poverty Reduction Strategy Papers RNE Royal Norwegian Embassy SAPs Structural Adjustment Programs SDGs Sustainable Development Goals TB Tuberculosis UNAIDS Joint United Nations Programme on HIV/AIDS URT United Republic of Tanzania USAID United States Agency for International Development VCT Voluntary Counseling and Testing (for HIV) WHO World Health Organization


15 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy AID WITHDRAWAL AND HEALTH CARE SUSTAINABILITY: SHIFTING MANDATES IN HE ALTH INSTITUTIONS AND HIV/AIDS PROGRAMS IN TANZANIA By Meredith Gretz Marten August 2014 Chair: Alyson G. Young Major: Anthropology This dissertation uses the concept of precarity to frame the lived experience of uncertainty among patients and caregivers whose lives and livelihoods depend on the volatile health system in Tanzania. The past decade was marked by dramatic increases in don or assistance and increased pressure on non governmental organizations (NGOs) to roll out HIV/AIDS programs. After the 2008 financial crisis, donor funding was scaled back, resulting in significant changes in the services available to many people living wi th HIV, and in the salaries and availability of work for Tanzanian health care workers. This research explores how volatility in global health funding and policy is experienced by patients, health care workers and administrators across multiple levels, pri ncipally within the context of shifting HIV/AIDS policy objectives. The data for this project was collected in twenty non contiguous months from 2008 2013 in two sites: Dar es Salaam and Haydom Tanzania. Dar es Salaam is the commercial capital of Tanzania , representing an area with a multitude of NGOs. Haydom hosts a small rural hospital in north central Tanzania. D ata collection in both sites employed ethnographic methods to understand individual experiences of fluctuations in services and employment oppo rtunities associated with short term, donor funded initiatives implemented via NGOs.


16 I use this ethnographic data to illustrate the contingent processes of aid withdrawal and efforts to create sustainable health care in Tanzania , and identify that health care is just one of many unpredictable factors that patients and caregivers experience . Results indicate that the proliferation of private and non governmental organizations in Tanzania contributes to an increasingly fragmented he alth system, which threatens the efficiency of national health care. NGOs exacerbate the brain drain of health care workers by encouraging employee migration from the public sectors to the high paying private sectors. Second, rising patient fees implemente d by some NGOs limit access to care. Third, cuts in donor funding and services is associated with patient attrition, declining HIV/AIDS program enrollment, and reduced salaries for Tanzanian health care workers. T h is dissertation concludes by identif ying o pportunities for health systems to provide sustainable and equitable care , and encourages the integration of disease specific programs into the Tanzanian public health sector.


17 CHAPTER 1 INTRODUCTION Global health car e quality and availability varies dramatically across temporal, structural and spatial scales. An integrated global perspective on health highlights the stark inequalities in, and unpredictability of, resources, services, and even exposure to infectious di sease across different populations. For tho se whose lives or livelihoods depend on this volatile system, everyday life can be very precarious. This dissertation examines the precariousness of life amidst fluctuations in health care provision and funding in north central Tanzania within the last decade . 2009), Tanzania, and sub Saharan Africa more generally, was exposed to dramatic increases in donor assistance for health, especially for HIV /AIDS care, treatme nt and prevention . This period in global health is often referred to as the vast improvement in health outcomes compared with the two previous decades, the 1980s and 1990s. However, this golden age was followed by cutbacks in do nor funding after the 2008 financial, food and fuel crises. My research asks how patients, health care workers, and administrators at the local levels experience this volatility, particularly within the context of HIV/AIDS programming and policy among inte rnational NGOs . When funds are scaled back , w hat services are eliminated? What is prioritized? What do these priorities illustrate about NGO funded and implemented health care, and how do they impact on the populations they are meant to serve? How do peopl e interpret these changing mandates in health care, and what does it mean t o them? I conducted twenty months of multi sited ethnographic research between 2008 2013 , in Dar es Salaam, the comm ercial capital of Tanzania, and Haydom, a smaller town in north central Tanzania. Haydom is home to the , and to the HIV /AIDS clinic in which I conducted the majority of my research. As I elaborate further in this introduction, the


18 volatility in HIV funding and prog ram services that I witnessed in Haydom over a short period of time became my central focus , in large part because those most dependent on that care people living with HIV/AIDS will need stable, reliable, and sometimes extensive health care services fo r the rest of their lives. The scaling back of donor aid for HIV care was draconian , not only for patients themselves, but also for the wider commu nities, health care workers , and for the health system as a whole. C ommunities and institutions benefitted fr om the attendant increases in funds dedicated to strengthening health systems and building up the health workforce , paramount for most effectively delivering HIV/AIDS services. This resea rch brings to light the precariousness of those who frequently fall through gaps in funding and services. It looks critically at the movement to promote sustainability in health care, as global health researchers and policymakers increasingly acknowle dge that volatility erodes lo ng term population health and economic development. With this research, I aim to better understand how people experience volatility, and to illuminate the ir principal concerns, barr iers to care and to good health; and for health care workers how volatility in funding and aid mandates affect t heir livelihoods . Finally, I hope to un cover ways in which global health policy may be directed in order to best address the things that most negatively impacts on population health and well being . The Golden Age of Global Health Th e golden age of global health (Messac and Prabhu 2013) was marked by two principal changes 1) the steep increase in donor assistance for health , and 2) the rapid rise in non governmental organizations (NGOs) providing health care services funded through this donor aid. D onor assistance for health increased from US$ 5.59 billion in 1990 to 21.79 billion in 2007 ( Ravishankar et al. 2009 ) which translated into dramatic improvements in global health outcomes. Increases in donor aid originated with the United Nation s Millennium Development G oals (MDGs) , implemented in 2000. The MDGs were focused on ending pov erty via eight


19 principal goals, four of which are explicitly health relate d : eradicating hunger, r educing child mortality, improving maternal health, and combat ting HIV/AIDS, malaria and other diseases. The funding increase for HIV/AIDS in particular came from many sources, including the Gates Foundation; the W orld Health Organization ; the U nited N ations through the Global Fund to Fight AIDS, Tubercu losis, and Malari a; and through the US G E mer gency Plan for AIDS R elief, or PEPFAR, the largest financial commitment ever, by any nation, for a major international health initiative dedicated to a single disease ( PEPFAR 2014 ). President George W. B ush established PEPFAR in 2003 , with $15 billion dedicated to its rollout. The scale up of PEPFAR was impressive as well by 2010, $46 billion had been committed to HIV, along with smaller amounts for malaria, TB and maternal and child health . This increa se in funds played a significant role in g etting underserved populations on antiretroviral treatment, which remains fre e to all those who need it in Tanzania . F ollowing the 2008 food, fuel and financial crises , and the beginning of scale backs in aid in light of expected funding shortfalls, the current PEPFAR strateg y is to focus on transitioning from an emergency response to The second significant change during this golden age of global health was in the arena of health care delivery principally, the steep rise in the number of NGOs that were tasked with implementing health programs established with this bolus of donor funds many of which were disease . HIV/A IDS programs are exemplars of this model of health care, which is understood best as part of the larger political economic context of expanding neoliberalism promoted throughout the world. In neoliberalism, the public sector (of which health care is a prin cipal part) is rolled back, with private corporations, NGOs and other civil society acto rs encouraged to take its place. These organizations oftentimes offer more


20 inconsistent services for higher fees, which cater to wealthier patrons who are better able to pay high fees for services. During this process, private actors benefit from the sale of social services , via the creation of privatize d industries for the delivery of socia l services. In this case , citizens have little say in what services are available, to whom, and under what guidelines, making privately organized social service provision inherently undemocratic . I mportantly, private o rganizations are principally accountable not to citizens but to donors, patrons, or stockholders. Theories of neoliberalism and globalization underline common critiq ues of global health governance. T he stark inequalities in services in availability, acc ess, and quality that emerge in neoliberalism have been exposed in many important ethnographies of health care as a principal focus of outrage (see Farmer 2001, 2004, 2006 ; Nguyen 2005 ). Inequality a s a central focus of critique is founded in large part upon Foucauldian theory, and in particular, the centuries old transition in state power from sovereignty to biopower ( 2010/1972 ). In his theory of this live longer and therefore (Foucault 2010/1978:264). In this system, a sovereign had the power selectively choosing who had access to life saving services, and who did not. In this space, Foucault writes, the biological existence was reflected in poli :264). Precariousness and Precarity Many ethnographers have discussed the politically governed and unequal means through which biological life is managed as a principal point of inquiry. M y central contribution to this research is my focus on the lived e xperience of this inequality . In particular, I investigate the


21 extreme preca riousness that defines everyday life for many people in resource poor countries, and specifically for people living with HIV (PLHIVs). This focus is significant in the context of HIV/AIDS because of the importance of consistency of health care and availabi lity of antiretrovirals for those who need it to survive. In this case, health care volatility becomes a question of life and death . For this purpose, the concept of precarity has served as an effective conceptual framework for understanding many of the pr ocesses I saw during my fieldwork. Judith Butler , the philosopher and gender and queer studies scholar , writes of precariousness as (Butler 2009:14). Precarity is, essentially, the recognition that exposure or vulnerability to precariousness is unequal and politically governed some people live exceedingly p recarious lives, while others only rarely experience it. Uncert ainty and unpredictability, and an absence of day to day life or long term fate, are not only understood as considerably bad armot 2001; van Rossum et al. 2000), but also increasingly characteristic of the experience of everyday life in the time of neoliberalism and expanding privatization (Muehlebach 2013). As Marmot and colleagues noted in their long term study of British civil service workers at Whitehall ( 1997; 2001 ), a lack job, for example, contributes to lowest ischemia, compared with highest grade workers. Ethnographies of precarity share several factors in marginalization, and injustice; environmental devastation and industrial recklessness; stunning ; Fortun 2012:459 as cited in Muehlebach 2013). Precarity is described as a central experience of many people outlined in ethnographies of


22 austerity, neoliberalism or state withdrawal, and particularly in work related to labor, generally, and creative labo r in particular (Muehlebach 2013; Neilson and Rossiter 2008; Puar 2012). Butler has written some of the most compelling work on precarity, including American experiences of it after September 11, 2001 in New York, where the global elite people who are mo re often exempt from experiencing precariousness up close did so in an instant (2006). A similar phenomenon, which I explain in more detail in Chapter 3 , outlines how the European experience of precariousness in the wake of austerity following the 2008 r ecession is distinctly different from that experienced by others in the developing world. In the European case, the welfare state is taken as the benchmark, the glorified period in history against which austerity is measured, with strong social safety nets in place. This gloried state never existed in many resource poor countries, however, or when it was present, it existed to a much lesser degree for a much briefer time. Sustainability Sustainability of health care services has lately emerged as a principa l topic of research and policy making, in large part to reduce the volatility of services that so often occur in predominantly donor funded health care environments. Health care sustainability emerged as a central topic of my own research over the course o f a few years because of my own experiences with health systems first as a public health graduate student and intern with an HIV non governmental organization (NGO) in Dar es Salaam , and later during my graduate education and fieldwork in Tanzania. My fi rst encounter with the concept o f sustainability in health care and the difficult ies that arise in promoting it, happened during a visit to a small, rural health clinic in Samburu District, central Kenya (Figure 1 1) . The clinic served mostly poor, nomadic populations, and our small group of grad uate students toured the building during a month long field course in HIV/AIDS programs. My British born (but American and Kenyan resident)


23 public health professor founded the clinic 25 years prior, and had been working at the clinic on and off since, still supporting it principally through international fundraising efforts. She never intended to still be fund raising for it, she told me, afte r so many years it was meant to be taken on by the community of nomadic herders who deal little in cash, or the government, by that health care available to these people would disappear. Figure 1 1 : Public health s tudents at SAIDIA Health Clinic, Samburu District, Kenya (2007) This initial realization of the precariousness of health care for many in the world profoundly shaped my interests in glob al health over the long term. I encountered similar problems of sustainability of funding and operations in a variety of health care contexts, alongside widespread unrealistic expectations of sustainability of care being established for the future.


24 Figure 1 2 : Samburu women waiting with their children to see the traveling nurse (2007). For my capstone global health internship the following summer of 2008, I worked in Dar es Salaam with an American HIV/AIDS NGO, which delivered care to five regio ns in Tanzania, including Dar es Salaam. This NGO was funded principally (over 95% at the time) by PEPFAR , Adherence and Psych osocial Support division, and much o f my job involved reading through pages and pages of policy documents and program plans, always very detailed and expansive. single paragraph in the nine page document was re common jargon sustaining support groups...ensuring continuit will work hand in hand with the MOHSW NACP


25 (Ministry of Health and Social Welfare National AIDS Control Programme) to see that there is active involvement of NACP in each potential step. This will ensure recognition and acceptance of the program from the start, resulting into national wide replication and scale up in the near That the end of the funding boom for global health, and HIV/A IDS in particular, would come just a few months later was likely office that summer, when my colleagues drafted their sustainability plans. But when the 2008 financial crisis came to a head that September, suddenly sustaina bility (and aid withdrawal) was front and center if foreign aid was cut back, how would resource poor countries like Tanzania manage to maintain, and sustain, the enormous, and enormously successful, HIV/AIDS programs that had been established just a few Methods Between 2008 and 2012, I conducted 20 months of multi sited fieldwork in Tanzania, in the small town of Haydom in rural Manyara region, and in urban Dar es Salaam . My goal was to capture a broad image of how aid withdrawal and sustainability were understood and e xperienced in a range of health care settings and in HIV/AIDS programs. I employed a combination of research methods, including participant observation, surveys, informal and semi structured interviews, in these settings and with a variety of informants: p atients, health care workers, health administrators, and policy makers, friends, and people from Haydom town and surrounding villages. Informants were principally Tanzanian, but many also were from elsewhere in Africa, the US and Canada, and Europe (partic ularly Norway).


26 I observed and experienced the phenomena of precarity and efforts to build more sustainable health care throughout the health sector and in a variety of settings in these two cities. To capture a broader image of how these themes were conc eptualized, operationalized and experienced in health, I conducted surveys and interviews with numerous informants in Dar e s Salaam and Haydom. I carried out 32 semi structured interviews with PEPFAR administrators, implementing partners, and program plann ers; health care workers in HIV, maternal and child health, family planning, hematology and tuberculosis clinics and programs; expatriates and Tanzanians, NGO, government or Ministry of Health and Social Welfare (MOHSW) employees alike. Questions sought to better understand how people working in health in Tanzania understood sustainability to mean, what in particular was being sustained, what did the imagined healt h system and the strategies employed to build it up. In Haydom, I wanted to better understand what the patient experience might look like, going through an unpredictable program that in its short lifetime had many ups before its long slide down. Using the these processes, I conducted 75 semi structured interviews with mothers who had, at some point in the past eight years, been enrolled in the PMTCT program at HLH, and could comment on the care and support they had received and we re currently receiving, their strategies to keep themselves and their families healthy, and their hopes and concerns for the future of their care, in addition to short health histories and family and social background. Finall y, I conducted 90 interviews (two rounds, conducted iteratively) with people living in Haydom and five surrounding village s, asking about health care quality and availability, changes in health and health care over the past 15 years, as well as observations about broad


27 social changes in education, development, agriculture and employment. To accompany these vill age surveys, I also conducted 61 consensus analysis surveys about what material things or these methods in chapters 4. 5 and 6 , but all were essential to me in a constantly evolvi ng sense of what aid exit and sustainability meant in relation to the health system in Tanzania, and all the pieces that affected it. Much of my best data, and most meaningful experiences, came from living with two Tanzanian families With these families, I was able to observe everyday life for people experiencing the broad social changes that are occurring in Tanzania. This included not only scale backs in foreign aid , but the longer ter independence past. Members of both families I lived with worked in the health professions, and could also speak to how these shifts affect ed their jobs and livelihoods, as well as those of their patients. Their hospitality, their help, and their kindness kept me going during the long field seasons. Summer 2009 Field Season In the summer of 2009 it became evident that the nightmare scenario of large scale aid withdrawal was not happening, at least not yet. I traveled to Haydom, a small town in rural northern Manyara region, to look at a Prevention of Mother to Child Transmission of HIV (PMTCT) program at the large mission hospital there Haydom Lutheran Hospital (HLH). What very well funded, with a lot of support for the mothers. It included at that point not only well established counseling and testing for all mothers in antenatal ca re, but free highly active antiretroviral therapy (or HAART), food support, mobile clinics, quarterly PLHIV meetings,


28 community home based care visits, and reimbursed bus fare, all things that HIV researchers have argued as critical pieces to elevating HIV care to treat the whole patient instead of just the virus (Kalofonos 2010). The food support and community home based care, in particular, were exceptional. For mothers during pregnancy and breastfeeding, they would receive millet, beans, flour and sugar, in addition to maize, palm oil spread, peanuts, and fruit for the household. micronutrient fortified flour. In 2009 there were 31 community home based care workers in the HLH catchment area, six for Haydom itself. For those PMTCT mothers who were very sick, or had problems adhering to ARVs, a health worker would visit them everyday if they lived within a walk able or bike able distance. If a PLHIV missed a clinic appointmen t, a health worker would visit their house within three days; for each new mother in PMTCT, and for sick PLHIVs who lived far away, a health worker would visit them once a month to check in. Finally, if a PLHIV delivered her baby outside of the hospital, a care worke r would deliver single dose nevira pine (a type of ARV) to the household as soon as the clinic found out, to give to the baby to prevent transmission of HIV from delivery. Another HIV researcher there, Carolina, was also working with the PMTCT program, and graciously agreed to show me around and introduce me to clinic staff, and some of the PLHIVs she would most often see. Carolina was a PhD student from Norway, and a nurse, and had been involved in research off and on for the past few years at HLH. For her dissertation research, she would frequently visit mothers in their homes, sometimes an hour Land Cruiser trip away from the hospital, to interview them and check on their care and if they had any problems breastfeeding, in particular. One day we visited Theresa, a breastfeeding mother on second line ARVs, who lived about an hour outside of Haydom.


29 Field notes 29 June 2009 : Went with Carolina today to see Theresa, a woman living between Haydom and Gumanga she is on 2 nd line ARVs because she had a hard time with adherence and is now resistant to 1 st line drugs, her five year old daughter is HIV positive, and she has a seven month old son who is still breastfeeding. We are sitting on three tiny wooden stools on the dirt floor in the middle of her mud and sticks house, with chickens pecking around outside and wandering through their small farm. She had what looked like burns on her neck, but maybe they were some kind of oppor Her husband is still around and greeted us today holding the seven month old, and apparently he getti ng money for milk receipt and get reimbursed to prove that they spent the money on milk, so they need to put up women are good for the money, this is often difficult. The same goes for transport for monthly trips to the clinic, and for the meeting they go to once every three months they need to somehow pay to get to the meeting or HLH to get reimbursed. So this wo milk for weaning, but needed Tsh 10,500 for a 15 day supply to essentially rent a cow for however long for milk. So Carolina gave her the money. She has been complementary feeding since the baby was about four mo nths old, Carolina said, giving the baby water and cream milk to supplement, which is bad for transmission, but I guess she felt her breast milk was not sufficient enough, so the kid has been getting complementary food. Just seeing this baby and mother was a little bit heartbreaking her in a more advanced stage, resistant to the good 1 st line drugs, and having problems with adherence, and the baby still breastfeeding and being


30 complementary fed. It might be interesting to see if being in the PMTCT program helps patients The Care and Treatment Center (CTC) nurses come to the patients in a Land Cruiser (some houses in the catchment area are very far away) new mothers a re visited about once per this is determined, but it seems kind of arbitrary. This is to prevent loss to follow up, or LTFU, which is apparently very successful very few LTFUs are at HLH (or went through the HLH system). Carolina says this is because they are consistently given help all the components to the PMTCT program, and help given once in the CTC system prevents LTFU. After spending several months worki second site to see a more common example of the kind of PMTCT and HIV care Tanzanians were getting at the time research at the government hos pital in Babati the regional capital of Manyara, the region in counseling and testing, like PLHIVs at Haydom, but the similarity ended there. Instead of 31 home based care wo rkers, Babati only had three, and they were spread out among eight wards effectively only three wards had a care worker, and the remaining five had none. The care workers in Babati earned only Tsh 15,000 per month, paid for by an international NGO, compa red with the Tsh 30,000 200,000 the care workers earned through HLH (funded by the fees, and no PLHIV meetings or mobile clinics.


31 These differences in programs at HLH and Babati, as I discuss in Chapter 2 , exemplify and abandonment that can c haracterize health care in res ource poor contexts (Tsing 2000; Ong the greater Haydom area, and beyond that, the even browner zone of the vast stretches of Tanzanian bush. Because many people in Haydom and in the surrounding catchment area who do not have HIV need similar support that the HLH PLHIVs get many are hungry, and need home based care, and assistance paying for transport to the hospital, for example Carol ina told me what many ethnographers of the well funded HIV initiatives have written, in many p laces 2011 2012 Field Season After preliminary data collection in 2009, I returned to the US with th e beginnings of a much of the free care the PMTCT mothers received. This test, I believed, would serve as a proxy for aid withdrawal, a process I saw occurring in many places but could not necessarily plan for. What I did not plan for in this interim stage was that the PMTCT program itself would lose considerable funding and support during the year and a half between visits effectively eliminating all the program support except for HAART, counseling and testing. The dramatic differences between the PMTCT program in 2009 and 2011 required I change my research plans, and study instead not a proxy of aid withdrawal, but large scale aid withdrawal itself, across multip le levels, and affecting many people. With the rollbacks in aid, a crisis of sustainability erupted in Tanzania, not just for HIV/AIDS care and treatment, but for other health and social services as well .


32 The PMTCT program lost funding from three principal sources, which I examine in detai l throughout this dissertation. First, c utbacks in PEPFAR funding were widespread across the continent, and in Tanzania funding was cut by 2.6%, despite increasing numbers of people needing access to treatment. Second, the Royal Norwegian Embassy (RNE) cut funding annually from a large five year grant , which currently funds 59% o f the hospital operating budget . This was because much of the grant money was disbursed earlier than scheduled to fill immediate gaps in funding brought on by the financial crisis . All funding from the RNE may be cut at the end of 2014 . A third source of funding for the HIV clinic and PMTCT program came from and e m aternal and child health in five countries, of which Tanzania was one. This program principally funded transport for hospital deliveries, and worked to integrate PMTCT services into th e and child health services. The MDG 4 and 5 pro gram ended in early 2012 when I was there, with the hospital continuing to fund parts of it through it s alrea dy stretched budget. The experiences of these cutbacks in PMTCT and HIV programming were varied among patients, health care workers and administra tors . As I explain in more detail in Chapters 5 and 6 , I examined these experiences in multiple settings in Tanzania, focusing on patients and health care workers in Tanzania, and health care workers and PEPFAR program administrators and policy makers in Dar es Salaam. In Haydom, people struggled not only wi th decreasing availability of treatment, but also more limited funds for salaries, and a critical lack of employment opportunities which crippled those seeking to make more productive lives with salaried employment. On top of this, the cost of living rose steeply following the 2008 crises, and in northern Tanzania during periodic droughts, the increasing costs of food were harshly felt.


33 Between 2011 and 2012 , the number of women enrolled in PMTCT decreased precipitously , from a high of 65 in 2011, to a low of 42 just a year later . Many w omen who remained in treatment sought out alternative treatments for their HIV in indigenous and faith healers, who often claim to be able to treat, and some say cure, HIV. Twenty two of the 75 mothers I inte rviewed (29%) in the PMTCT program went to see one faith healer in particular a retired Evangelical Lutheran pastor, known as Babu Loliondo. Babu Loliondo is named for Loliondo region in northwest Tanzania, where he lives and performs his healing. A s of 2012, Babu had allegedly seen four million people since 2010. At times, people would wait up to a week to see Babu, and to drink a cup of his tea brewed from the black currant or kikombe is believed to be particularly powerful in healing five principal chronic diseases: HIV/AIDS, cancer, diabetes, asthma, and hypertension. Absolute faith in the power of drinking from the cup is essential for the full benefit of those who come to him mothers I interviewed appeared to have stopped their antiretrovir al therapy despite seeing Babu , though I conducted my interviews in the hospital and therefore did not interview any women who were not still seeking care there. Many of the other mothers I interviewed who did not go see Babu dearly wanted to, but could no t afford the trip; round salary for a day laborer. One woman told me she sold two cows to pay her way; it cost her Tsh 350,000 ($215) in bus fare for her and one of her children, and for food alo ng the way. Many other PLHIVs at the clinic did appear to stop taking their ARVs . Mama Danieli, the head nurse


34 , clinic (10 15%) were lost to follow up in the first six months of my research in Haydom , meaning they no longer continue to come to the clinic for care. During the drawback in funds, Mama Danieli took some of the burden of decreasing funds and services on herself, helping several patients find employment and housing in the community . She tells me that each year the budget gets smaller and smaller, in a process she This decrease in funds worries many of her patients, s he says, who are increasingly lost to follow up. The quarterly PLHIV meetings that the hospital used to host she particularly misses, not only so clinic staff could educate PLHIVs on ways to adhere to treatment and stay healthy, but because patients themse lves could help each other manage their care and act as a support group. Magdalena is another health care worker taking on a greater burden as funding decreases. She is a c ommunity home based care worker , or CHBC , who works with Haydom Hospital , and she goes to town everyday to check in on and counsel PLHIVs from the HIV clinic, particularly mothers in the PMTCT program. Magdalena was hired in 2004, in the first years of the multi billion dollar PEPFAR initiative. Up until 2010, she received between Tsh 1 00,000 to 300,000 a month for her full time work . Today, she receives a salary of about Tsh 60,000 . She wa s also thinking of quitting, over which she expressed regret and deep feelings of guilt . S he explained to me the pressures of effectively working full time for no salary: allowance now. We are working hard, especially us CHBCs, because we go around to the villages without relying on cars we go on foot family, you have ki ds, you have a husband, and you have a farm, now you are going to volunteer to work? Really, I think, ah, I do not know .


35 Throughout my research, women appeared to be taking on a more significant burden than men during this period of greater financial instability and limited funds for health care workers , and look ed after patients and family members according to gendered role s of caretaking. Things were getting harder for most of the men, and most of the PLHIVs I knew too , it seemed. A friend of mine, Tumaini, highlighted that difficulty in getting work which he considered more important than anything was his principal con cern , even more than his HIV+ status . Finding work, and maintaining steady employ ment, was difficult for Tumaini because he lacked the strength required of much of the work in the rural areas of Tanzania, and frequently needed time off in order to go to th ife is hard , money. For now, I have no hope at all. My plans for my future are ruined, as far as I can see. Because there is no work at all for me that I can do, I have no work. There is no order to my life . Tumaini , whose story I tell in more detail in Chapter 4 , died in prison a year later. Similar sentiments about the importance of money I heard again and again in interviews I conducted in Haydom town. O ne phrase in particular I heard many ti mes changes that have happened in Haydom in the past 10 15 years, and interestingly, people were able to pinpoint when the love had gone 1996 1997 which were the years in which structural adjustment policies started to be really felt in Haydom, during the course of increasing privatization experienced throughout the country . Sustainability in Policy and Practice These cases of aid wi thdrawal paint a picture of precariousness in health care experienced by patients , and pervade nearly every level I encountered during fieldwork. At the same time, however, there was widespread acknowledgement of this precariousness and concern for rectifying it, in policy if not quite yet in practice. Understanding and conceptualizing


36 sustainability what it meant, how people in different contexts were using it, what concrete changes the sustainability rhetoric might bring was from t he beginning convoluted and confusing, full of seeming contradictions and ultimately little change from the status. Prescriptions for sustainability in health care center around two principal, related goals the expansion of universal primary health care , and health system strengthening, with priority toward building the public sector for durable, equitable care. The rationale for this include the assumption that, in resource poor and aid dependent countries, the waves of funding would continue to ebb and flow, and donor interests would continue to shift among favored projects. Additionally, expanding the private sector would do little to make care more equitable and accessible, particularly for the millions of rural farmers (an estimated 75% of the Tanzan ian population, or about 35 million people). With universal primary health care, the basic health needs of populations would be managed, prevention of disease better supported, and the public sector governed by Tanzanians would be the bedrock of the he alth system. Primary health formalized at Alma Ata, USSR. As I discuss further in Chapter 3 campaigns and child health initiatives, in particular (Basilico et al. 2013; Brown et al. 2006; Walsh an d st World Assembly, in which she charted her vision for new global health governance: With an emphasis on local ownership, primary health care honoured the resilience and ingenuity of the human spirit and made space for solutions created by communities, owned by them, and sustained by them. Above all, primary health care offered a way to organize the full range of health care, from households to


37 hospitals, with prevention equally important as cure, and with resources invested rationally in the different levels of care. orial staff (2008) observed focus of the global health community is shifting from a biological to a social model of health, from vertical to horizontal programmes, and towards health 2008). These goals, and health system strengthening in particular, are considered essential to the sustainabili ty of health care, and more importantly, for the sustainability of good population health. Health which includes: 1) effective, safe and quality service delivery; 2) a well performin g health workforce; 3) effective health information systems; 4) equitable access to quality medical products, vaccines and technologies; 5) a good health financing system; and 6) effective leadership and governance (WHO 2007). Despite efforts to expand primary health care and health systems strengthening, only modest improvements have been made in realizing these goals in Tanzania and other resource lden age of and Prabhu 2013), significant strides were made toward achieving specific health goals expanding HIV/AIDS treatment and prevention in particular with some improvement to the functioning of health sectors alongside it (Goosby et al. 2012; Palen et al. 2012). The overall trend in global health funding is to funnel money toward NGOs, instead of public sectors. In 1995, 5% of donor assistance for health was dedicated to NGOs; by 2010, that percentage rose to 66% (Mbacke 20 13). Part of the legis lative intent of PEPFAR, for example , i s from aid effectiveness advocates working in Africa especially, who argue that bolstering the public sector is also critical for sustainable health care (Mbacke 2013; Pfeiffer 2013 ). Cheikh


38 in Paris and Accra and instead building up an increasingly fragmented, and private, system of providing health care. As I outline in Chapter 6 , the privatization of health care is a fundamental barrier to health care sustainability, yet continues to be promoted as a stop gap measure to fund disease specific health initiatives. This trend toward privatization follows what Stuart Kirsch highlights in his critique of Sustainability, Kirsch a rgues, is a slippery term that takes on different meanings depending on the context. Over time, and with pressure from many different international lobbies and organizations, sustainability has shifted in meaning and consequently has been emptied of mean ing allowing it to be co opted into meaning practically anything. In particular, the meaning of sustainability can move almost effortlessly between the (oftentimes) incompatible goals of environmental conservation, social welfare, and economic developmen development sense if it continually employs a large workforce from a particular region, for example. T his process can become cyclical and have detrimental effects on population health corporations who employ large populations of people and contribute to local economies can effectively threaten to leave unless environmental regulations constraining their destructive and polluting practices are not eased, or favorable tax breaks fixed. In global hea lth, as I discuss in Chapter 6 , the idea of sustainability is most often centered on cost effectiveness and contributions to economic growth, prioritizing the fiscal sustainability of individual vertical (and often private) health programs, instead of supporting entire (public -


39 run) health systems (Yang et al. 2010; Farmer et al. 2013b). This model, however, can be blind to the social impacts of policies and programs, in particular the internal brain drain of health care workers from the public to private sectors, and the increasing fragmentation of service provision and epidemiological reporting, increasing inefficiencies in health care delivery (see also Pfeiffer 2012; Sherr et al. 2012; Sullivan 2011). Scale backs in donor assistance for health w ere often discussed as problems of sustainability , though as I detail in Chapter 6 , efforts to increase health care sustainability adhered obliquely to current best practice s. In Haydom, for example, when I asked administrators at the hospital what their plan for sustainability was , it revolved around increasing the costs of services, sca ling back services, or reducing the number of salaried employees. Currently, the HLH website warns that if funding from the RNE is not renewed, patient fees will be reduced by 40%. The sustainability plan for PEPFAR NGOs in Dar es Salaam involves the original American NGOs creating new Tanzanian NGOs, or working with current ones, to slowly take over service responsibilities in a countrywide transition. As many informants noted, particularly those administrators working w ithin the se American or Tanzanian PEPFAR funded NGOs, the proliferation of NGOs contributes to an increasingly fragmented system of health care delivery, making health system strengthening more difficult. However, there are some bright spots on the horizo n. James Pfeiffer who has worked with PEPFAR brought about by PEPFAR has dramatically altered the calculus and sense of possibility in global health broadly, and in Africa specifi state of high agitation in global health, major


40 progress and innovation are possible but only if we maintain a focus on the resurrection of a public health sector health commons . To guide more effective public health policy, a critical goa l of this research is to document the vulnerability and precariousness experienced by people within these times of economic and political crisis. Indeed, this is an important contribution of ethnography as well, and historically, stories of the lived exper ience of crisis ha ve furthered some of the most significant social welfare policies. As Julio Frenk of the Harvard Sc hool of Public Health notes, history teaches us that many of the most enlightened soc ial protection measures have be e n crafted precisely a t tim es of economic or political cris Organization of the Dissertation In this dissertation I examine the contingent processes of impending aid withdrawal and efforts to create sustainable health care. This work focuses particularly on the live d experience of patients, health care workers and administrators as they adapt to funding and policy changes Plan for AIDS Relief (PEPFAR) program in Tanzania. Th e names of the people whose stories I tell, and in some cases defining features about those people, have all been changed to protect their identity. The rapidly shifting social, political and cultural environments of the past three and a half decades acro ss the world have changed the contours of global health, which I examine in more detail in Chapter 2 . In this chapter I examine more closely the history of neoliberalism in the creation and promotion of selective primary health care, or vertical programming as it came to be known, and in the process undermining primary health care. Primary health care, m any global health researchers argue, is potentially the best hope for achieving sustainable good population health and the realization of a human right to health. Chapter 2 also introduces the ethnographic


41 context of research in two sites: in Dar es Salaam , the commercial capital of Tanzania where the majority of global health NGOs operate; and in Haydom, the town in rural Manyara region in north central Tanzania where Haydom Lutheran Hospital is located. I introduce the background of the HIV/AIDS epidemic in Tanzania, and the successes of global health initiatives in Tanzania to curb the epidemic and establish care and treatment services for nearly 200,000 people. I examine these two field sites i n greater detail , and the context in which I came to Tanzania to begin fieldwork and my encounters with aid withdrawal and sustainability. Finally, I introduce the key informants I came to rely on, the families with which I lived, and my research assistants who provided valuable guidance over the course of my work. In Chapter 3 , I more closely examine the theoretical frameworks used to explain the ideologies behind the current structure of global health. In particular, I look to theorists of neoliberalism to examine how neoliberal ideologies drive globalization, and how development and global health have contributed to an ever expanding network of non governmental organizations (NGOs) taking the place of state run institutions. In this process, health care services are increasingly privatized, while populations seeki of them, culminating in an increasingly precarious existence (Harvey 2005). I also examine the of biopower as a foundation, I examine the ways in which anthropologists have employed this theory in ethnographies of global health. I focus on criteria for the inclusion and exclusion of participants in health programs, methods for evaluation of participants and health programs, and some outcomes of these methods of discipline on population health and wellbeing. Finally, I tease apart the two concepts with which I frame much of this dissertation: precariousness and sustainability. Both concepts overlap considerably with other concept s unpredictability,


42 uncertainty and vulnerability on the one hand, and sustainable development and cost effectiveness on the other. Chapter 4 precariousness of life in Haydom experienced by many people (HIV+ and HIV ), and across many different dimensions, including education, employment, and livelihood strategies in particular. This chapter examines at its heart the phrase I heard over and over again gone, every by informants in Haydom. This idiom speaks to many processes at the same time. The shift to a market economy is paramount here, in which money, and much more of it, is necessary to access good health care and education, as well as to buy goods Tanzania experienced a skyrocketing cost of living accompanying the food crisis that followed the financial crisis in 2008 (NBS 2013). I follow the lives of several key informants over the course of the year, mostly young people, as they try to find their place in the new economy with an educational system in considerable disorder, which does not prepare many students for well paying jobs that are emerging in the growing Tanzanian national economy. Chapter 5 examines more closely the multiple w ays in which aid withdrawal occurred, and is occurring, in Haydom and in Dar es Salaam within in the broader health care system. I focus on five principal case studies of aid withdrawal: 1) international aid to Tanzania, principally from bilateral donors, being scaled back; 2) funding for Haydom Lutheran Hospital itself, and its dependence on Norwegian funds and volunteer doctors for running HLH; 3) PMTCT at HLH, as described above; 4) the RNE funded maternal and neonatal program at HLH, coming to a close; and 5) PEPFAR itself. Chapter 6 charts the effects of PEPFAR and other donor funded health initiatives on human resources in Tanzania. In particular, I examine the promotion of an internal brain drain in


43 which clinicians and nurses fled their practices in the public sector to take more highly paid jobs with NGOs, and particularly those funded by PEPFAR. In many cases, these NGO jobs involved little medical practice, and much more policy writing, courting donors and copious paperwork and reporting. This int ernal brain drain is one of many processes that undermine the long term sustainability of the Tanzanian health system, which will require at the very least, a legion of well trained health care workers who remain at their practices. I conclude this chapter with the beginning of a framework for understanding how sustainability appears to follow the structure of the health system itself divided amongst vertical programs, and for the entire health system itself. The concluding chapter tie s these principal t hemes together, while introducing other viewpoints I believe shed light on these patterns: the conversion of time in late stage capitalism term (Ho 2009a; Ho 2009b; Guyer 2007); and the endurance ( vumulia ) vulnerable people must have to live day to day with rapid social and economic c hange (Povinelli 2011). I consider the limitations of this research, as well as possibilities for next steps in studying these processes, in p articular, examining health care sustainability from the vanta ge point of the public sector. Finally, I summarize the principal contributions of this dissertation, including 1) elevating the v olatility of health care to the primary focus of research , inste ad of minimizing it as something either inevitable or unsolvable; 2) highlighting the experiences of this volatility as part of a larger context of precariousness of everyday life; and finally, 3) examining current policies and priorities targeting the pro blem of health care volatility, and the methods used to create more sustainable health care.


44 CHAPTER 2 GLOBAL HEALTH AND ETHNOGRAPHIC CONTEXT This chapter introduces the background of HIV/AIDS care, treatment and prevention programs in the context of an underfunded and fragmented health care system in Tanzania, as well as the ethnographic settings in which I studied these programs, policies and processes over the course of twenty months during a five year time span. I jump between levels and across time from the historical background which sets up the current way things are, to the international and Tanzanian responses, and to the particular policies, projects and programs that were implemented to curb the spread of the epidemic across the African cont inent. I begin with the historical roots of post colonial development, beginning with post WWII reconstruction policies implemented by the Organization for European Economic Co operation and the two Bretton Woods institutions, the World Bank and Internatio nal Monetary Fund (IMF). I examine the role neoliberalism and globalization have played, historically, in the dismantling of public health systems and the building up of more precarious vertical programs. Philosophical and political conflicts about governa nce and health care have been brewing since the end of the colonial era and the dawn of the Cold War. These conflicts have been exacerbated with structural adjustment, the Washington Consensus, and the rapidly expanding HIV epidemic. Next, I address the HI V/AIDS epidemic in Tanzania in more detail, and the massive global health interventions Relief (PEPFAR), the US government funded response that is a principal f ocus of this dissertation, followed by an examination of the history of aid in Tanzania. In the second half of this chapter, I introduce the sites and important people I focus on for this multi sited ethnography. I begin in Haydom, the home to Haydom Luth eran Hospital, and to the HIV clinic in which I conducted the majority of my research, particularly with a Prevention


45 of Mother to Child Transmission of HIV (PMTCT) program. I introduce the city, with about 20,000 people in a predominantly rural part of no rthern Tanzania, and how over the years it has come to be exceptional in the region, with electrification, job opportunities, and access to good health care. The hospital itself, principally funded by the Norwegian government, is facing significant funding and policy shifts itself, as the Norwegians debate future hospital funding. I also introduce the network of NGO actors I worked with in Dar es Salaam, my second principal field site. Finally, I introduce some of my key informants, particularly those with whom I lived and worked in both cities. Historical Roots of Global Health and Development In the past thirty years, private and public international development agencies and humanitarian organizations have proliferated around the globe, building up what Ticktin suffering. Our modern conception of development as a policy and a movement has its roots in human rights discourse in response to the atrocities of Wo rld War II (Asad 2000) and the redevelopment of Western Europe through international programs such as the Marshall Plan (George 1999; OECD 2009; Edelman and Haugerud 2005:6). The creation of the World Bank and International Monetary Fund (IMF) at the 1944 Bretton Woods Conference laid the foundation and philosophy for international development roject 2007). Three years later, in 1947, the Organization for European Economic Co Operation was founded to organize and implement development and administer aid through the Marshall Plan (OECD 2009). In 1961, the OEEC became the Organization for Economic Co Operation and Development, emphasizing sustainable macroeconomic growth for its 30 member countries, and to provide assistance to 40


46 other developing economies. Today, the OECD works with many Northern bilateral agencies to coordinate development initi atives around the world (OECD 2009; Sida 2008 ). U.S. foreign aid and development objectives in the 1950s and 1960s increasingly reflected Cold War strategies for stemming the spread of communism in newly independent countries, proceeding increasing decolo nization in Africa and Asia and the establishment of new systems of government (Edelman and Haugerud 2005; Brown et al. 2006). Cold War animosities and allegiances influenced global health policies during this time as well. Brown et al. (2006) historicize the role of the WHO in global health policy and programming over the past century, and illustrate how the political (and largely neoliberal) agendas of the United States and World Bank inserted themselves into global health governance. A notable shift in p olicy concerned primary health care, which was first debated, outlined, and celebrated in 1978 at The International Conference on Primary Health Care in Alma Ata, Kazakhstan , in the former USSR. Declaration for Primary Health Care (PHC) (Brown et al. 2006:67). Health for All by 2000 were ensuring primary health care for all people and working to improve local capacities for horizontal health care delivery. Because the initial research on primary care was tasked to a Soviet representative in the WHO and the location of the conference was held in the USSR, this conference, and subsequently the goals for extending primary health care, took on new political meaning (Brown et al. 2006; Litsios 2002). American policy makers in particular conceived of the PHC movement as indicative of socialist ideology in practice, and instead of supporting this new directive, used their influence to shift WHO objectives (Brown et al. 2006). An alternative to Alma Ata was proposed at a second international conference in Bellagio, Italy, sponsored by the Rockefe ller


47 philosophies of health care organization that preferred vertical programs that could be implemented and evaluated easily (Brown et al. 2006). The goals of building u p health care capacity in resource poor countries and providing comprehensive primary care were eclipsed by new programming goals that targeted specific diseases, such as malaria and tuberculosis, child survival programs, and found success in smallpox erad ication efforts (Basilico et al. 2013; Brown et al. 2006; Henderson 1998). Soon after, in the 1970s and early 1980s, the new central role of the World Bank in global health governance firmly took root. As the World Bank assumed more power in health care f unding, particularly in the midst of widespread loan defaulting by LMICs, it was also increasingly able to demand that recipient countries implement social and political changes that accompanied loans (Brown et al. 2006; Pfeiffer and Chapman 2010). Their d emands included an expansion of free markets and a weaker role for state and national governments. These structural adjustment policies, or SAPs, required recipient countries to dismantle or scale back their state funded and managed social welfare programs , and in their stead, private, for profit companies and programs were tasked with providing these services. In many countries, the private sector could not fill the void left by the removal of public services, and the services simply disappeared. Filling t hese gaps then largely became the mission of humanitarian organizations. The proliferation of these humanitarian organizations, or more commonly non governmental organizations (NGOs), is historically associated with this increasing global spread of neolibe ral policies and practices, reflecting fundamental philosophical changes in macroeconomics and foreign aid.


48 A significant increase in philanthropic giving buoyed humanitarian organizations and based research and global health themselves enjoyed substantial tax breaks in exchange (Cohen 1999:214). This bonanza continued to gain momentum through the 2000s, inspired in larg Development Goals, which enjoyed exceptional political commitments from government donors (Sachs 2013). OECD data show that between 2000 and 2006, donor funding for global health research and interventions increased 200%, from 15 billion to 45 billion US dollars (Schneider and Garrett 2009; OECD 2009). Much of this increase is due to the emergence of HIV/AIDS and the number of organizations dedicated to HIV treatment and prevention (Schneider and Garrett 2009:2; Messac and Prab For AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Other private organizations, such as the Bill and Melinda Gates Foundation and the William J. C linton Foundation, became involved in HIV/AIDS research and funding as well, and collaborate with public organizations and governments to facilitate the expansion of public private partnerships (PPPs) for HIV research and care (Buse and Walt 1997). Though many researchers and policy makers have criticized the elevation of HIV/AIDS care and treatment to the possible detriment of other diseases, few argue that HIV/AIDS was not a global emergency in need of significant mobilization of resources, drug developme nt, health care workers, and support from wealthy countries. In the past thirty years, HIV/AIDS has transformed the global health landscape. The HIV epidemic has caused the death of 36 million people, orphaned 12 million children, and been the


49 principle cause of reducing life expectancy by twenty years in the most affected countries (UNAIDS 2008, 2011; WHO 2013a). The HIV/AIDS epidemic has also drawn attention to other devastating diseases, global heal th inequalities and entrenched poverty, and has led to the mobilization of unprecedented numbers of health and civil society organizations to help prevent its spread and provide care and treatment. Ethnographies of HIV/AIDS have illuminated the social, pol itical and economic roots of the epidemic, the different mechanisms that catalyze or scale back its spread, the day to day experiences of people living with HIV (PLHIVs), and the numerous risks and stressors, and coping responses, PLHIVs may encounter and negotiate over the course of their lives. Currently, 35.3 million [32.2 38.8 million] people live with HIV/AIDS, and an estimated 33 million have died from HIV/AIDS related causes (UNAIDS 2013a). 23.5 million people, or 67% of PLHIVs live in Sub Saharan Africa, the epicenter of the epidemic, as do more than 90% of children living with HIV. HIV/AIDS is the 6 th leading cause of death for all ages in the world, and is (by a significant margin) the leading cause of adult mortality in Africa, causing 35% of a ll adult deaths (WHO 2013b; Mathers et al. 2009). Countries with the highest prevalence rates are located in southern Africa; Swaziland (26.5% prevalence), Lesotho (23.1%) and Botswana (23%) have prevalence rates significantly higher (> 5% points) than any other country in the world South Africa ranks 4 th with a prevalence rate of 17.9% (UNAIDS 2013b). because it originated there, and was the first in the world established within the general population, largely before any effective programmatic response was conceptualized and rolled out (Iliffe 2006:1).


50 Tanzania has the 13 th highest HIV/AIDS prevalence rate in the world (UNAIDS 2013b). The 2012 adult (15 49) pre valence rate in Tanzania is 5.1% (4.6 5.7%), with prevalence among women (6.2%) considerably higher than among men (3.8%), and urban prevalence at 7% and rural prevalence at 4% (TACAIDS et al. 2013). In 2011, 1.5 million Tanzanians were living with HIV/A IDS. The number of people treated with ARVs increased from 136,000 from all donors in 2007 to 197,000 from PEPFAR funds alone in 2009 (PEPFAR 2010). 473,500 PLHIVs received HIV care and treatment support, which may or may not include HAART. Nearly 40,000 women requiring PMTCT services received it in 2009 from PEPFAR alone, an increase of approximately 8,000 women since 2007. VCT and other prevention services also expanded in 2009, including 3.2 million people receiving education about condom usage and 2.8 million people learning more about abstinence and the importance of being faithful to one partner at a time (PEPFAR 2010). After a decade and a half of unprecedented social and political activism for the development and increased access for people living with HIV to life saving antiretroviral medications, three major global health and HIV initiatives began: The Global Fund for AIDS, million people with HIV/AIDS by 20 ever global health current efforts to tr ansition to sustainability, is a central focus of this dissertation. At 6:45 pm, Monday September 30, the Senate Foreign Relations Committee, with five hours to spare before the 2013 US Government sh utdown, approved the PEPFAR Stewardship


51 a vitriolic and partisan political climate, PEPFAR continues to enjoy broad bipartisan support and is celebrated for bein law that M ay, following two other large scale HIV/AIDS global initiatives The Global Fund to year, $15 billion initiative to expand HIV/AIDS prevention, care and treatment s ervices to 15 focus countries, the majority in sub Saharan Africa, and the epicenter of the epidemic. It was scaled up quickly 35 target countries are now supported by PEPFAR funds, as of FY 2012, over 46 billion USD has been allocated to HIV programs an d initiatives, as well as support for TB, malaria and maternal and child health (PEPFAR 2013b). PEPFAR was reauthorized by emergency response to promoting sustainable PEPFAR III (PEPFAR 2013a; USG 2008). Political support for PEPFAR has persisted despite the food, fuel and financial crises of 2008, though funding for it has been scaled back. Right after the 2008 crises, ma ny global health scholars wrote of their concern for the potential of cancelled aid commitments from bilateral, multilateral, and private donors, and the future impacts it may have on global population health (Garrett 2009; Mills et al. 2010). Particular c oncern was reserved for the future of the HIV/AIDS response feared a return to the recent past where AIDS related deaths were over two million per year and infection rates were c


52 warning that because many African governments were largely dependent on external support for their HIV/AIDS programs (about two thirds of funding), HIV care and treatmen t was at great risk for failing should donor funds dry up (UNAIDS 2012). When the Global Fund reported it was cancelling Round 11 of their funding because of a lack of money in promoting UNAIDS 2012). In 2003, the year PEPFAR was established, global HIV prevention coverage was ble to about 10% of populations in resource poor countries, fewer than 5% of pregnant women were able to access PMTCT care and treatment, and only about 1% of PLHIVs in Sub Saharan Africa had access to antiretrovirals (UNAIDS 2003). The annual number of de aths from HIV related causes continued to climb, reaching 2.2 million deaths in 2003 before its peak two years later at 2.3 million, though the number of new infections was on the decline that year, at an estimated 3 million per year, down from its peak in 1997 of about 3.4 million (UNAIDS 2011; 2013). Against this backdrop, PEPFAR implemented its emergency response. That year, with billions of aid money dedicated to HIV prevention, care and treatment through PEPFAR and the newly established Global Fund, th globa l momentum to expand access to HIV/AIDS treatments in developing countries a


53 o get In Tanzania, six non initial PEPFAR HIV plans: Family Health International (FHI); AIDS Relief (part of Catholic Relief Services); The International Cent er for AIDS Care and Treatment Programs (ICAP); Muhimbili, Dar es Salaam City Council and Harvard (MDH); The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF); and The Clinton Health Alliance Initiative, or CHAI. These implementing partners divided up the country in what one PEPFAR administrator called the PEPFAR funded HIV/AIDS services in their regions (usually four to five each). This strategy was implemented in par reduce the confusion over which agency is supposed to handle which services in an otherwise very complex health program. Since PEPFAR and The Global Fund launched, global rates of new i nfections have declined to 2.3 million in 2012, and there has been a significant decline in deaths due to HIV related causes, down to 1.6 million in 2012, largely a function of PLHIVs increased access to more effective antiretrovirals (UNAIDS 2013). In Tan zania, by 2011, 3.1 million had received HIV counseling and testing; 1.2 million had received HIV care and support; 289,000 were receiving antiretroviral treatment; 58,000 HIV+ pregnant women received PMTCT care (70% of those estimated who needed it); and an estimated 17,386 infant HIV infections had been averted (PEPFAR 2013a). PEPFAR HIV/AIDS funding in Tanzania increased from $70.7 million for the year 2004 to $361.2 million for 2009, alongside $240 million the Global Fund disbursed to Tanzania during th at time (de Jongh and Atun 2009; PEPFAR 2013a). From FY 2009 to FY


54 2012, Tanzania received over $1 billion from PEPFAR, though the annual funding rate has decreased slightly since its 2009 peak, reduced by about 2.6% (PEPFAR 2013b). PEPFAR was renewed aga in in late 2013, and attention is focused on if and how a giant, multi billion dollar health initiative can effectively transition to sustainable HIV/AIDS prevention, care and treatment programs housed within strong, national health systems. During PEPFAR II, Partnership Frameworks (PFs) for each of the countries hosting PEPFAR funded new era of dialogue and collaborative planning between PEPFAR country teams and partner al. 2010). The PF for Tanzania was produced in 2010, in collaboration with a multidisciplinary team of delegates from the Tanzanian and US governme nts, civil society organizations and NGOs. Partnership Framework legislation in Tanzania specifically outlined the following goals (PEPFAR 2010): 1. Service Maintenance and Scale up : Reduce morbidity and mortality due to HIV/AIDS, and improve the quality of life for people living with HIV and those affected by HIV/AIDS. 2. Prevention : Reduce new HIV infections by increasing the efficacy of prevention programming; bringing to scale prioritized prevention interventions; and enhancing the enabling environment thoug h sustained leadership, policy change, and attention to structural factors affecting HIV transmission. 3. Leadership, Management, Accountability, and Governance : Provide well coordinated, effective, transparent, accountable, and sustainable leadership and man agement for the HIV/AIDS response. 4. Sustainable and Secure Drug and Commodity Supply : Strengthen procurement and supply management systems of all drugs and commodities related to the HIV/AIDS response. 5. Human Resources : Ensure the human resources capacity ne cessary for the achievement of quality health and social welfare service at all levels.


55 6. Evidence based and Strategic Decision Making : Improve the use of relevant and comprehensive evidence, provided in a timely manner, in HIV related planning and decision making . Despite the horrifying statistics of the late 1990s and 2000s, a hazier picture of the HIV epidemic as an emergency emerges in hindsight. By the time the legislation that birthed PEPFAR the United States Leadership Against Global HIV/AIDS, Tuber culosis and Malaria Act (Public Law 108 25) was signed by George W. Bush in May, 2003, the peak of the HIV epidemic per number of infections (in 1997) had already been six years past, and was on the decline (UNAIDS nd to Fight AIDS, Tuberculosis and Malaria, and the two giant HIV donor initiatives had just been implemented in the two previous years, which dedicated billions themselves to HIV/AIDS prevention, care and treatment. Despite it s relative late coming to HIV/AIDS funding and policy making, from the start legislative documents suggest. The reasons for this may be many, but several of my own informants expressed their opinions that HIV was no longer an emergency when PEPFAR was rolled out, and was more politically motivated than anything. One informant, who works at the Tanzanian MOHSW, told me he believed PEPFAR was in direct response to (and competition shirt and hat that PEPFAR funded NGOs frequently pass out to communi ties and at clinics. Critical scholars of global health have made similar assertions. Alex de Waal makes a compelling argument for the global political strategies of the US as a principal reason for the PEPFAR rollout and other


56 part (2010:313; 312). mission under President Bush, part of the expansion of the moralization of global health and interventions in general over the past few decades (de Waal 2010:304 prevention abstinence, be faithful, and correct condom use (with an emphasis on the A and B) that were requirements of t City Policy/Global Gag Rule, in which no health care provider can perform, or speak about, abortion was widely panned in the global health community for being unrealistic and of limited effectiveness in preventing the spread of HIV. In the US, however, PEPFAR enjoyed strong bipartisan consensus and support, being voted in to law by a significant margin, despite a bitterly divided political landscape in the early mid 2000s (de Waal 2010). of American politics, an imaginary space in which partisan interests could dissolve in favor of The 2008 global recession catalyzed a decrease in foreign aid and non profit development funds. This recession, coupled with periodic waves of aid fatigue and waning international political support for HIV/AIDS and global health, presents a potentially disastrous situation. HIV programs may not only not be able to k eep up with the increasing numbers of HIV+ patients presenting in clinics, but may have to begin to scale back programs and ration the supplies of antiretrovirals (ARVs). At the time, the incoming US Global AIDS Coordinator Eric Goosby wrote that PEPFAR fu nding cannot be sustained at previous levels of growth (2009) and with


57 this, plans for program scale up are severely curtailed (MSF 2009). Since 1996, annual funding for HIV/AIDS in LMICs has increased from US$300 million to US$8.9 billion (Oomman et al. 2007). Funding for HIV/AIDS is almost entirely dependent on donors, particularly in PEPFAR target countries. In Tanzania (a PEPFAR target country), 90% of its funding for HIV/AIDS comes from international donors (UNAIDS 2009). Tanzania is also one of four priority countries, along with China, Ethiopia and Zambia that together receive more than one 2007). A similar pattern plays out in much of East Africa. The food, fuel and fi nancial crises of 2008 brought a sobering end to the boom in overall, bu t with significant blows to the cotton, coffee, Nile perch and tourism industries (Ngowi 2010). Foreign direct investment in Tanzania decreased by 10% since 2008 (Ngowi 2010), and official development assistance (ODA) to Tanzania decreased by nearly US$500 million, from US$2.82 to 2.33 billion (World Bank 2010). Further, the economic crisis directly impacts the individual incomes and job security of PLHIVs, hurting their chances that patients will be able to afford user fees, transportation to health clinic s, or nutritious food needed to metabolize ARVs and maintain health (Wenner 2009). Because of a projected decrease in funding, Wafaa El Sadr, director of the International Center for AIDS Care and Treatment 2009:830). Primary Health Care and Health Systems Strengthening In response to this worst case scenario, policy makers and health care professionals are h and funding to horizontal


58 programming, health system strengthening and capacity building, and most importantly, primary health care for all (Chan 2008; Garrett 2009; Lancet 2008). In her address to the 61 st World Assembly, WHO Director General Dr. Margar et Chan declared that returning to Alma Ata objectives was paramount among her goals for her tenure at the WHO. In this speech, she outlined the vision of Alma Ata and her vision for new global health governance: With an emphasis on local ownership, primar y health care honoured the resilience and ingenuity of the human spirit and made space for solutions created by communities, owned by them, and sustained by them. Above all, primary health care offered a way to organize the full range of health care, from households to hospitals, with prevention equally important as cure, and with resources invested rationally in the different levels of care. focus of the global health community is shifting from a biological to a social model of health, from vertical to horizontal programmes, and towards health 2008). If this indeed is the case, anthropologists may see their role in public health expand if social determinants of health, in particular, do indeed become more central fixtures in the global health landscape (CDSH 2008). primary health care is gaining momentu m, again, post global recession. As part of the goals to achieve a human right to health, universal primary health care is meant to allow every person, regardless of socioeconomic position, access to essential health services. In particular, the WHO has id 1) reducing exclusion and social disparities in health (universal coverage reforms); 2) organizing health services around people's needs and expectations (service delivery reforms); 3) i ntegrating health into all sectors (public policy reforms); 4) pursuing collaborative models of policy dialogue (leadership reforms); and 5) increasing stakeholder participation (WHO 2013).


59 Advocacy for universal primary health care is in part a response to the increase in neoliberal, donor funded health care, filling the gaps left by the withdrawal of the public sector the newly named Poverty Reduction Strategy Papers, or PRSPS). As Pfeiffer and Chapman across the develo ping world, in addition to other social services such as education, infrastructure structural adjustment (2010:158). Government responsibility, with legal teeth, not resting on the fickle morality of NGO donors and administrators, and the even more fickle whims of the global marketplace is critical (Smith Nonini 2006; Reid and Taylor 2010; Pfeiffer 2013). Instead, Smith and not a market, where people are accountable to each other and risk is shared. Smith Nonini approach to health would actually look like, addressing what Maru and Fa health commons, she suggests, can achieve several goals. First, a health commons approach pt that governments and societies have a responsibility to the collective social welfare, and that the health of populations should be maximized and thought of as a public nd, it requires more transparency, accountability, participation and sharing of risk; and third, to raise the level of awareness about the quality of health care, using an evidence based model to reduce the number of possibly superfluous health procedures (Smith Nonini 2006: 235 236). Smith -


60 Nonini also suggests that the often invisible successes of public health, disease prevention, for and Chapman History of Aid in Tanzania independence can serve as a case study of the impacts of neoliberalism and foreign aid on national health and governance. Tanzania adopted a socialist government model after gaining independence in 1961. In 1967, lawmakers drafted the Arusha reliance, rural development and economic growth, and initially focused on the nationalization of the economy and sectors of p roduction like agriculture and industry (Catterson and Lindahl innovation and vision, and inspired a windfall of aid, particularly from countries with socialist or social democratic governments (Catterson and Lindahl 1999:32). In a major effort to provide universal social services and increase rural access to health care, education and sanitation, the government also created a policy called ujamaa (family), that involved moving rural populations into newly established villages that served as the focal point for service delivery (32 33; Jennings 2008). Soon after, in 1974, Tanzania began an initiative for rapid urban industrialization that marked the initial contra development, and began a decades long economic slump (Catterson and Lindahl 1999:33). Urbanization proved too dependent on the import of raw materials, and the reorientation of economic strate 35). The ujamaa strategy became a political liability for the


61 Tanzanian government, as people were resistant to being forced off their l ands and settled elsewhere. These multiple blows to government and economic restructuring, along with the increasing demands for social services coinciding with a fourfold increase in population between 1957 and 2002 (Tanzania Population and Development 20 05) stretched the national budget beyond its capacity (Catterson and Lindahl 1999:35; Jennings 2008). The IMF/World Bank structural adjustment policies in the 1980s also contributed to problems supplying and managing social services, particularly with a st rict reduction in government spending and liberalization and privatization of many elements of the economy and modes of production (35 6). Despite implementing a markedly different development model than agreed upon, foreign donors continued to funnel fun ds into Tanzania to buoy the system, largely to no avail. The ensuing economic slump landed Tanzania near the bottom of most international rankings of th out of 179 countries in a 2008 UNDP report, and per the human deve lopment index, calculated with literacy rate, life expectancy and educational attainment indicators, Tanzania ranks 159 th out of 177 (UNDP 2008). The economic growth rate in Tanzania, however, is significantly higher than other Sub Saharan African countri es, as well (World Bank 2014c). Tanzania is expected to maintain its high growth rate through the next two years, continuing to exceed estimates and forecasts for othe r similarly poor countries. The failure of development aid like this has not escaped attention, and the co processes of aid fatigue among donors and aid dependency among partners in many countries become more evident amidst global economic crises. The goal of international development, in the beginning, was on rebuilding devastated economies and infrastructure, and providing emergency assistance to newly emerging governments in low and middle income countries (LMICs) (Garrett 2009).


62 The emphasis was on sust ainability, a temporary infusion of capital and pooling of talent, technology and resources, which would then bring about self sustaining development worldwide wo rking itself into obsolescence, development has become entrenched. Tanzania is a principal example of this failure; it is a country that has, over the past 40 years, secured more funding than the vast majority of other African countries. In spite of this, the problem of aid in Tanzania incited one Sida Tanzania of today is the epitome of an aid dependent country, some would say a country nomist Dag Aarnes (Dempster 2007). The Zambian economist Dambisa Moyo (2009) believes that the failure of aid in Africa is largely due to non emergency aid enco uraging conflict and corruption, and discouraging free enterprise. Increasing investment and trade with Africa, like China is now, may be a better antidote to widespread poverty (Moyo 2009). The Health Sector in Tanzania After three decades of structural adjustment in Tanzania, there are several critical issues inhibiting the strengthening of a health system and making it so that aid exit now would be particularly detrimental to realizing the goal of HSS and universal access to primary care. Specifically t he critical shortage of health workers, the internal brain drain, and medical education and accreditation, which are now typically in the form of external trainings, taking health care workers out of the already understaffed clinic. The critical shortage o f health care workers in Tanzania has been widely reported, and is currently the biggest obvious challenge in building up a sizeable workforce with technical expertise. In a joint stakeholder assessment of the Tanzanian health sector, the country currently


63 fills only 35% of what the WHO considers a base level of necessary staff for health sector functioning (Musau et al. 2011). Tanzania ranks lowest in the world for physicians per capita, with only one MD for every 50,000 people (10/50,000 is the WHO standa rd), and 1 nurse for every 2,857 people (World Bank 2013a). Task shifting is a current stop gap, where the cases a doctor would usually handle are instead seen by an assistant medical officer (AMO) or clinical officer (CO), but even AMOs and COs are in sho rt supply (URT 2008). The human resources crisis in health care in Tanzania has deep historical foundations. Bech et al. (2013) outline a history of health care post perceptions, relying on retrospective data collecte d in Mbulu District in 2009. At independence, the British colonial government left Tanganyika (mainland Tanzania) with few human resources at all (2013:66). The socialist government, conversely, promoted health care workers and teachers in particular as critical for building the new nation, as President Nyerere encountered critical focus on these builders of the nation had impressive results; as he said in a 1999 interview: After the Tanzanian debt crisis of the mid 1980s, however, large scale lay offs of publi c sector health workers were enacted in the early 1990s as part of austerity measures associated was enacted, and the estimated number of Tanzanian health care wo rkers decreased from 67,000


64 in 1994/1995 to 54,000 in 2001/2002. A hiring freeze on health care workers was also enacted creating a bizarre and ultimately devastating situation in which there was incredible need and wasted talent Tanzanian Human Resources for Health Strategic Report notes that from 1993 1999, 23,474 sector (URT 2008). At the same time, the Tanzanian population increased by 11.3 million people in 14 years from 23.1 million in 1988 to 34.4 million in 2002. The number of Tanzanian doctors working abroad external brain drain reached extremely high levels as wel l during the 1990s (Bech 2013:92). In an OECD report on immigrant health workers abroad, Dumont and Zurn (2007) analyzed expatriation rates for doctors and nurses and placed Tanzania in the top ten exporting countries with 55.3% of Tanzanian MDs (1,018) and 6.8% (970) of Tanzanian nurses working abroad in 2000 (Bech et al. 2013:92). Although patterns are changing now, from 1995 2005, an estimated 16% of all health care workers trained in Tanzania ultimately worked in the public sector (URT 2008; Songs tad et al. 2012). To fix this, Tanzania is currently investing heavily in primary and secondary education, and medical and nursing schools are educating thousands of future health care workers (World Bank 2013 b ; URT 2008). But the cavernous gaps in the cu rrent medical workforce are making it difficult to effectively educate students, as student to teacher ratios are very high, clinical supervisors in the wards are stretched too thin, and supervision in medical internships is sometimes absent. As was the ca se in Haydom, some hospitals rely in part on a revolving cadre of expatriate volunteer MDs to step in and help, training and supervising Tanzanian medical interns alongside the other Tanzanian doctors. But with a growing interest in global health in


65 Wester n universities as well, more and more medical students on global health rotations require limited time. Further complicating the health care human resources crisis is the lack of equipment and infrastructure that allows those health care workers who do stay in clinical practice to effectively work. One European expatriate informant, Henry, from a large international NGO in Dar es Salaam, spoke at length with me about the extent of the problem th at he has witnessed over the several decades in which he worked in the health sector in Tanzania. Health care workers are limited by the shortage of equipment, he said, and to a point, without the proper diagnostic tools that doctors are trained to use, it does not matter whether it is a doctor or a nurse seeing patients: T environment is not there. You can put a well trained doctor in a national or a regional hospital, but if there is no blood pressure machine, if there are no gloves, if there is no standard operating procedures for delivering babies, if there are no clinical audits for people who died to find o ut why they died; if all that is (not) Other research highlights the poor working conditions, lack of equipment and infrast ructure deficiencies of government facilities in particular. Inadequate working conditions 103). More strikes occurred in early 2012, which are also explained in more detail in Chapter 6 . Introduction to Fieldwork As outlined in the introduction, I became interested in sustainability and health while working as a summer global health intern in 2008 at one of the large American run HIV/AIDS


66 NGOs in Dar es Salaam, at that time flu sh with aid money from the multi billion dollar PEPFAR initiative. I examined PEPFAR implementing agencies and programs as an initial case study over the course of 2009 2012. The short but eventful history of PEPFAR the initial burst of funds and large scale expansion from 2003 2008, the leveling off and slight decrease of funding after the 2008 financial crisis, and the calls for a transition to sustainability seemed a good first step to study health care sustainability. As the initiative grew to k eep millions of people alive on antiretrovirals, the contraction and possible demise of PEPFAR worried many in the global health community, not to mention the patients themselves and their families (Garrett 2009). For this research, my principal field sit e was a PEPFAR funded HIV clinic operating at a large, rural, faith based hospital in northern Tanzania, Haydom Lutheran Hospital (HLH). After funded and successful Prevention of Mother to Child Transmission (PMTC T) program, I had planned a panel survey of mothers and their babies as they transition out of the two year program, expecting the program to continue on in much the same form as it had when I returned for the research. When I did return in early 2011, I f ound the program had been significantly scaled back, having lost funding for many of the PMTCT services that were not considered essential like food support, bus fare, and home based care. At the same time, the hospital itself was facing an impending fun ding crisis donor (that provides nearly 60% of the operating budget) may cease funding in 2014 after the end of the current funding cycle, leaving the hospital to scramble to find funds to continue services. When I left in June, 2012 , hospital administrators were preparing for an uncertain future, laying out plans to find other sources of funding: producing a fundraising documentary that was unveiled in San Francisco, USA, and developing a new website to court donors, alongside the sl ow dance with the Tanzanian government to more fully integrate the hospital into


67 the public system, which could then garner more government dollars. In the HIV clinic, staff braced for the next cuts to their budget PEPFAR would no longer fund their salar ies beyond Like my experiences at Haydom, discussions of sustainability in health often come coupled with fears of aid exit or decreasing funds from donors (and in many cases, use of t he about aid exit or stagnation and sustainability swirled around me over the course of my fieldwork, but it was the context in which it was occurring the ove rwhelming precariousness of people for whom aid exit would most affect that also captured my attention. The patients for whom care was critical for their lives, and the health care workers for whom HIV/AIDS donor funds were critical for paying their sala ries none of these people had any choice in it, in what the future would bring. They could do little, if anything, to change the fundamental course of HIV/AIDS care in Tanzania, there could be little bargaining with donors for this or that, and there wou ld be no real geopolitical consequences of pulling funding (except for the funding of ARVs) that lawmakers would have to face, no elections to lose. Since the funding and services were there in the beginning not as a right, but as a charitable inclination for a time when money was flush, the sustainability of funding at current levels over the long term is unlikely. For reasons I will explain in more detail in Chapter 3 , I have chosen to use the concept precarity to describe this phenomenon, which, coupled with sustainability, provides much of the theoretical structure for this dissertation. Fieldwork Setting I arrived in Dar es Salaam in early March 2011 to begin the long process of securing research clearance from the numerous national, regional, district and village offices. From March until early June, I lived and worked in Dar es Salaam, and met a few times a week with a Swahili


68 tutor to brush up on my language skills. In June I headed off to Haydom, and by mid August had found research assistants, tran slated informed consent, survey and interview documents, and began research in Haydom town and the PMTCT clinic. Over the course of the next month I realized that my dissertation plan of tracking mothers and their infants transitioning out of the PMTCT pro gram was no longer feasible, and needed to reevaluate what was important and relevant to my study of health care sustainability and aid exit. At this point I began conducting semi structured interviews with people in town, in an attempt to gather necessary background information and search for new ideas. As new ideas came for work in the hospital and with the HIV clinic, I kept up with the village interviews, because they were a great source of information about many intersecting things, which over time all pointed toward increasing precariousness, which will be examined in more detail in Chapter 4 . I stayed in Haydom until February 2012, when I returned to Dar to renew my research permits, catch up with friends, and begin interviews with some of the large, international NGO workers and administrators. I returned to Haydom in March, finished up work in the hospital, HIV clinic and in town, and returned to Dar in mid June. After collecting a few more interviews with informants in Dar, I concluded my fieldwork and left for home, in mid July. Haydom, (Mbulu, Manyara, Tanzania) Haydom is a town of about 20,000 people on the western edge of Mbulu District, in Manyara Region, in northern central Tanzania. The town exists in large part because the hospital is there, speakers who migrated south from Ethiopia about 3,000 5,000 years ago, eventua lly settling in a small pocket of northern central Tanzania in Mbulu ( Iraqw Da/aw is the Iraqw homeland, in the highlands of Mbulu district, approximately 80 km northeast of Haydom) (Patil 2004:26). The


69 Iraqw began to expand geographically into traditional Datoga pastoral lands in the early 1900s, and once the British Protectorate government cleared the land of bush and tsetse flies in Haydom in the 1950s, sett led in Haydom as well . Many Iraqw living in Haydom are agropastoralists, farming maize primarily, but also pumpkins, beans, sunflowers and lentils. Some Datoga live in haydom is Datoga for the hump of a zebu cow (Patil 2004). Since the bush clearing and the establishm ent of the hospital, the population of Haydom has increased dramatically. Many people from other ethnic groups ( makabila ) live there now as well, including Sukuma, Hadza, Iramba, Isuzu, Pare, Maasai, Chagga, among others. Additionally, infrastructure devel opment in Haydom has far surpassed much of the surrounding area, making Haydom a central hub for social services and economic activity. Driving in to Haydom, it is easy to see this the nearest electrified town, Dongobesh, is 50 kilometers away, and many of the small surrounding villages do not operate in the cash economy. The district capital, Mbulu, is 80 km away, about an hour and a half by Land Cruiser, and the regional capital, Babati, 120 km, is (inexplicably) about a four hour trip on a good day. In between are a few towns but mostly vast stretches of bush. From 1967 to 1985, ujamaa was enacted in Tanzania , in which centralized location s were established for rural Tanzanians to access social services , but also changing the composition of rural vill ages (Rekdal 1996) . Ujamaa Tanzanians. A central requirement of ujamaa w ization in which six million rural people were forced to move into government designated villages that could offer centralized social services (Jennings 2008).


70 Other developments, residents told me, had significant effects on settlement. Electrificatio n of the town in the 1990s by the Canadians brought many people and businesses to town. Primary schools, and the only secondary school in the area was also a draw for people to settle in Haydom. But the hospital, for three principal reasons, was a signific ant factor motivating migration to Haydom. First, people with chronic illnesses receive long term, high quality care here, without having to travel long distances and pay the often expensive bus fare. This is a common reason for some of the PLHIVs I knew f or moving to Haydom, who sometimes are also, as a form of care and support, offered jobs in the hospital as v ibarua or day laborers, usually earning about Tsh 60,000 (~$40) a month. Additionally, patients suffering from diabetes, tuberculosis (and especial ly harder to treat multi drug resistant, or extensively drug resistant, TB), alcoholism, epilepsy, and other chronic health conditions, come to Haydom to receive longer term care, and end up living, and sometimes working, in, around, and near the hospital. Second, short term patients and their families are in need of guesthouses to stay, markets to buy food, and other shops to buy the usual requirements of daily living. Small shops or maduka ance gates, selling prepared and packaged food, water, alcohol, clothes, and lots of odds and ends (Figure 2 1) . Pharmacies and drug stores also opened up, catering to patient populations. Guesthouses and patients, their families, and other visitors stay.


71 Figure 2 1 : Shops along the road near the entrance gate to Haydom Lutheran Hospital (2009) . Finally, as in all company towns with opportunities for salaried employment, people move to Haydom for work. The hospital, in 2012, employed 720 people, filling a range of jobs with various skill requirements: the vibarua , housekeepers, gardeners, maintena nce staff, electricians, and drivers keep the hospital running and grounds maintained; teachers and administrators run the nursing school; administrators, office staff and evangelists work for the ndants, nurses, clinical officers (COs), assistant medical officers (AMOs), and doctors care for patients. The hospital also has a large research center, employing about 50 local researchers, and is officially recognized as a rural post for the National In stitute for Medical Research (NIMR), which grants research clearance and oversees medical research in the country. For shorter, few year stays, the hospital attracts 60 80 new nursing students a year, who stay for a three year nursing program; 10 15 m edical doctor interns, posted in Haydom for a


72 year of training before finishing their medical education; and hundreds of students, volunteers and researchers from outside Tanzania coming to stay in Haydom for anywhere from a few days to a few years. Most v olunteers are Scandinavian, and Norwegian particularly, giving Haydom students include medical and nursing school students doing a two or three month rotation in glo bal health at the hospital, several coming from universities in the Netherlands, Denmark, Norway, Sweden, and the US. Other students came in large groups as part of study abroad or field courses, or working as volunteer researchers on larger health researc h projects operating through the research center. Haydom Lutheran Hospital Figure 2 2 : Entrance gate to Haydom Lutheran Hospital (2012). Haydom Lutheran Hospital (HLH) was built in 1955 by the Norwegian Lutheran Mission, strategically situated to provide medical care to some of the more geographically (and socially and economically) marginalized populations of northern Tanzania the Iraqw and


73 Datoga, as well as the Hadza, some of the last hunter gatherers in Africa. Today HLH is the fifth largest hospital in Tanzania (2014), with 429 beds. I n 2012, the hospital had 15,400 inpatients , 70,151 outpatients and 5,164 deliveries (HLH 2013). The h ospital caters to an immediate catchment area of 300,000 people, with the larger catchment area caring for two million, encompassing seven districts in four regions (Manyara, Singida, Shinyanga, and Arusha) (HLH 2013). Figure 2 3 : Haydom Lutheran Hosp ital (2012) . Since 1963, the hospital has been owned and administered by the Evangelical Lutheran Church of Tanzania (ELCT), and was officially opened as part of the Tanzanian central health system by then President Julius Nyerere in 1967 (HLH 2013). Fun ding for the hospital, however, has been somewhat spotty over the decades. Funding for the post independence expansion of the hospital in the mid 1960s came from the Lutheran World Federation, Oxfam (UK), and Brot für


74 die Welt (Germany); the Norwegian Luth eran Mission funded it afterwards until the early 1990s, the Canadians took over funding for a brief period, with the RNE funding it again until 2014. Figure 2 4 : Currently 59 % of the hospital operating budget comes from the Royal Norwegian Embassy (RNE), major funders of the hospital for the past two decades. Largely dependent on outside, international aid since its start, HLH continually struggles to find a realistic Plan B for majority funding; as it was pur posefully established to cater to largely impoverished, rural Tanzanian farmer and pastoral communities, it has few options apart from donor or government Mæstad and Mwisongo 2009 ). For these reasons, HLH is also an ideal c ase study for examining the problems of aid exit and dependence on international aid, and potential solutions for mitigating negative effects of exit and promoting sustainability.


75 Table 2 1: Annual b udget, Haydom Lutheran Hospital. Income Source In USD$ Expenses In USD$ Patient fees 670,000 (13.3%) Salaries 3,850,000 (70.2%) Other local income 240,000 (4.6%) Medicine 490,000 (8.9%) External income (P rivate donors) Tanzanian government Norwegian government Total 220,000 (4.2%) 950,000 (18.5%) 3,060,000 (59.4%) 5,140,000 Medical equipment Other expenses Schooling Total Deficit 180,000 (3.4%) 790,000 (14.5%) 170,000 (3%) 5,480,000 340,000 In July 2010, the hospital was designated as a Level 2 Regional Referral hospital with the Tanzanian government Ministry of Health and Social Welfare (MOHSW), allowing patients from government or other clinics to be referred to HLH for non specialized care (HLH 2011). As part of a long process of inclusion into the government system, the hospital also receives a staff salaries grant from the Tanzanian government (Tsh 485,700,000/; or 7.1% of the hospital budget, in 2010), in addition to a block grant from the RNE (US$3.4 million, or 50%, in 2010) to pay salaries, primarily. Health worker salaries take up a significant percentage of the hospital budget (70.2% in 2013), and because the Tanzanian government has raised civil service worker salaries several times over the past decade as p operating budget (HLH 2011; Songstad et al. 2012). Health care financing, particularly for salaries, was easily the most contentious of all topics discussed in interviews among health care workers and administrators. This, and related themes, will be explaine d in more detail in Chapters 4 , 5 and 6 .


76 HIV and PMTCT at Haydom Lutheran Hospital Figure 2 5 : HIV Clinic at Haydom Lutheran Hospital (2012). HIV care and treatment services at HLH are held in an eight room, unmarked clinic in a relatively inconspicuous spot, apart from the reception hall and main buildings of the hospital (where most people roame d around) and in the mix with a few other outpatient clinics for diabetes and optometry administration buildings. A revolving cadre of two COs, three nurses (one of whom, Mama Danieli, was the clinic administrator/manager), two ward attendants, one driver, and a data manager staffed the HIV clinic which he ld hundreds of bottles of antiretrovirals (ARVs) in numerous different prescription combinations, several small tubs of pills used to treat opportunistic infections, condoms, numerous ledger books and an ancient computer. Ward attendants run back and forth from the front desk a wooden table and two chairs set up in the waiting room to the records room in the back, which holds the thousand or so files of all patients ever treated at HLH for HIV. Other


77 and conduct preliminary patient check ups with patients before they line up to see the CO, who, like an MD in the US, checks up on each patient and prescribes medication. During the days, patients sit on benches stationed along the walls in a large waitin g room, decorated with colorful posters about food and the importance of purifying water, with Swahili TV. On Tuesdays and Fridays patients show up en masse at 8:00 am for in house CD4 test ing, system function, and are a critical measure in determining their health, and the effectiveness of the particular kind of ARVs a patient takes. Since many patie nts live far away and have to travel by bus or on foot for many hours to get to HLH, most people try to make sure their regular clinic visits coincide with those two days a week that CD4 testing is available. On those days, it was not unusual to see patien ts standing in the hallways, shoulder to shoulder in between the doors to the examination rooms, and lounging in the shade outside, for five or six hours. Mondays, Wednesdays and Thursdays, however, and most every afternoon, the clinic is very quiet. Some days, it is positively desolate. On quiet clinic days, Josephu, the driver, and one nurse will typically head over to one of the understaffed government HIV clinics ( kituo cha afya ) in the wider hospital catchment area, to help out. Like in many countries in sub Saharan Africa, the shortage of health workers in Tanzania is a major problem, and in addition to overburdening those few health care workers who do staff the clinics, long lines, hurried care, and widespread bribery can often lead to patient dissa meaning they have not returned to the clinic for their scheduled follow up appointments. The


78 addition of one HLH nurse in a rural clinic every other week can make a si gnificant difference. LTFU is sometimes a problem at HLH as well, and on the quiet clinic days, HIV clinic staff will those mothers in the PMTCT program. They may also head out to check on patients, deliver ARVs, or bring people back to the hospital for care. Josephu, the driver, knows where each PMTCT mother lives, and can find them all without a map or directions. The HIV prevalence rate in the Haydom catchme nt area is low, with approximately 2% of women in antenatal care clinics testing positive (Yahya Malima et al. 2007). According to health care workers at HLH, a 2% prevalence rate continues to be a stable rate (personal communication, Head Nurse, HLH 2012) . Epidemiologists studying HIV disease patterns in the Haydom catchment area warn that imminent HIV epidemic, however, is possible, due to high rates of sexually transmitted infections, a high proportion of men with multiple sex partners, and extremely low rates of condom use (Yahya Malima et al. 2006; Yahya Malima et al. 2007). Dar es Salaam residents and counting some estimate Dar could have as many as 7.2 million by 2025 (BBC 2012). Although it is not the political capital of Tanzania anymore, it is without a doubt the commercial capital of the country, with a large port and thriving commercial areas, the vast majority of government agencies, as well as a burgeoning t ourist industry. Much of the tourism in Dar es Salaam is to serve as a mid way point between the traditional safari Zanzibar tourist circuit (Zanzibar is an island about a two hour ferry ride away from the launch point at the port of Dar es Salaam), as wel l as to serve the thousands of NGO consultants who fly in to work at related.


79 Figure 2 6 : Fish market and air traffic control center, downtown Dar es Salaam (2011). Buse and Walt famously called t he system of NGO administered health care in resource poor countries an unruly mélange (1997). The word mélange to describe Tanzanian HIV/AIDS prevention, car e and treatment services is apt . Despite the seven or so months of research and interning in the T anzanian PEPFAR world, it still confuses me a bit about what organization they coordinate, how gaps in funding and service provision are preempted, and so on. It app eared to me to be more of a dance, skillfully executed by talented, knowledgeable and well connected people, principally expatriates. It did appear in many ways to operate parallel to the public sector, which many Tanzanian and expatriate health care worke rs acknowledged and lamented. Many of these health administrators have moved around from NGO to NGO, from HIV to maternal and child health to tuberculosis to malaria, and after awhile, everyone seems to know everyone.


80 I met many of the global health expat riates in some of the exclusive clubs and weekend spots in and around Oysterbay, a section of the northern peninsula of Dar es Salaam where the rent for about $2000 $3000 USD a month, effectively excluding most people without a foreign government living allowance. The Dar es Salaam Yacht Club, in particular, is where I saw just about everyone I either had interviewed or needed to interview. On one occasion, I was i ntroduced to the director of one of the largest global health NGOs as he steered a sailboat on a trailer down the ramp to the harbor. Another time, I found myself lounging on a beach towel next to the sustainability coordinator of another of the HIV/AIDS N GOs. Many expats ran in very similar circles, I discovered over the year, and the circles tended to be quite small. A few Tanzanians successfully integrated into these circles, but they seemed pretty exceptional. Entrée into the Yacht Club, for example, wa s strictly regulated sign up costs were astronomical, monthly fees also quite high, and to become a member, one needed to be recommended by current Yacht Club members. I walked through the gates on several occasions with no membership pass, however (I wa s not a member) my white face seemed to serve just fine. owned and run NGOs, either newly created by the Track 1.0 partners, or selected among the pool of formerly establ ished Tanzanian NGOs to be built up to accommodate HIV care and treatment services. During my fieldwork, I was able to visit several of these offices, and meet with many of the people working out through the transition process. One of the most notable thin gs I (whether in the American Track 1.0 partners or the Tanzanian NGO partners slowly taking over their role). A few expatriate administrators an d medical docto rs worked at the Track 1.0 NGO I


81 worked at, and some expats would fly in from the US for a few week consultanc y. But the vast majority of NGO employees were Tanzanian, many of whom were MDs. I found the same to be true in the other NGOs I visited as well. Each of the six original PEPFAR Track 1.0 partners had responsibility for a geographic area of Tanzania to provide all prevention, care and treatment services. ICAP, for example, worked in Pwani region (where Dar is located), Kagera, Kigoma and Zanzibar. Each of these regional outposts had a network of staff and clinical services, and ICAP workers from the headquarters in Dar es Salaam would frequently fly or drive out to the regions to check in on th ings. At the Dar es Salaam headquarters of the NGO offic e I worked at, work i s divided up into targeted projects and programs PMTCT services, HIV/TB care, Adherence and Psychosocial Support (APSS) among others. I worked with APSS at first, and my first task was to sit in on two weeks of trainings for peer edu newly diagnosed PLHIVs navigate the care and treatment center (CTC) for health services, learn how to best take medication and adhere to their prescribed drug regimens, and serve as counselors an is taken up in slightly modified forms at countless clinics, hospitals and NGOs throughout sub Saharan Africa (HLH had its own as well), to deliver services cheaply in reso urce poor countries. A network of peer educators, or village health workers (VHWs) or community home based care workers (CHBCs), oftentimes work upwards of thirty hours a week and are officially volunteers, but often (at least in the early days of PEPFAR, when money flowed in to CTCs) receive a small stipend and maybe a bike or bus fare; today at HLH, their stipends have been reduced dramatically. The effectiveness of these services, and the ethics of using volunteers to deliver critical health services, wi ll be examined in more detail in Chapter 5 .


82 I also worked with Esther, a Tanzanian MD who became a dear fri end and key informant, in the PMTCT program at this NGO . She recruited me over instant coffee one afternoon in the brainchild was to find a way to use PEPFAR money, earmarked for HIV services only, to expand safely when they may not be able to get to a rural dispensary or clinic. Her idea was to train traditional birth attendants in emergency medical care, which could benefit all women regardless of HIV status, while also being able to counsel and test pregnant women for HIV, and delive r ARVs to them (single dose nevira pine) in case they could not make it to the hospital, in order to prevent mother to child transmission. This method of attempting to use the copious amount of HIV PEPFAR money to distribute to other areas o funded NGOs told me. Now, in policy as well, expanding its mandate to include maternal and child health services, and address seven of the 19 neglected tropical diseases. These efforts comprise current attempts in global health to convert explicitly vertical programs (like PEPFAR) into initiatives that may more e ffectively build up the health system in the process for longer term sustainability. A history and description of vertical programming, and the efforts to build up primary care and sustainable services, comprise much of the proceeding chapter on neoliberal health care, Chapter 3 . Key Informants I lived with two Tanzanian families during my fieldwork Esther and her two children, David and Katherine , in Dar es Salaam; and Mama Grace and Wilson , and their seven children and two grandchildren, in Haydom. Est her, Mama Grace and Wilson all work in some capacity


83 in the health care system, and could talk about many of the changes, for better or worse, that they had observed relating to health care over the course of a couple decades. Living with these families wa s instructive and illuminating, and for reasons of ease, trust, and mutual caring, became key informants for many different questions and subjects. Once Esther recruited me for her safe motherhood project, she became my de facto supervisor, and close frie nd. We kept in touch over the years, and she was the first person I called in Dar es Salaam after my abduction she sent a trusted taxi driver to my hotel to pick me up, and I lived with her for three months after that. At that time, Esther lived in a one story three bedroom apartment with her two children on the relatively exclusive peninsula of Dar es Salaam, just north of downtown and surrounded by the Indian Ocean, and the ocean of NGO office buildings, expatriate friendly shopping plazas, hotels, and foreign government housing complexes, as well as within walking distance to the Yacht Club. She had lived there for a few years, after she had to leave the larger house closer to town that her husband, who recently died, received as part of his job. The ap artment was large, with a yard in the back surrounded by brightly colored bougainvillea, and a covered deck with chairs. It was within walking distance to The Slipway a tourist centered mall on the water, which had a Swahili language center as well as de cent pizza and beer, where I spent many afternoons discussing politics and health with my Swahili tutor, a hopeful pre med student himself. Working and living with Esther was wonderful she is extremely caring, intelligent, talented, driven, charming, an d has a strong desire to improve health care for women, working all day at her non profit, Tanzanian NGO hospital in Dar es Salaam as well as courting donors and networking with other health professionals in her free time, all the while caring for her two


84 children on her own. While I was staying with her for the first three months of fieldwork, she recruited me to help her set up a mo nitoring and evaluation system for a program the hospital was conducting with another American health NGO , training midwives and nurses from government hospitals in obstetric and neonatal care. Over the course of this process, I went to trainings and meeti ngs, and worked in her office with a small team of others two midwives, a program administrator, and a fundraising coordinator, who were principally occupied working to find funders and developers to build hospital I was able to see firsthand the daily struggles that go in to funding, conducting, and monitoring a health program, and working to integrate it within the Tanzanian public health system. Beyond that, I observed her and her NGO hospital capacity of health care workers in the public sector and build critical infrastructure that will relieve the extremely overburdened maternity wards of the four massive government hospitals, and network of clinics and dispensaries, in Dar. From these experi ences, during both my internship and working with her at her new hospital , I came to see Esther as exemplary of what many resource poor countries need someone who is dedicated to working in Tanzania for the long term, in the service of her compatriots, a dvocating for their right to high quality health care; while also advocating for the fair treatment of health care workers and professionals, highlighting the injustices that sometimes occur with a vertical program riddled health system overly dependent on international donors. I went back to stay with Esther, David and Katherine two more times during fieldwork to renew my research permits and conduct interviews with people associated with PEPFAR and other HIV, global health and government organizations. Sarah, a friend I met at a security briefing at the US Embassy, became a good friend and candid key informant as well. Sarah worked at the US Embassy in the Country PEPFAR office,


85 and as a Global Health Fellows intern, we shared many dinners out and days at the beach discussing global health, HIV/AIDS programs and policy making, though she never spoke about PEPFAR officially. She did, however, introduce me to several official informants in PEPFAR offices and organizations in Tanzania, who were more able t o discuss official matters with me. Her help and ideas, however, were invaluable. Agnes (or Mama Grac e, as she is most often called) came to be like my own Tanzanian mother, because she cares Direc grandmother, and nearly 50 years old. She takes care of most everything there cleaning, cooking all meals, baking, shopping, and helping to host and fete the freq uent guests of the MMD, Jostein, and his wife, Turid. Mama Grace has worked for the MMD (three different Norwegian men by now) for 20 years. Her husband, Wilson , is a driver for the hospital, and has worked there himself for several years. The house I liv the original house structur e before Mama Grace and Wilson upgraded to the much larger con crete and brick house they live in now. It has three rooms a large bedroom with room for a desk, a smaller sitting room, and a smaller bedroom in the back. The house had no running water, so I had a 15 gallon bucket with a spigot perched atop a wire stan d to work as a sink, and took bucket baths in a separate concrete building that had a room for baths as well as two latrines. The insects I encountered in this building were sometimes horrifying. I lived in this little house alone, which suited me very wel l I was close enough to the family to hang out with them when I wanted, and could close the door for some privacy. Mama Grace and her daughters also


86 fed me three meals a day, helped me navigate the town (and town politics the town m wenyekiti , or mayor), and helped me to better understand the various things I learned during fieldwork. I also had five research assistants at different times over the course of the year in Haydom. Samueli was my first assistant recommended to me by a c olleague who had conducted several research projects in Haydom in the past, who proved also to be invaluable. He helped me secure research clearance from all of the required authorities in Manyara region, Mbulu district and Haydom town, as well as helped m e translate informed consent documents, interviews and surveys, and found a student to transcribe all of my Swahili language interviews. More importantly, perhaps, we met monthly to catch up at one of the small restaurants in town, where he would regale me with stories about Haydom since its establishment in the 1950s, the Norwegian family that ran it, and the political intrigues in Haydom and at the hospital. Two of my research assistants were daughters of Mama Grace and Wilson , Grace and Asha. Grace, gra duated from Haydom Nursing School the month I arrived in Haydom, August and I shared one of the small houses on the family compound, and she worked with me as a r esearch assistant for the first two months of my research, and as a key informant for much of the year as well. Asha started working with me soon after, and helped me conduct all interviews with PMTCT participants, and most of the semi structured and conse nsus analysis interviews in interviews in Haydom town and other villages. Finally, Paulina, recommended to me by another researcher and colleague in Haydom, helped me on t he weekends to finish up interviews with people in Haydom, as well as conduct many of the consensus analysis interviews. All of my


87 research assistants I consider friends, and hanging out with them at the bar on Saturday nights, or for an afternoon chipsi m ayai (potato omelet ), gave me the opportunity to make sense of the things I was learning over the course of the year. Conclusion In this chapter, I examined the historical foundations of global health, and the role of neoliberalism in the creation and prom otion of selective primary health care to the detriment of the austere way international health was implemented globally, which amounted to a phenomenal increase in funding, changes in policy, and the rise of global health NGOs which were the principal architects of the HIV/AIDS program rollout. I also introduced my field sites, in Haydom and in Dar es Salaam, and key informants and assistants with whom I worked. In the next chapter, I review some of the principal theories in global health that have informed this work. In particular, I look at the ways in which humanitarian and civil society organizations may be changing the landscape of global health, and how the theory of biopower may be useful in some ways to advance global health interventions.


88 CHAPTER 3 THEORETICAL CONTEXT Building on the historical foundation provided in the previous chapter, in this chapter I review the current literature that seeks to explain the current form of health care and health care policy its design and delivery, its cultural and philosophical foundations, and its emergent mechanisms of gover nance behind the tools effectively used to improve population health and well being, but in the process, establish hierarchies among populations and justify inequalities in health and access to health care. Second, I examine biological citizenship, one of the most compelling theoretical expansions of biopower looking at how forms of citizenship, based on biology, become the rules for which inclusion and exclusion or exception in health care is justified. In the remaining pages, I more closely examine pre carity and sustainability, two linked themes that I consider together as a principal framework for the bulk of the ethnographic work. Both are imperfect ideas, and overlap considerably with other theories and concepts, but I use intentionally. Precarity I use primarily because it overlaps with other themes in useful ways, incorporating pieces of structural violence, unpredictability, risk and vulnerability, inequality, and social abandonment by way of neoliberalism. Sustainability I use because it is what i s used in global health, although, as I examine in more detail below, has changed in meaning significantly over the years. I consider these shifts in meaning, and what that may accomplish and for whom, at the end of this chapter. Global Health Inequalitie s Global inequalities in health and the rapidly changing patterns in disease spread and scope are principal issues for global health researchers and practitioners. The HIV/AIDS epidemic forced a spotlight on global health and health inequalities, and is a principal driver in


89 mobilizing more expansive and intensive global health efforts in general (UNAIDS 2008; Schneider and Garrett 2009; Messac and Prabhu 2013). In is central : G lobal health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes inter disciplinary collaboration; and is a synthesis of population based prevention with individual level clinical care (1995). Examining t he existence and persistence of health inequities is a principal goal of anthropology in global health. In this context, anthropologists seek to identify where inequalities exist, the causes and consequences of these inequalities, and the processes and mechanisms behind their perpetuation. Fro may help reduce these inequalities and improve health and well being (Janes and Corbett 2009:169 ). Biopolitical theory is an important lens many anthropologists use to understand global health processes, particularly for identifying the systemic foundations and drivers of inequalities in health. Foucault proposed that a shift in governance from sove reignty to biopower, a type of governance that exercises power over life (instead of death), first allowed for widespread social inequalities to be justified and entrenched through more extensive use of standards and norms (Foucault 2010/1972). Through the se mechanisms, biopower more effectively subjugated bodies 2010/1978:263 ). Capitalism, and later neoliberalism, further produced inequalities.


90 Since the shift to biopower in the late 18 th isks freed from these risks of death, inequalities in health grew. Methods of power exercised by the state over life decreased the randomness in which death occurr 264). A consensus is emerging within global health circles that researchers, policy makers and practitioners must confront the political and economic foundations and realities of poor health and health inequalities to more successfully overcome them (Nichter 2008; Farmer 2004; Farmer et al. 2013; Pfeiffer and Nichter 2008; Chan 2008; CSDH 2008; Marmot 2005; Baum et al. 2009). Anthropologists o f development and global health have amassed a significant body of work illustrating these foundations, popularizing concepts such as structural violence (Farmer 2004), biological citizenship (Petryna 2002; Rose and Novas 2005), zones of exclusion (Biehl 2 005) and social abandonment (Povinelli 2011). Many of these theoretical critiques of development in anthropology center on Foucauldian theories of social discipline and exclusion, and Marxist theories of capitalist production and exploitation (Graaff 2006) . Because of this, I anchor much of this chapter in anthropological analyses of biopower and neoliberalism, including the biopolitical underpinnings of global health policies and projects (Foucault 1997; Ticktin 2006; Fassin 2007) within a neoliberal world system (Harvey 2005; Ong 2006). In this chapter, I first examine the mechanisms powering the perpetuation of health inequalities, focusing on increasingly powerful neoliberal ideologies governing society and social services, as well as its role in drivin biopower as a foundation to examine the ways in which anthropologists have employed this


91 theory in ethnographies of global health. I focus on criteria for the inclusion and exclusion of participants in heal th programs, methods for evaluation of participants and health programs, and some outcomes of these methods of discipline on population health and wellbeing. Following that, I review some of the principal ways in which humanitarian and civil society organi zations may be changing the landscape of global health, and how the theory of biopower may be useful in some ways to advance global health interventions. Finally, I examine precarity and sustainability in more detail, the fundamental framework s that struct ure the ethnographic data in this dissertation. Neoliberalism, Globalization and Health Many social scientists fault neoliberalism and structural adjustment for setting Tanzania and other low and middle income countries on a trajectory toward entrenched poverty and poor health (Baum et al. 2009 ; Pfeiffer and Chapman 2010 ). Neoliberalism and globalization are difficult to conceptually tease apart, and are often conflated in academic literature. Both concepts are tightly bound, and over the past thirty year s have produced what many consider to be a radically different system of global governance (Harvey 2005). Neoliberalism is largely being can best be advanced by liberating individual entrepre called oppressive state run institutions (Harvey 2005:2). Globalization is one outcome, a world increasingly interconnected, globe into webs of interconnection, compressing our sense of time and space, and making the Reinicke and Witte (1999) argue that globalization is a process that is primarily structured relations (Buse and


92 and Walt 2002:52). Thi s process is in large part a consequence of shifts in governing philosophies leading up to neoliberalism, which has increasingly allowed the market to govern policy and society by reducing the role of the state (George 1999; Harvey 2005). The neoliberal me freedom, that trade unions should be curbed and citizens given much less rather than more social Privatization in health care is a particularly pernicious part of the operati onalization of neoliberalism , and impacts on population health in multiple ways. In African contexts in particular, privatization can do little to rectify large scale problems that affect health, including improving sanita tion and water quality, regulating i ndustrial pollution, enforcing laws th at prevent violence and injury, providing state security , among other preventative, population based measures (Turshen 1998) . Further, p olit ical scientist Meredeth Turshen writes that f undamentally, private medical c 1998:42). Privatization of health care, however, is mandated through structural adjustment, and has famously collapsed health care systems in many parts of Africa and turned away people who often need health care the most the poorest of the poor. Turshen writes (and much other evidence suggests) that when faced with high prices for health care, pe ople abandon during the period of donor funding cutbacks , meaning they stopped coming to the clinic for antiretrovirals and other care. Many health care workers in the clinic suspected that these patients sought out a cure for their HIV from one of the nearby, and exceedingly famous, indigenous healers Babu Loliondo (see Chapter 5 ).


93 principal mechanism responsible for the transition to privatization and deregulation, creating an increased need for development and humanitarian organizations , and the NGOs that deliver health services (Harvey 2005:178 79). Through this mechanism, people or entities occupying core regional economies dispossess people of the rights and services that were once given by the state for free (as rights), by creating private industries for the provision of services for a cost. This serves as an avenue to further siphon money from the populace to concentrate more wealth at the core, creating great social and material inequalities among populations as evidenced today (Gundar Frank 1966; Harvey 2005:162). Humanitarian organizations fill the increasing gap between tho se who can afford to buy these services and th ose who cannot, but in so doing, tacitly support this system and its perpetuation (Harvey 2005:177). As a consequence, the provision of medical and social services by humanitarian organizations in time releases the state of the responsibility to provide these services to its citizens (2005:177). Even those organizations that were founded to provide low cost or free services for poor populations those who often fall through the gaps NGOs are tasked to fill ma y over time need to raise fees in order to continue service. In Haydom, for example, the mission hospital provided free or very low cost services for decades for th ose who could not afford to pay principally rural farmers and pastoralists. Now the hospit al is faced with the p ossibility of dramatic cutting back available services ( by up to 40%), in addition to raising patient fees by 100% after already raising fees significantly in the past few years. The ability of the hospital to continue to provide hi gh quality health services for the poor its original intent is slipping away in this environment of privatization of care. Without the responsibility to its citizens for providing social services that occurs in neoliberalism , the state also gives up c ontrol of those services (and the perhaps the legitimacy


94 needed in order to govern populations) to private or international bilateral or multilateral agencies. Ferguson and Gupta (2002:990 he outsourcing of the functions of the state to NGOs and other run governing bodies to international ones and transnational private corporations. This sets up a largely undemocratic system of governance, where people are now beneficiaries who consume services rather than citizens with rights making claims on the state (see also Turshen 1998; Jennings 2008). The effects of neoliberalism on society are wide rangi ng, but inequalities in wealth and health are most stark. Anna Tsing ( 2000 ) and Aihwa Ong (2006) argue that globalization is neither uniform nor neutral, and the increasing speed and spread of global connections leads to a (Inda and Rosaldo 2008:30; Ong 2006:77). Ong (2006) argues that segregation and inequality emerge as the result of a calculated effort on the part of nation states to best situate themselves in the global economy. In her book Neoliberalism as Exception , she writes that green and brown neglect but out of a neoliberal calculation to invest in and insert groups differently into the hen resources are diverted to regions considered more advantageous to a country within a market system, people living within brown zones are left with little access to the fruits of globalization in a globalized world.


95 Green zones and brown zones can emer ge within health and development projects as well amount of funding or forei gn aid is funneled into one region. This process is most popularly and resources are funneled into a village in a short period of time (Schlesinger 2007; Carr 2 008). In health systems, health providers and programmers focus treatment and prevention efforts on a few diseases, while all but neglecting other health outcomes. This occurs largely with vertical programming, as single diseases or health outcomes are tar geted for aid and interventions, while other health outcomes, perhaps less marketable to donors, are otherwise neglected (Garrett 2007). Similarly, oftentimes NGOs independently select their areas of focus within global health, oftentimes overlapping their efforts with other organizations or leaving competing NGOs may come to dominate health systems, overwhelming national ministries, competing for donor attention, un dermining local authority, overlooking local technical expertise, and distorting local economies by inflating demands for services to satisfy the food, transport, and entertainment needs of oftentimes temporary workers (Buse and Walt 1997; Janes and Corbett 2009:175 76). Health experts are increasingly hired by well funded foreign aid agencies and NGOs to serve as consultants and technical advisers for programs, drawing them away from practicing in clinics and hospitals that are already understaffed (Brautigam and Knack 2004; Aitsi Selmi 2008; Pfeiffer and Nichter 2009). At the national and international level, illustrates the process contributing to glob al inequality (Garrett 2007; Sherr et al. 2012 ). The


96 governments of resource poor countries experience several levels of medical migration: not only do well educated citizens leave these countries for Western ones (McCoy et al. 2005), but government employ ees leave for higher paying jobs at private clinics and hospitals as well (Benson 2001). Expatriate aid workers employed by foreign agencies and NGOs rarely pay income tax in the host country, nor are import taxes applied to the vehicles and property impor ted for their use (Brautigam and Knack 2004). When a greater percentage of people providing social services shift from taxable public and private employees to untaxed expatriate foreign aid workers, total tax revenues decrease, significantly reducing natio nal budgets (2004:261). Berg (1993) reports that at one point in Tanzania, the salary total of (untaxed) aid workers was double that of (taxable) government employees. A lop sided social service sector like this also means that the government institutions oftentimes spend more time monitoring the plethora of projects proposed by foreign agencies, to the detriment of their own. In Ghana, another heavily aid dependent African country, Braugitam and Knack (2004) estimate that the Ministry of Health spends 44 w eeks of the year facilitating and participating in programs foreign agencies want to fund and addressed. Numerous aid projects in Tanzania similarly take up time away fro m the priorities of the Ministry of Health and Social Welfare. In the fiscal year 2007/2008, the tax exemptions in Tanzania amounted to 30% of its total tax revenue, or 3.5% of the Tanzanian GDP, the highest for any country in the East African Community ( U RT about 1% of its GDP, while in Uganda tax exemptions amount to only 0.4% of its GDP (56). The Tanzanian Minister of Finance and Economic Affairs stressed that the increasing number of tax exemptions for these non p rofit organizations contributes to decreased tax revenue collection,


97 services that aim to improve the well being of Tanzanians (56). While much research has focused on the spatial patchiness of the global map, there is a temporal aspect to it as well brown zones of neglect can suddenly become bright green, like with the three massive HIV/AIDS initiatives rolled out in the early 2000s and green zones can turn brown just as suddenly, as donors and governments shift interests and priorities, or lose some of their funds in recessions and depressions such as happened in 2008. Lauren Carruth ll examine in more detail within the section on precarity later in this chapter. Biopower and Biopolitics Inequality underlines much of globalization and neoliberalism. Foucault contends that inequality came to be legitimized in societies over the course of shifting systems of governance over the past 250 years, particularly the shift from sovereignty to biopower. Fundamentally, th century onwards, in which power is increas ingly exercised over life (the power to make live and let die) (Hardt and Negri 2000:23; Foucault 2010/1978; 2010/1972). Sovereign rule, a dominant paradigm of governing systems before the 18 th century, instead executed a power over death, not life the p from efforts to optimize the capacity of populations in order to maximize the economy (Foucault in institutions such as the army and the schools, and in reflections on tactics, apprenticeship, 8/2010:262).


98 Anthropologists of global health frequently use biopower to explain the fundamental mechanisms of inequality in health and health care systems. Foucault did not fully develop this idea, which is likely the reason for its wide and variant use. Biopower and biopolitics appear to governmentality. In his two works on biopower (1972, 1978), Foucault applies many of the concepts of governmentality to human biology and stat e sponsored public health and sanitation programs. In doing so, he somewhat roughly establishes biopower as a particular type of governing system, and biopolitics are the tools and tactics used to exercise biopower. The current philosophy of government, a guide, and the production of docile bodies within a disciplined society (Foucault 1995:135 168): bodies that are well adapted to be productive, contribute to the expansion of the economy, fight in war s and provide security (Foucault 1995:208; 212). institutions, procedures, analyses, and reflections, the calculations and tactics that allow the exercise of this very specific albeit complex form of power, which has as its target population, as its principal form of knowledge political economy, and as its essential technical means physics of power applied to bodies.


99 Foucault imagined that biopower controls life in tw o ways or directions, constituting two human body, includes how individuals come to understand themselves within society and regulate themselves in order t o fit in with the socially or culturally sanctioned order through ind (Agamben 1995:5). The idea of personal responsibility or patient compliance perhaps most clearly exemplifies this pole, as well as the patterning of identities a nd subjectivities that are central to the formation of biosocial groups based on biological categorizations (Rabinow 1996). Second, biopower operates at the community or population level in a regulatory capacity, , focusing on the species body, the body imbued with integrates the care of Methods to establish norms, particularly through statistical measures, are principal techniques through which this pole operates, as well as medical indicators of health and epidemiolo gical models. These measurement outcomes then direct policies and the distribution and organization of public health programs, the standards around which programs will be evaluated, and criteria for the inclusion and exclusion of participants. The process problems and questions of public health and development. Three tactics or mechanisms of biopower in particular contribute to the process of increasing health inequalities: 1) the processes

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100 of normalization and standardization that classify and hierarchize individuals; 2) the establishment of forms of citizenship based on biology, which justifies the inclusion of some people, and the exclusion of others, from health programs and ser vices; and 3) the methods, measures and techniques that manage inclusion and exclusion. The expansion of civil, political and social rights over the past century, and the tactics of governing that administer them, illuminates some of the dilemmas associat ed with governmentality and biopower. Historically, as we gained these rights, the state apparatus had an increasing need to register and monitor us, to establish eligibility in order to ensure only those who are eligible to receive these benefits do so (L yon 2001:294; Torpey 2001:270). More people gained freedom from excessive disease, freedom from exploitation, and freedom from crushing poverty, but these were accompanied by an increase in several forms of surveillance and disciplinary tactics that seeped into our everyday lives in order to maintain and monitor these power. For Foucault t entrenched inequality; the disciplinary society is at its core an extensive pro ject of exclusion. In this way, biopower functions primarily to normalize and hierarchize, and to justify normalization and the establishment of hierarchies through tools and tactics that establish norms. Biological C itizenship The categorization of indiv iduals based chiefly on biological characteristics is a hallmark of biopolitics. Categorizing individuals, however, becomes shrouded in the accepted neutrality of science, statistics and biological characteristics. This neutrality obfuscates the political origins and practices of the health policies and projects that use statistics and scientific measurements to

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101 target populations, and design and evaluate interventions (Ferguson 1994). Biological citizenship interrogates these phenomena and extends it to id eas of citizenship. Biological citizenship refers to a biopolitical system of membership principally rooted in biomedical beliefs, indicators and citizenship projects that have linked their conceptions of citizens to beliefs about the biological existence of human beings, as individuals, as families and lineages, as communities, as Biopower appears to operate through thre e tiers or systems of biological citizenship. First, biological citizenship acts as biopolitical system in which health indicators and statistics are employed to form parameters for the inclusion or exclusion of people in public health or social welfare pr ograms. Second, monitoring and evaluation strategies within public health programs can then create a further division of patients: compliant, responsible patients and those responsibly (Whyte 2009:11; Rose and Novas 2005). Third, these designations then affect their chances for inclusion in future programs or continuing care. Inclusion or exclusion is legitimized by use of these health indicators. At HLH, as in many clinic s and hospitals throughout the continent, PLHIVs receive care free health care for life and food support/rations when available, and oftentimes additional things like regular home based care, bus fare reimbursements and preferential employment opportunities. Notable about these extra supports is that they are the kind of support that most everyone in the community needs, but does not have ready access to. This observation came up s everal times in interviews with people in Haydom that PLHIVs were somehow special in the eyes of health care workers,

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102 and in particular, donors and policy makers. In a lively interview with one hospital guard, Gideon, he said that those who would be aff ected most by a draw down in Norwegian foreign Chapter 4 ). This awar eness among people in the community that special care and attention was reserved for PLHIVs was always qualified by the recognition that those with HIV were weaker ( hawana nguvu ) and needed more help ( msaada ). This preferential care, as briefly described i n the introduction, is an example of a green zone in health care. This paradox that PLHIVs have the opportunity to access basic health care and food that many without HIV do not prompted Carolina, the Norwegian HIV researcher at HLH, to say that in . PLHIVs, therefore, have the necessary biological citizenship to be healthier, overall, than many other people. This sentiment has been discussed in other ethnographies of HIV care, perhaps most notably by Vinh Kim Nguyen ( 2010 ) in his book The Republic of Therapy set in what forms of politics might emerge in a world where sometimes the only way to survive is by having a fata Foucault advocates that criticism should not exist simply for its own sake; criticism is a tool for locating, considering and working to solve the problems that plag ue societies today (Rabinow and Rose 2006 ). In thi understand global health and development for three principal reasons. First, it operates under the fundamental assumption that power is everywhere and can be accessed by anyone with the knowledge of how to do so. It makes room for the agency of all people in the creation and perpetuation of social trends, norms, values and policies. Second, it asserts that power is an

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103 ht and difficult than enacting them. Third, because of this, biopower is in many ways a philosophy that can inspire hope and political action. Rabinow and Rose (2006) r emind us that despite the criticism of global health and development interventions in anthropological circles, most projects e humble, the mundane, the little shifts in our ways of thinking and understanding, the small and contingent struggles, tensions and negotiations that mundane componen ts of larger issues can make seemingly intractable problems less overwhelming, and better inspire active problem solving to counter them. Through the sharing of ideas and activities among a larger number of more diverse actors and thinkers, whether within civil society organizations, research institutes, government agencies or in communities, we can perhaps more effectively work toward a healthier and more meaningful social existence for all of us. he mundane, and the possible, also emerges in the theoretical frame of precariousness and precarity, which I turn to next. Precariousness recognizes that human lives require social, political, and economic conditions in prisoner in the hands of the sovereign who was brutally tortured and killed, and the HIV+

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104 Tanzanians I worked with during fieldwork, our lives, no matter where we come from or who we are, are always to some degree at some points in our lives, in the hands of another. That there is considerable difference in the duration and severity of the precariousness between me locked in the car for a few hours, and a person living with HIV in Tanzania, is what precariousness is distributed unequally across populations (Butler 2009). Via social norms, social for some and mi step here is to consider how human lives are valued, and valued differently, around the world. f life, we must first consider those lives as living, in the full, political sense of the word. A liveable life entails one that is recognized as being valu ed, being loved, and being able to be grieved (Butler 2009:13 32). used across class, ethnic, and gendered lines and denotes three things: 1) reality condition an happen; with

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105 Precariousness and Precarity One of the most confusing things I encountered during my fieldwork was whether or not this constant shifting of funding, the constant unpredictability of available health care, was really n which I worked. Everything I had read, all the forecasts for rolled back funding and grim predictions for the toll that would take on Tanzanian lives, suggested that the situation in Tanzania was nothing short of dire. But when I arrived in Dar es Salaam , in discussions with Tanzanian health workers and policy makers, few seemed particularly phased by the gloomy predictions, assuring me that this happened all the time and something would work out. In Haydom, where I expected people to be more concerned wi th the possibility of the hospital losing funding, people seemed even less worried. This contrasted sharply with the panic many of the expatriate health workers and volunteers had over it all, including me how could an entire population lose access to th e health care the hospital offered? Where would they go? The closest hospital was two hours away by Land Cruiser! These conflicting messages the ones generated by the largely Western news media and global health literature, and the panic most Westerners felt, with the relatively laid back, unaffected airs from the Tanzanians caused me to constantly question what was actually going on. Is this really a big deal? Is it even truly happening? I considered that I was being duped a bit by aid agencies promot ing panic in order to court donors and make themselves feel indispensible. However, the fact that aid was being rolled back in various sect ors was an empirical fact the PMTCT program was losing considerable funding and supp ort I saw with my own eyes. Y et many people seemed to be content and happy with whatever help they were getting as if the expectation of anything was, for the most part, not there. Ann Swidler and Susan Watkins (2009) described a similar situation to this in reference to volunteer aid workers

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10 6 and their attempts to get in to the paid system of NGO work. They described this work as ic program supports, compared with the more predictable This also fit wit h what I increasingly understood as a culture that, on the surface anyway, was pretty laid back; hamna shida, Mary! (N o problem, Meredith!) was an expression I hear d all the time, even though there oftentimes was a big shida that anyone could see. Was the impending shida of the hospital possibly losing funding an overreaction on my part, or an under reaction on theirs? Or just the way life is? One day I sat down with Samueli to ask him his opinion, and mostly to see if my entire research premise that we w ere on the brink of health care collapse of which HLH was just one example was valid. He was a bit ambivalent, and like other Tanzanians I had talked with seemed to lean to the side of hamna shida . He also seemed to perceive it as a bit of a helpless sit uation on the part of Tanzanians if the Norwegians were going to pull funding, there was likely nothing he or anyone in town could do. He reiterated another point I would hear frequently chance is the dominant system in play is a scary realization for many, but one that he thought Tanzanians accepted and embraced. A similar, and indeed more common, expression was also at at a faith based hospital like Haydom, perhaps was important currency in and of itself. To me, this seems like the conditioned outcome of a lifetime, and a long history, of precarity most Tanzanians have perhaps always lived in precarious times, and may not have experienced much different. This is set against the European context and history, from which the majority of precarity theorizing takes place, with the welfare state as the benchmark for a

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107 rations against austerity, Lorey describes, include those protesting the disappearance of predictable opportunities and stability, 2012:166). The different exp ectations of precariousness, and the different histories of social welfare from which it is set against, illustrate that precariousness is not distributed evenly around the world the fundamental point of the politically oriented concept of precarity. Pr ecarity This system of unpredictable and unstable aid and aid dependent health care, as established now, is described by many social theorists as exemplifying precarity, or a universal state of vulnerability, dependency and exposure to the uncertainties of life t hat is experienced more intensely in industrial capitalism (Puar 2012:163; Butler 2006, 2009). Precarity features prominently in discussions of the decline of social welfare in the post Fordist, neoliberal era, where services like health care are no t provided automatically as a citizen of a state, or as a right, but only when available, and is instead dependent on the fickle, unstable fluctuations of capitalism itself. l age, refers to the post Fordist, post welfare state age where by formerly state provided services health care, education, social security, and so on are rolled back and dismantled in favor of privatization and the deregulation of the state that figure prominently in neoliberal philosophy. Precarity has different dimensions, and is referred to by different names depending on the author, and more specifically, the language in which the author is writing, which contributes to some confusion over naming conventions (Lorey 2011). Judith Butler, the philosopher from th e

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108 US most noted for her contributions to a largely European theoretical conversation , writes about precarity extensively as well (see Precarious Life 2006 and Frames of War 2009). Discussions of precarity have increased alongside expanding austerity measures in Europe, where debates about rough intellectual circles and are given voice in public demonstrations (Puar 2012; Neilson and Rossiter 2008). source articles on the topic (2006; 2011; and as cited in Puar et al . 2012): precariousness, precarity, and governmental precarization, which is akin to the more common term social abandonment, the term I will use (Povinelli 2011; Biehl 2001). By precariousness, she means the existential state of perpetual danger inherent to all mortal beings, human and non human. Precariousness at its most basic is a universally shared fact of life violence, injury, or devastating illness can happen to anyone anywhere at any time. We all exist in a web of precariousness togethe r, however, and this social aspect is what she argues is particularly important, and sets up the second dimension of the precarious: precarity (which is the term most often used by theorists to describe all three phenomena together). Precarity, Lorey argue s, is the normalized inequality and the establishment of hierarchies among people and beings, which (2011:1). This dimension many have written about at length ; that the subjection to precariousness is very uneven across populations some experience great precariousness all the time, others less so, and others still rarely at all the frequency and severity of precariousness in fferently, particularly along global class lines (Butler 2009).

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109 This inequality in the subjection to precarity, and the experience of it, perhaps makes most intuitive sense cross sectionally across the globe at a given time, but is an interesting case to (Muehlebach 2013) relates to the idea that the welfare state is the ideal, and indeed the norm, for governmental organization and the provision of social services . In an examination of political movements in Europe associated with precarity, however, (in most cases the increased precariousness of workers), Neilson and Rossiter (2008) question this assumption, based in part on the failure of these movements to attra ct people beyond the Western middle class. They argue, convincingly, that precarity itself in historical context is really the normal political state, which is not the norm everywhere, nor is it the historical norm for the West (2008:54). Lorey (in Puar et al. Further, as Neilson and Rossiter consider, if Fordism and the welfare state is an exceptional historical time period for a small(er) population of people, it helps to explain why the working cl asses, and those of the Global South, never took part in these political movements because precariousness is perhaps more accepted as inherent to life (Neilson and Rossiter 2008). The social safety nets afforded by Western countries are only given to the ir citizens; and within the citizenry, not distributed equally so as to exclude large populations of the lower middle and working classes. This argument goes against the near consensus forming the argument for the third dimension, social abandonment, whic h refers to the progressive and inexorable rollback of the

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110 state in neoliberalism, and with it, the dispossession and privatization of social services which have come to be interpreted as natural, or as rights (see also Harvey 2005). This dimension is fles 2013:298). Lauren Carruth (2011) examines this phenomenon extensivel y in her work with humanitarian aid in famine plagued northern Ethiopia. Specifically, Carruth studies the longer term effects of short term humanitarian aid, and identifies the experience of medical insecurity as one of the more pronounced and devastating stemming from that lack, particularly after a period of provision (Carruth 2011:17). Medical insecurity, she writes, can heighten anxieties concerning the predictability of care, as well as heighten the expectations for care people come to have through their experience with a health program or humanitarian mission. From this, trust can erode between health ca re providers and patients who remain after the program or mission ends (2011:17 18). The definition is adopted experience related t o food and food system volatility (2003). a situation that exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary ne eds and food preferences for an active and healthy life (FAO 2009). Using these definitions of hunger and food insecurity, we can draw comparisons with the precariousness of donor funded health care as a social phenomenon, and medical insecurity as the s ubjective experience of that phenomenon.

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111 Precarity in HIV/AIDS P rograms in Tanzania Precarity is an intersecting point between three critical theories and concepts I feel are important to describing the lived experience of people with whom I worked str uctural violence, vulnerability , and unpredictability structured by historically given (and often economically driven) processes and forces that conspire to restrain agency, whether through routin and that is, indirectly by everyone who belongs to a certain In Bourgois and Scheper piece An Anthropo logy of Structural Violence structural violence shines important light the political economy of violence, the concept itself is ied perhaps on the same piece goes further noting that ly 2004: 322). He goes on to say that an unexamined and deterministic heat (322). Hughes and Bourgois (200 4) address in their own framework of violence a violence continuum that includes direct physical assault, routinized everyday violence, political violence, and symbolic violence in which the people affected by systemic violence come to believe that i t is a natural system and

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112 they are deserving of subjection to violence; for example, undocumented migrant workers who come to believe they do not deserve the same rights as others (Holmes 2013) . The empirical limitations of structural violence are address ed elsewhere in emerging literature of structural vulnerability (Quesada, Hart and positionality that imposes physical/emotional suffering on specific population groups and of class based economic exploitation and cultural, gender/sexual, and racialized discrimination, as well as complementary processes of depreciated Importantly, it critiques the concept of agency exposing how structura l forces constrain decision making and limit options shaping the subjectivities, and everyday lives, of those vulnerable to systemic violence. Structural vulnerability is still assessed at the level of the community, and is specifically not an individual measure. The individual experience of everyday violence may be lost in a larger scale metric. Risk and vulnerability frameworks also principally operate on a larger, community scale metric, and rather than risks and vulnerabilities being determined by th e people subjected to them themselves, risk and vulnerability to risk are typically assessed by outside agencies and ascribed to communities. Precariousness, however, relates to experience . Matched up with risk and vulnerability, precariousness can be cons idered a risk to which people are vulnerable to; precarity extends this further to say that people are differentially vulnerable to precariousness. P recarity is the phenomenon, and vulnerability is the condition of being subjected to it, a consequence of o various forms of structural , symbolic, and everyday violence (see also Carruth 2010). Unpredictability and uncertainty, finally , signals a loss of control over life (Marmot and Wilkinson 2001), a sense that anything can happen, and not necessarily in a good way.

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113 Uncertainty is used to describe a widespread consequence of living in our current era of (2000), with the dissolution also 2012: 1223 4). But t here is a structure to uncertainty, as t heorists of precarity recognize. S ome people experience uncertainty more often, and in more extreme ways, than others, and this tends to track alongside global socioeconomic gradients. It also tends to impact on health in certain ways. Michael Marmot, for example, studied the health outcomes of British civil service workers in the famous longitudinal study at Whitehall ( 2 001 ). In it , he found that within the rigid hierarchical population at Whitehall, those lower in the civil service hierarchy experienced far more negative health outcomes, higher morbidity and mortality, than those higher up. Marmot has shown that loss of control (control over work, less autonomy at work, also associated with more subordination, and more job insecurity) is a significant predictor of these negative health outcomes, which include depression, anxiety, cardiovascular disease and coronary heart disease (Marmot and Wilkinson 2001). As a bridge between many other theoretical frameworks, anthropological analyses of precarity more than anything need ethnographic data, empirical evidence of the day to day experiences of living in the balance in a con text of neoliberal state withdrawal and increasing inequality. Like Rebecca Marsland and Ruth Prince (2012 ) advocate, anthropological theory must be rooted in the empirical realities unearthed through ethnography, which can then inform and create more comp rehensive and meaningful theory.

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114 a subjective and experiential counterpart to larger scale , and oftentimes limited, structural view s . T he following chapters are my attempt to do so. Sustainability and Sustainable Development in Health Sustainable development, according to the World Commission on Environment and Our Common Future , Nation al Research Council 1987:43). The World Commission on Environment and Development is more popularly known as the Brundtland Commission, named after its chair, Gro Harlem Brundtland, former Prime Minister of Norway, who, six years later, would also be Direc tor General of the World Health Organization. The Brundtland Commission set the foundation for research and policy regarding sustainable development a term popularized there and Brundtland also helped organize the 1992 Earth Summit in Rio de Janiero, t sustainable development. The US Research Council, in its similarly named 1999 publication Our Common Journey, preferred the use of the word sustainability instead of sustainable development, which agendas ecological sustainability and economic development to that of reco nciling both these Bank, as well, adopted this language, and sustainability is typically the term used in public health today. Six years after chairing the Rio Ear th Summit, Brundtland was named the fifth Director General of the WHO, principally because her neoliberal views were considered by many to be dominated health policy

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115 making (Brown e t al. 20 06). During her tenure , the WHO redefined the role states should play in public health; rather than providing care and running the health system themselves, states should in private partnerships, or PPPs, came in to favor, in large part because of their ability to draw funds from sources outside o f the WHO and governments themselves. Roll Back Malaria, a PPP itself, was the first large scale vertical program the WHO implemented under Brundtland in 1998, adhering to the principles of her neoliberal views on health care provision. Today, sustainable development is coming back in to favor, and it is the core objective of the next major UN initiative, the Sustainable Development Goals (SDGs), which will take over in 2015 when the Millennium Development Goals expire. Sustainable development goals expand the definition to include social factors in addition to ecological sustainability and economic development, though perhaps reflect the increasing contradictions inherent in it, as economic development continues to be paramount. In its current iteration, s ustainable development includes 1) social welfare (of which health is subsumed), 2) economic development, and 3 ) environmental sustainability . Social welfare needs, according to the World Bank (2001), include: equity, participation, empowerment, social mob ility, cultural preservation; economic needs include: services, household needs, industrial growth, agricultural growth, efficient use of labor; and environmental needs include: biodiversity, natural resources, carrying capacity, ecosystem integrity, clean air and water. Most would argue, however, that economic needs continue to trump all of these, in part

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116 2010). This approach prioritized the equity of the Global S outh and North, and attempted to sustainability policy impede their efforts to develop their economies . The equity centered approach was an interim step to the development, which has taken hold since the Rio Conference in 1992, setting aside prior 90; Reed 2002). Through all these changes, additions, and expansions of the word sustainability, the env ironment (Kirsch 2010). As Stuart Kirsch writes in his historical examination of the relationship of sustainability to the mining industry, pressure from different constituencies shaped the meaning of sustainability, to the point at which sustainability ca n come to mean adoption of sustainability, he writes that despite few changes to make mining less destructive to the environment, now it can mean sustainability as excl usively economic development, and the sustainability of economic value. Kirsch writes: A ccording to this formula, a mine that pollutes a river and causes extensive deforestation may be considered sustainable if the profits from the project are successfull y converted into manufactured capital with an economic value that equals or exceeds the value of what has been consumed or destroyed in the process. From this perspective, a mine is considered sustainable as long as the same or increases (2010:90 91). Missing from the list of current goals in sustainable development is an explicit reference to health, and as mentioned above, the most recent draft of SDG policy plans from the Rio +20 Summit The Future We Want does no t include an explicit reference to health either except

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117 for in eight, brief, health specific paragraphs subsumed within other, larger goals (below). These eight vague references to health also lack precise directives the same charge leveled against the 2013). Table 3 1: Health related sustainable development goals, from "The Future We Want" (UN 2012). Paragraph Description 138 Recognition of health as a precondition for an outcome and indicator of sustainable development and a call for the right to enjoyment of the highest attainable standard of mental and physical health 139 Recognition of the importance o f universal health coverage and a pled ge to strengthen health systems towards achieving this aim 140 Strengthening the fight against communicable diseases 141 Acknowledging the global burden and threat of non communicable diseases. Recognition that reducing pollution has positive effects on health. 142 Reaffirming previous trade commitments, including TRIPS, the Doha Declaration and the WTO General Council de cision from 2004 143 Call for further international collaboration in global health and acknowledgement of the leadership role of WHO in this respect 144 A call for the full and effective implementation of the Beijing Platform for Action and the ICPD Programme of Action, emphasizing the need for universal access to reproductive health and the integration of reproductive health in national strategies and programmes 145 A commitment to reduce maternal and child mortality. Access to modern methods of fam ily planning. In a special issue of the Lancet, several contributors lamented the scrapping of previous Rio+ Summit draft policy language that prioritized health as one of the principal SDGs, and

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118 Working Groups the UN has commissioned in the process of drawing up the final SDG initiative plans (Singh et al. 2012). Singh et al. (2012) note that in previous draft versions of the Rio+ Summit sustainable development policy plans, most contributors accepted health as for the realization of sustainable development, and an obvious benefit of sustainable development (Raviglione et al 20 12; Lancet 2012b). But health is conspicuously absent in principal sustainable development policy, and further, the very conceptualization of sustainable development (Lancet 2012a). Since the Millennium Development Goals (MDGs) focused heavily on health, as did several other large scale initiatives of the past ten years like The Global Fund and PEPFAR, energy or the environment deserves center stage now, partic ularly with the SDGs (Lancet 2012a). After the largely unsuccessful battle to include health as a topic on the agenda at the UN Conference on Sustainable Development the Rio+20 Summit it is clear that health advocates must better articulate the place o f health in sustainable development, and its importance as a principal goal in sustainable development initiatives (Lancet 2012a). e global health literature, specifically in policy and programming documents for NGO and governmental health programs and services. Indeed, as programs and initiativ es. One reason for this divide is likely the continued (perhaps purposeful) programs.

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119 her clearly defined Sustainability can come to mean many things, like the sustainability of funding or of technical assistance, and efforts to make somethi ng sustainable are usually operationalized through the planned use of series of trainings, infrastructure building and improvements, and plans to diversify funding, through fund raising appeals to individual private donors or seeking larger grants from oth er donor agencies. Broadly speaking, however, sustainability in health typically means financing, and more specifically, financing individual vertical programs over the long term (Yang et al. 2010). The sustainability of the good health of a population, wh ich should be the ultimate goal, is of less concern (130). Like Kirsch observes in his study of the purposeful and political semantic changes of the word sustainability in reference to mining, similar shifts appear to be occurring in health circles as wel movement to address the instability and precariousness of health care. Particularly as public health systems were dismantled in the wake of structural adjustm ent, the intent of promoting programs over the long term. As short term, emergency aid implemented by NGO and private actors began to predominate global health, a dvocates of sustainability in health worked to effectiveness, principally envisioned and calculated in the short term, which can work to undermine long term population health (see also Basilico et al. 2013; Suri et al. 2013). Which I will describe in length in the next few chapters, the implementation of short term health care i s

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120 preferentially rolled out via NGOs and the private sector, which in the process erodes the sovereignty, and strength, of public health systems, which are essential for the sustainable health care of populations (Pfeiffer 2013; Mbacke 2013; Messac and Pra bhu 2013; Basilico et al. 2013). The sustainability of individual, private sector and NGO run vertical programs is in many ways the antithesis of sustainability in health care, which prioritizes whole health system strengthening. Conclusion This chapter introduced the principal theories and concepts I use to understand and interpret the ethnographic data I collected, which follow in the next three chapters. In particular, I frame the problem of health care instability in a neoliberal, histori cal context, in which health care became increasingly inaccessible for the global poor after structural adjustment mandated the rollback of public health sectors. A consequence of this is the increasing precarity of populations, and particularly the rural poor in Tanzania, many of whom I worked with over the course of fieldwork. The next chapter introduces the first of three related topics rooted in the ethnographic data I collected the precariousness of everyday life in Tanzania, the precariousness of th e health sector in Tanzania and experiences of aid exit, and an analysis of the efforts to curb such instability through building sustainability in the health sector.

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121 CHAPTER 4 Fieldnotes, 12 March, 2011 (Dar es Salaam) Yesterday was really scary. I was still very jet lagged, following a 67 hour odyssey from Tampa, Florida through northern Europe, to northern Africa, to Dar es Salaam; I was very aware that I was being short and unfriendly toward everyone. At breakfast, after I was silent and irritable toward the woman at the hotel serving me eggs and toast, I made a silent vow to myself that I would calm down and be nice, these are my compatriots for the year! After finishing my cup of super caffeinated door, and walk down the twenty meter dirt driveway that connects with a busier, paved road lined with taxi drivers, women selling doug hnuts and grilled maize, and several people vending air time for cell phones amidst the passers by. On the sidewalk at the corner of the dirt road, I meet a tall, thin man wearing a red and black Marlborough jacket and NY Yankees hat. He smiles at me and, in English, asks if I need help finding anything. Resolved to be friendly, I tell him I need to go get my US phone unlocked so I could use it in Tanzania. He tells me he knows of a place a few blocks away that may help, and I can follow him. We walk and ta lk for a bit, he tells me his wife is German and works for an NGO in town. It seems possible. We stop by a car much shorter. Not thinking very clearly at t hat moment, I get in the backseat (did I just do that? ), the Yankee gets in next to me. We drive a few blocks and pick up another guy in a baby blue button skin is burni ng, unsure of what to do but trying to be calm, some small hope left in me that we end up at a phone store. We drive for a while, further than it should have been, but of course

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122 ssan Mwinyi Rd., one of the major arteries of the city, and pull off onto a side street at a busy market. The man in the blue button down in front turns around to finally look at me his eyes are wide and The Yankee next to me lights up a cigarette. He takes my purse off my arm and starts rifling through it, and hands my cash up to the blue button down guy. I frantically try the door handle, the locks, and slam my shoulder against the d oor, but nothing happens. The child locks my tiny flashlight and inspects it, a pack of strawberry gum, and finds my ATM card, stashed in the inside pocket. I l vast, complex melee of small shops that populate Mwenge bus stop, a place I know well, having lived down the street for two months several years before. There is a sea of people m illing around, bumping up against the car and each other. A few people walk by just inches from me, home. The dirt they kick up with their feet turns the air out my window a dusty brown. The air inside the car is suffocating from the equatorial heat, from the billows of smoke from the chain smoker next to me and fear has a vice grip on my chest. We drive around Myinyi Rd stopping at ATMs. The card fails a t two banks, and I start works at the third ATM and who knows how much money they take out, but of course they see the balance is about $4000 USD. We stop at thre e more ATMs. Since they can only take out only so much cash each day, they animatedly discuss in loud, fast paced Dar es Salaam Swahili what I can buy them after they reach the cash limit. First they decide on motorbikes, then diamonds. I

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123 whatever they want. The blue button down guy comes up with an idea that I thank god!) they want me to ask him for $30,000. After circling town for a while, we drive back to Mwe nge bus stop and pick up a fourth man, Raymond, at one of the small shops near the bus stands. Raymond is probably twenty, tall, and has a calm and friendly young face. I learn he will pose as my fiancé for the shopping trip we are about to go on ( are they letting me out? ). We go to the suburban American style mall across the busy intersection, and park in the lot. They ask me to write down all my information: full name, address on file with the bank, university affiliation, the hotel I'm staying at in Dar, in case anyone asks about the legitimacy of the card ( they may have done this before ). The Yankee and Raymond get out to go shopping, and the blue button down man jumps in the back to sit next to me. He is the scariest. We drive around and around, and eve ntually pull off onto a deserted dirt road. We just sit. Uncle tells me not to worry. He cracks a window because it is chances screaming might help me, and I decide nowhere, so I just sit quietly, staring out the minute walk from the crush of movies as a kid. After who knows how long, the Yankee and Raymond call, and we drive back the short distance to the mall to pick them up. Across from a fast food restaurant, we find them walking on the side of the road with several shopping bags clothes, evidently . Once Yankee climbs in, survive

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124 Tsh5000 for bus fare (about $3). We drive t o another less populated part of Mwenge, behind all the shops and near a stand of trees, leaves covered in dust that the buses kick up en route to the you, mo remember how the rocks in the road felt beneath my feet. It was a surreal feeling, getting out of the car, walking in the sunshine. With my bus fare I buy a bottl e of water from one of the hundreds of little shops, and get on a bus to the center of town, and head back. Other people having regular days sit next to me, chatting in sing song Swahili. I feel like the blood has drained out of me. Since I wrote down the name of my hotel on a piece of paper, I was worried they would like and unemotional. When I get to the hot el, I find I have enough money stashed in my luggage to buy a phone, so I make the trek back to the anyone. I get back to my hotel, lock and barricade the door w ith the desk. I call my dad first, and cry. Precariousness With this exp erience, I was primed from the beginning of this research to see precariousness all around me. As a personally transformative experience, the abduction altered the way I saw things, a nd caused me to pay attention to precarity in ways I could not have otherwise. The onset of the feeling of precariousness I felt in an instant, but the memory of the experience tightened my rib cage with fear every now and again, as if the air was forced o ut of my lungs. Fear would surface frequently over the course of fieldwork, and then less and less, in spikes of radiating heat and irrational hysteria. I had the real concern that I had been raped and

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125 my mind was repressing all memory of it, or for awhile , the irrational concern that I had been shot in the head and dumped in a Mwenge ditch, and was experiencing a really disappointing heaven. Regardless, the overly trusting, naïve student that I was disappeared that morning, and for the first time I really, hands. This feeling of extreme precariousness informed my research in many ways, and for a moment I had fleeting kinship with some of the most vulnerable people on the planet peo ple living with HIV/AIDS (PLHIVs) in a resource poor country. This study of donor aid withdrawal for HIV/AIDS programs in Tanzania has at its heart precariousness entirely dependent on antiretro virals, which are in turn almost entirely dependent on foreign aid. Precariousness, as Butler (2006) writes, is the experienc e of existential vulnerability common to all humans (and animals) injury, harm or de ath can befal l any living thing at any time . Like Butler and others note, however, some people are more often vulnerable to injury, harm or death than others, and this important sociopolitical element to precariousness creates precarity the unevenness of precariousness across societies and throughout the world. Chapters 5 and 6 more closely address the experiences of some of the most precarious people on the planet PLHIVs living in a resource poor and largely aid dependent country like Tanzania. In thi s chapter, I illustrate more generally the precariousness of everyday life I witnessed throughout fieldwork, in Haydom, particularly, which serves as a foundation upon which I understand precarious HIV/AIDS programs and the health sector in general. On the surface, the people whose stories I share appear very normal and common, which indeed they are. Their lives are typified by an almost constant shifting and planning of endurance trying to best make a life in an impoverished, and largely unpredictable, part of the world.

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126 There are several layers to the precariousness experienced in this place Haydom, Manyara, Tanzania well, let alone of the experiences of those whom I never met. First, in a global space, Tanzania is ranks slightly below the global mean of low income countries at $590, and ranks #193 of 208 countries in the world reporting G NI data (World Bank 2014a). It has also, as described in Chapter 2 , experienced great political and social changes in the last fifty years gaining independence in 1961 from the UK, establishing itself as a socialist state in 1967, and enjoying impressiv e gains in social welfare for its citizens as well as international attention for its and support from the wealthy socialist democracies of Scandinavia, whi ch are still active donors today. In the mid 1980s, however, like many resource poor and heavily indebted countries at the time, structural adjustment profoundly changed Tanzania, its social programs, its health care system, and the way of life for many pe ople. The shift from socialism to capitalism and the expanding privatization and widening social inequalities I encountered has also had a profound impact on livelihoods, and underlies much of the pain and resentment symbolized in the phrase I heard ag ain and again in interviews commonly describe life in Tanzania today its national efforts to expand and improve acc ess to education, its youth unemployment crisis, and the gendered dimensions of these large scale social and political changes. First, I explain the results of the semi structured interviews and consensus analysis data from Haydom. I highlight the answer k ey from the consensus analysis questionnaire, which lays out in hierarchical order which items, skills or experiences most people

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127 Priorities that may often compe te having a farm and having a college education are near the top, illustrating the demands on time and resources that many feel important, as well as the shifting livelihood strategies people engage, from agriculture to wage labor. Second, I discuss i n more detail some of the principal findings from the semi structured interviews and participant observation I conducted. In particular, I underline three intersecting themes: the experiences associated with a shift to a market economy and and wage employment is prioritized, though distinctly lacking. Using these themes, I then present several stories of people I believe exemplify the precariousness of everyday life, and doing what they can to endure it vumulia tu Methods After I shifted focus from the PMTCT longitudinal study to a broader study of aid withdrawal, vulnerability and coping, I began an exploratory phase of ethnographic data col lection in Haydom town and several surrounding villages. I emphasized broad changes people had perceived over the course of the past 15 20 years, and the role of the hospital and foreign ncipal methods during this exploratory phase: participant observation, one round of semi structured interviews, and consensus analysis. The first se t of interviews I conducted centered on relevant themes that emerged in casual conversations, as well as sug gestions and recommendations made by a few key informants and fellow researchers. After analyzing these data to identify emerging themes, I conducted a second round of semi structured int erviews focused on these themes. I clarified and probed the topics th at were most often discussed and considered important, and those that had the most relevance to my research questions about aid transitions.

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128 Semi structured Interviews: Haydom Town and V illages (92 total) Two rounds of semi structured interviews were cond ucted with residents (92 in total), using a list of piloted questions and an Olympus LS 10 voice recorder. I employed two research assistants (RAs), Asha and Rehema, for these interviews, both bilingual in KiSwahili and KiIraqw. One RA asked questions, and translated questions and answers from KiIraqw into KiSwahili for me whenever necessary. The second RA took notes about the interview and summarized the answers for each question in a field notebook. After d ata collection was completed, 45 interviews were transcribed by three experienced transcriptionists using ExpressScribe software, and in a few cases translated interviews from KiIraqw into KiSwahili for data analysis. I recruited respondents using a combination of purposive, snowball and convenience sam pling strategies, in four vitangoji (neighborhoods) in Haydom. Some vitangoji (singular: kitangoji 20 for each kitangoji to achieve a more representative sample of re sidents. For example, many doctors, nurses, administrators and other hospital employees reside in Ngwandakw, which made it particularly difficult to find people available to talk during the daily working hours, and respondents would more likely be wealthie r working professionals. Here my RAs and I principally used convenience and snowball sampling, asking people who would be available to talk with in the early evening after work and scheduling interviews, or who was home from work on that day or worked a ni ght shift, and might have an opportunity to talk with us. Uwanja wa Ndege is less populated and has fewer working professionals. Here we could walk around and more easily find people at home during the day, so we walked door to door for interviews. Additio nally, using purposive sampling I scheduled interviews with local political leaders,

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129 respected community members and business owners. Elders in the community also provided very valuable interviews, as they were able to reflect on the changes in Haydom over the course of decades and a few generations, and could comment more broadly on how things had changed. The majority ( 80 of 92, or 87%) of inter views were conducted with women; only 12 men participated in the semi structured interviews. Thirty nine residents of Haydom and 17 residents from five nearby villages were included in the first round of semi structured interviews, for a total of 56 interviews. These interviews focused on questions about changes in disease patterns and health care within the past 10 15 years, as well as changes in economy, development, farming and crop yields, education, and the difficulty of work. Additionally, I asked people to explain the ways in which people help each other during times of stress or need, times of celebration, and times of great trouble, and to explain the ways in which these helping practices changed over the years. This question yielded many fruitful conversations, and along with a follow up question about hospital funding and development aid in the interview, I learned much about the social buffers for stress and unpredictability, how these buffers change, and how the development aid funneled to HLH have changed these practices. The questions for the second village interviews were elicited fr om the answers from the first set of village interviews. I selected the principal themes that came up in the answers from respondents in the first interviews to inform new questions for the second interviews. Themes included 1) perceptions of the need to n care workers and teachers, particularly), 3) changes in disease patterns and increases in drinking and dru g use, 4) the widening gap between the wealthy and poor and how this affects social

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130 future. After pilot testing new questions with seven individuals, I clarified the questions, eliminate d redundancies, and expanded on questions that related most directly to my research with HIV and health care sustainability. Following the same routine as in the first round of interviews, my two research assistants and I interviewed 36 people total, 26 fr om Haydom and 10 from two of the five surrounding villages. I also identified several key informants through these interviews, and in the following months conducted focused interviews with them concerning two related topics in particular: 1) the increased need for self reliance, most often considered in the form of stable, salaried work of which little is available; 2) a shift from previous traditions of helping each other to a time in which people perceive they cannot depend on others. The inspiration for these questions stemmed from emerging themes in the interview data and from participant observation, heard from many informants (29 of 45 transcribed respondent i nterviews, 64% of sample). Cultural Consensus Analysis I also conducted cultural consensus analysis to determine what people in Haydom and in important for living relevant model for social status. To elicit a list of materials, qualifications, and experiences that may contribute kuishi maisha mazuri ), I pulled from a variety of sources: five free lists with people in town (research assistants, patrons at a local villagers about the materials, skills and life expe riences that comprise high and low social status;

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131 informal discussions with friends and family members; and six months of partic ipant observation. In the end, I compiled a list of 55 items: Is it very important, important, a little important or not at al to live a good life? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.

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132 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. many cows are needed?) 51. 52. 53. 54. 55. For each consensus analysis interview, my RAs and I gave respondents a 5x6 laminated index card written with the possible answers (1 = not important, not even a bit; 2 = a little important; 3 = important; 4 = very important), and another card with the qu 30 minut es to complete. For the final four interviews in Haydom we a sked each respondent to explain in more detail why they chose which answers they chose, and afterwards, to help explain patterns we were finding among respondents in the community. These interviews took about 45 minutes each. In total we completed 61 cul tural consensus analysis interv iews with people from Haydom (30 respondents) and three of the smaller surrounding villages in the hospital catchment area: Laba y (approximately 25 km from Haydom; 10 respondents), Hayderer (20 k m; 11 respondents) and Maghang (7 km. from Haydom; 10 respondents). To capture a somewhat representative sample of the communities, I diversified the respondent sample based on age (45 respondents under 45 and 16 over 45), sex (36 women and 25 men), and education (7 with no formal educ ation, 37 with primary school education, and 17 who had finished secondary school).

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133 Several items I eliminated after it became apparent that we were not measuring social ho goes to activities is widely considered to be important, and serves as a network from which congregants can draw from. In the more in depth interviews, however, it became evident that people considered being Christian as important for living a good life in the sense that they were close to God and followed Christ, not because of the social network access it afforded them. It is also possible that respondents thought I was asking specifically about the importance of closeness with Christ, with the missionary history in the region. Additionally, I dropped questions #27, phras e these specifically enough most people seemed to understand these as having enough food and having water, and did not distinguish between that and having enough to sell or having a well inside the house. For this reason, I eliminated them as well. After dropping these items, I analyzed th e data based on 51 total items, in two separate analyses, one for Haydom, and the other for the surrounding villages. To analyze these ranked data, I used UCINET ( Borga tti et al. 2002 ) to evaluate cultural consensus t o determine whether or not two cases 1) in Haydom town itself, and 2) in three surrounding rural towns. Presence of a cultural model is indicated by a 3:1 eigenvalue ratio of the first and second factors in the data set (Weller 2007) . In addition, UCINET evaluates each partici , the relative cultural expertise of an informant regardi ng this domain, in addition to a weighted answer key, indicating how important each it em on the 51 item list is according to the cultural model.

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134 Results In both Haydom and in the three villages surrounding Haydom town evidence of a cultural m odel existed. In the Haydom model , the eigenvalue of the first factor is 12.087, and the eigenvalue of the second factor is 1.977, giving it an eigenvalue ratio of 6.113 :1 , above the 3:1 ratio threshold for determining evidence of a cultural model. This means that there is agreement among Haydom respondents about which items constitute living a good life. Competency scores of Haydom CCA participants were also evaluated in UCINET, which Mean c ompetence was 0.59 somewhat low wi th a standard deviation of 0.22 . T he highest competency score was 0.907, and the lowest was 0.073, the single negative competency score of the group, which indicates a lack of fit with the cultural mode l . Many other low competency scores were recorded (three scores below 0.2) , however, pe rhaps indicating more widespread lack of fit with the model, and an avenue for further analysis examining reasons for variability in answers. In the analysis of the village cultural consensus model, the eigenvalue of the first fac tor was 14.43 , and the ei genvalu e of the second factor was 1.92 , giving it an eigenvalue ratio of 7.53 :1 , which also crosses the threshold to indicate presence of good in model, and the mean competency score among respondents was also higher 0.668 (standard deviation = 0.14) . Competency scored ranged from a high of 0.907 and a low of 0.42. Discussion of Cultural Consensus and Interview Data Consensus and interview data s how that the shift to a market economy in Haydom and environs appears to have left people with one foot in farming and one foot in what they perceived to be necessary for the future salaried employment best achieved through long term

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135 formal education. Fa rming, employment and education are changing rapidly, and not netting the same return as people perceived they did in the past. In short, many told me, life is getting harder ( maisha ni ngumu zaidi ). Consensus analysis illustrates this dilemma: having a fa rm (and in particular, farming beans and corn), having cattle, and securing a college education were among the three highest, and in some ways mutually exclusive, items rated by respondents as most important for living a goo d life. These ratings of items i n a hierarchy are presented in the answer key s (Table 4 1 and 4 2) that were generated using factor analysis, with the answers of those respondents who best fit with the cultural model, given more weight. The two answer keys resemble each other in many important respects: the highest ranked items (4 or 4.01 on both lists), farming corn, having a farm, having respect in the community, and being a person others go to for advice, were all ranked as the most important to living a good life. These four items highlight the importance of social bonds and neighborly helpfulness in both contexts. Farming, for example, is a decidedly social activity in which all members of a family are typically involved, and neighbors oftentimes help each other plant seeds, harves t crops, and store food. Having cattle in the villages was a bit more important (3.94) than in Haydom (3.86), while farming beans was perceived to be more important in Haydom (4) than in the villages (3.92). Most of the material items having a concrete floor, glass windows, metal roof, satellite dish, solar panel, internet connectivity, computer, car, motorcycle, refrigerator, and store or private business appeared in both lists as near the lowest in importance. Having a phone is exceptional in this ca se, reported by people in the villages as being significantly more important to living a good life in ranking.

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136 Table 4 1: Consensus a nalysis answer k ey , Haydom t own Answer Key Score Item 4.01 To farm corn 4 Have respect in the community 4 Be someone people ask for advice 4 Have a farm 4 Farm beans 3.9 9 Read and write KiSwahili 3.96 Have special clothes 3.94 Go to college 3.94 Finish college 3. 94 Have goats 3. 92 Have chickens 3.9 Read and write English 3.86 Have cattle 3.83 Come from a good clan 3.81 Have a cart for hauling water 3.76 Farm sunflowers 3.76 Have a cow/plow 3.71 Finish secondary school 3.6 Have children who study 3.52 Have salaried work 3.51 Farm lentils 3.45 Have children who have finished school 3.43 (Be able to) eat a variety of food 3.42 Have sheep 3.37 Farm squash 3.35 Have a farm tractor 3.32 Finish primary school 3.22 Have a phone 3.2 Have a bicycle 3.19 Be able to depend on oneself 3.14 Have children 3.06 Have donkeys 3.05 Have a store or private business 3.05 Have a motorcycle 2.94 Build a good house 2.92 Have a car 2.88 Have a computer 2.86 Have electricity 2.85 Work with the government 2.85 Have I nternet 2.74 Have a refrigerator

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137 Table 4 1: Continued Answer Key Score 2.73 Have a solar panel 2.71 Have a housegirl 2.56 Live with a husband, wife or partner 2.54 Have pigs 2.52 Have a satellite dish 2.48 Be able to fry food 2.47 Have a house with a metal roof 2.37 Have glass windows 2.26 Have concrete floors 2.24 Have family in the same town Having a solar panel was also considerably more important in the villages ranked at 3.09 compared with 2.73 in Haydom, a difference of 0.36. Conversely, having a computer, a car and a of 0.37, 0.32, and 0.43, surrounding villages, so having a solar panel in a village would be essential for access to providing help with housekeeping, cooking and child care was significantly more important in Haydom (2.71) compared with the villages (2.03), though ranked relatively low in both lists. In this case, a wo m a n working outside the home is more likely to occur in Haydom than in the village where wage employment is less common. Also in both lists, having family who lives in the same town was ranked lowest of all items, though with considerable difference in rat ing in the villages, having family in town was rated 1.86, while in Haydom it was rated 2.24 (a difference of 0.38).

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138 Table 4 2 : Consensus analysis answer key, villages s urrounding Haydom Answer Key Score 4 Have respect in the community 4 Be someone people ask for advice 4 Have a farm 4 Farm corn 3.9 4 Have cattle 3.92 Farm beans 3.9 Have goats 3.88 Finish college 3.87 Have chickens 3.86 Have a cart for hauling water 3.83 Have a cow with plow 3.83 Read and write KiSwahili 3.8 Have children who study 3.76 Finish secondary school 3.75 Have children who have finished school 3.75 Have special clothes 3.72 Have a phone 3.7 Read and write English 3.68 (Be able to) eat a variety of food 3.65 Go to college 3.65 Have children 3.62 Come from a good clan 3.59 Finish primary school 3.44 Have a farm tractor 3.31 Farm sunflowers 3.29 Have salaried work 3.29 Farm lentils 3.24 Have a bicycle 3.1 Have electricity 3.09 Have a solar panel 3.04 Build a good house 2.93 Be able to depend on yourself 2.93 Have sheep 2.89 Work with the government 2.87 Be able to fry food 2.75 Have I nternet 2.72 Have a store or private business 2.69 Have a refrigerator 2.68 Have glass windows 2.67 Have a satellite dish 2.66 Have a house with a metal roof 2.62 Have a motorcycle

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139 Table 4 2 : Continued Answer Key Score 2.61 Have donkeys 2.6 Have a car 2.51 Have a computer 2.51 Farm squash 2.42 Live with husband, wife or partner 2.39 Have a concrete floor 2.04 Have pigs 2.03 Have a housegirl 1.86 Have family who lives in the same town I probed four Haydom respondents to answer in more detail why they ranked certain items above others, in particular for those items I did not expect to be ranked so highly. All answered that finishing primary school was not as important as going to college or finishing college , because if you stop after primary school, and do not continue on you cannot get a job. If one has to finish secondary school and preferably go to college of so KiSwahili refers not only to university studies, but can also include certificate programs (in programs such as computer science, secretarial work, and tourism) which typically takes a few months; a diploma program (in nursing, for examp le) which can take several years; or a degree program at a university, also several years. Now, at the hospital, even though many people who currently work there have only finished primary school, few are able to find work there with just a primary school education, and even for someone who has finished secondary school it is very difficult to get a job unless one is linked up, through social networks, with appropriate channels for employment. So many students study now (compared to the recent past) that th ere are more qualified people for few jobs, and in small towns like Haydom, it is increasingly frustrating for

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140 many young, newly graduated people. In interviews, many older people told me this is a major reason for the increase in drinking and drug use, be cause young people lose hope for securing a better future through school. The Shift to Market Economy In the Haydom area, this shift to the capitalist market system happened over a few decades, as vestiges of the socialist system fade away and increasing privatization and deregulation roll back the state apparatus. These changes were principally brought about through widespread implementation of it throughout t he country. Stories of upheaval following the adoption of a market system are common throughout Africa, perhaps most dynamically in areas with high industrialization and rich natural resource bases, like in South Africa (gold and diamonds) and in Zambia (copper), as H unter (2010) and Ferguson (1999) write in their respective ethnographies. In each of these cases, and as is happening in Tanzania presently, several things occurred at similar times: the agrarian economy shrank; population increased, placing more demands o n natural resources; economic development initiatives skewed toward industrialization and not agriculture; rural to urban migration expanded as people left their homes in search of wage employment; and fewer people can depend on agriculture, horticulture, and pastoralism (Catterson and Lindahl 1999; ADB 2013). In Tanzania, 75% of people currently participating in the labor force do so through the agricultural sector (ADB 2013). Both the World Bank (Gaddis et al. 2013) and the African Development Bank (2013 ) write that agriculture in Tanzania is decreasing in productivity because of unpredictable rainfall patterns and increasingly depleted soil. These in turn, contribute to both food and employment insecurity. Agricultural work, according to the World

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141 Bank, is also considered to be more precarious than formal sector wage labor, as it is often seasonal, short term, and lacks security of wages and most often has no attendant benefits (Gaddis et al. 2013). The decline in agricultural productivity may also be re lated to the current population boom in Tanzania the Tanzanian population has tripled in the past forty five years, from 12.3 million people in 1967 to 44.9 million in 2012 (URT 2013). A decrease in crop production and productive land in and around Haydo m was mentioned by many of my respondents as a principal concern, and one of the starkest examples of the changes that have occurred in the past 15 20 years. Increasing development and building construction has swallowed up much of the land, many mention ed, and the farmland that remains now cannot be allowed to fallow for longer periods of time like in the past, and often requires fertilizer. he L ove is Gone, E verything is M oney N upendo ) came about in the first set of sem i structured interviews when we asked informants to describe how people help each other, and the ways in which helping each other has changed in the recent past. In this case, their responses about upendo means something akin to helpfulness, neighborliness , and being able to depend on others for help when needed. The examples people would give of love decreasing or ending were usually coupled with wide ranging discussions of money. The need for money for health care was mentioned by a few people as one exam ple, a reference to the increase in user fees at the hospital, as well as increasing uzembe , or negligence among hospital workers. The need for money for school fees for children was also mentioned by a few people, particularly as school fees are increasin g. But for the most part, the majority of people cited the increases in the cost of goods as the most distressing, and causing the most need. People who had money, some mentioned, were still loved wealthy people would help other wealthy people out often but for those who did not have any money, the love was gone.

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142 That numerous respondents identified a precise range of years that upendo (love) went missing (1996 1998) was particularly notable to me throughout the interview process. When I asked a few key informants to explain this, they told me it was when the changes implemented with structural adjustment reached the rural areas, and people in Haydom began to experience the effects. Before the mid 1990s, upendo or love principally involved helping eac h other out they experienced upendo in the early 1990s and before. Asha remembered that when she was a little girl, sharing food among neighbors was commonplace. I what their mother was cooking for dinner, for example, she could wander next door to get a plate of whatever the neighbor was cooking. Now, she tells me, this never happens. include an expansive list of themes, incorporating those such as morality, ideas of value as a human being, employment and salaries, running a household, gender, age, sexuality, and education, as well as the price of goods and services. Most reported that several economic changes had occurred in Haydom, including an increase in the number of businesses in town, a rise in incomes (mostly due to salaries from the hospital, or increased business and trade in town), and a rise in prices for goods and services i n town. Not all benefitted from the changes in the economy, however, and many respondents noted both an increase in the number of wealthy people, as well as an increase in the number of poor people. Part of this had to do with increasing population across the board as noted in Chapter 2 , many people migrated to Haydom for work or for health care. But the widening wealth gap economy corresponded with some notabl influenced the economy of the village, not only for bringing many new people to Haydom for

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143 hospital work and private business to accommodate the influx of patients in previous decades, but also the ch anges in donor funds and salaries over the years affected the accumulation of wealth among those with salaried employment. Salaries among health care workers in particular have increased dramatically over the past few years (Songstad et al. 2012; Bech et a l. 2013). This alleviate the severe worker shortage in the health fields by raising salaries and expanding pension plans for government health workers to attract and retain workers (Songstad et al. 2012; URT 2008). In Haydom, the hospital is a voluntary organization, principally funded by foreign aid from the Norwegian Embassy, and its workers do not benefit from these government sources (though there is a staff grant from the government which supports some health care worker salaries) (Songstad et al. 2012; Mæstad and Mwisongo 2009 ). Consequently, HLH has been forced to expand its own worker salaries in step with the government sector to retain its own staff (Songstad et al. 2012). Additionally, the onset of big vertical programs netting big budgets (including the HIV care and treatment center), seem to have resulted in many people earning much higher salaries than in previous years, as well as more opportunities for em bezzling money without notice, which many people in town allege, and will be discussed in more detail in Chapters 4 and 5 . As more people find salaried employment, and more children attend school (see below), however, many women told me that they have had a difficult time managing work at home. Some women reported that, now that they had a day job, they worked all day and then returned home to do all of the housework. A decreasing number of children at home to help with cook ing and cleaning as well appear to have put more burden s on women, particularly. If a family can hire a housekeeper, and if they can buy or rent farm equipment, work is generally reported as

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144 easier. This is supported by cultural consensus data as well having a housekeeper or home in addition to cooking, child care, and housekeeping, while in the villages, fewer women take on work outside the home. Men, it should be noted, do very little housekeeping themselves. As several men told me, the kitchen in particular is a place where men do not go. It should be noted, however, that men were underrepresented in this sample of respondents; only 13% of interviewees were men. Finally, many respondents reported that wealth is a principal measure of worth now. Rehema told me once, bitterly. Older people who did not (or could not) study could not easily find salaried emplo yment, and having money is important for earning respect now. Additionally, finding work among younger people, even those who have completed secondary school and college, is increasingly difficult (Gaddis et al. 2013). Many believed this caused younger peo ple to lose hope in their future, subsequently causing them to drink, some respondents believe. A question about alcohol consumption triggered wide ranging discussions about the problems of youth in the community today, including increases in sexual activi ty, sexually transmitted infections and prostitution, lost hopes for the future, difficulty getting work, increasing concerns about the future, and a loss of respect for elders. This final point, loss of respect for elders, was cited as the reason for youn g people drinking alcohol (and smoking marijuana), because in the past only the elder men would drink, and they would do so in secret in their homes or in the fields and farms. Now, teenagers and young people, and both men and women, drink publicly. Some e lders I discussed this with believed this loss of respect, and consequent public drinking, was because of increases in education among younger generations, or more specifically young

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145 people who are now in their teens and 20s, who were the first in the area to benefit from the expansion of secondary schools. Many of their parents did not study at all and may be illiterate. Now, parents are often the ones who seek advice from their children, and children, they feel, have since lost respect for their parents a nd no longer seek advice from them. At this juncture, the consensus data and interview data appear to conflict indeed, respect in the community and being someone people go to for advice, were ranked highest (at 4 .0 ) in both the Haydom and village cultural consensus models . Having salaried employment or a store or private business the two items which would net people the money that is now in interviews are ranked considerably lower per the cultural model: in Haydom salar ied employment was ranked at 3.52 and a private business at 3.05; in the villages, 3.29 and 2.72. The material items listed in the cultural model concrete floors, glass windows, satellite dishes, etc. also ranked near the bottom of both lists in relati ve importance. The production of cultural models through consensus analysis , however, is achieved by people ranking ideals , and not necessarily realities. The cultural model of living a good life in both Haydom and in the surrounding villages still center on community, helpfulness, and upendo , though the inter view data speak to the mechanisms in place that are threaten ing these values . These patterns, and seemingly conflicting findings from both measures, point toward the anxiety produced over the r apid shi ft to a market economy and the erosion of cultural ideals. Education and Employment Male and female participation in the Tanzanian work force is nearly equal (.99 ratio, 90 women to 91 men), and ranks #4 in the world for equality of labor participation (W EF 2013). In a 2013 report on the global gender gap, however, the World Economic Forum estimated that Tanzanian women receive $0.68 for every $1.00 men earn for similar work, and far fewer women (a .61 ratio) comprise the professional and technical workfor ce, and Tanzania ranks #118

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146 in the world for equality of educational attainment (WEF 2013). Sex ratios in secondary and tertiary school enrollment are low compared to other countries, resulting in differential access to more highly paid, skilled and secure employment. These differences are particularly pronounced in rural areas as well, where wage labor is scarce, and many women with few skills have few options (Kushner 2013; CRR 2013). Perhaps unsurprisingly, some women take up prostitution as a principal way to make money. For those people who do not have a farm or cattle, entrée into the wage economy is widely believed now to hinge on success in school, and the more schooling, the better (see consensus analysis results). In Tanzania, primary education is compulsory, and in 2012, enrollment in primary school was 93% (World Bank 2013b). In Haydom, however, attendance did not seem to me to be regularly enforced. Primary school consists of seven years, called standards, and is conducted in Swahili. Tanzania has one of the lowest rates of primary to secondary school transition, according to the World Bank only about 35 40% of students go on to secondary school (World Bank 2012). Secondary school is not required, and consists of four years, called forms. At t he end of the four years, students take ordinary level exams O levels qualifying students to continue further on for university studies. In 2012, only 35% of students in Tanzania passed their O levels, increasingly worse than the two (also) bad years b efore it in 2010 only 50% passed, while in 2011 53% passed. In Mbulu District where Haydom is located, the numbers of students passing the Certificate of Secondary Education Examination (CSEE) within Division I, II or III (the highest three groups) was t he lowest in the country only 2% of test takers passed with scores in this range in 2011 (NECTA 2011; Exploring Tanzanian Education 2014). Further, only 4% of

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147 Tanzanians continue on to tertiary education college of some sort, or university, one of the lowest in the world (Gaddis et al. 2013; World Bank 2013c). Despite these failure rates, investment in education in Tanzania continues to be high. Per capita education spending has increased 175% (Lee and Morisset 2012) since 2005, which is manifested lar gely in the expansion of secondary schools to rural areas that previously had little or no access to secondary education. Largely because of this increase in access, secondary school enrollment has increased 290% since 2005, a change that interviewees note d as particularly significant in and around Haydom (Lee and Morisset 2012). As the educational system expands in terms of number of schools and enrolled students, however, concerns over the quality of education has also expanded. Many interview respondents told me that education has improved significantly in Haydom and the surrounding villages, mostly due to the expansion of secondary education (four new secondary schools have been built in the Haydom area in the past ten years). While the number of schools built, and the number of children attending schools has increased, a few people worried that the quality of education had decreased overall, while the price for attending school had increased. Part of the problem is the very high, though decreasing, stude nt to teacher ratio in primary school in 2012 the ratio was one teacher to 46 students (1:46), an improvement over the 1:51 ratio in 2010 and 1:54 ratio in 2009 (World Bank 2013d). Little data exists for secondary education, including spotty enrollment r ates, dropout rates, and student to teacher ratios (World Bank 2012; CRR 2013). The data that do exist, however, indicate extensive problems associated with teacher quality and English language instruction in secondary schools (Bwenge 2012). English langua ge education is not typically provided in primary schools, even though secondary school is (supposed to be) conducted entirely in English, using English textbooks and English as the language of instruction. The Swahili language is oftentimes the

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148 language o f instruction, either to ensure students understand concepts without letting language barriers hinder learning, or because the instructor is not proficient themselves in English (Bwenge 2012). Nonetheless, most informants relayed to me the importance of at tending secondary school, and the high tuition fees they were willing to pay to make sure their children succeeded. The number of graduating students looking for salaried employment still regularly exceeds the numbers of job openings for which they are qu alified (900,000 youths entered the labor market in 2010/2011 for an estimated 50,000 to 60,000 jobs) (Gaddis et al. 2013; Kushner sector, without any formal co hopelessness was shared by many of the young adults I befriended in Haydom, where even if you successfully finished a degree your prospects were limited for salaried employment, yet was also widely v Haydom for larger cities, particularly Arusha ( about six hours via Land Cruiser), Singida or Dar es Salaam were considered better bets, but still out of reach for many people. Even those people who are lucky enough to secure some form of employment, the wages they earn are often not considered enough to live a comfortable life, even in the rural areas. umbers of which are growing alongside continued underperformance of the agricultural sector, particularly (ADB 2013). World Bank bloggers Isis Gaddis, Waly Wane and Jacques Morisset (2013) attribute the poor quality of jobs outside the agricultural sector to a growing uneducated labor force in Tanzania, which is particularly impacting Tanzanian youth (15 24 years of age). They illustrate this with some particularly surprising statistics:

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149 The poor quality of jobs held by Tanzanian youth are to a large exte nt determined by their low level of education attainments. Of the approximately 900,000 youths (15 24 years) that entered the labor market in 2010/11: 14 per cent did not complete primary school, 44 per cent finished their primary but did not transition to secondary, an additional 38 per cent went to secondary but did not reach or finish Form IV, and a mere 4 per cent went beyond O level. Many of them are unlikely to find a good paying job as the majority did not acquire the necessary skills to create and grow a successful enterprise (2013). particularly health care and education was a central paradox that became apparent to me, especially living in Dar es Salaam for par t of the year. Hearing how overburdened health care workers and medical school professors were, and how long it took some NGOs to fill vacancies for certain skills (monitoring and evaluation, particularly), stood in stark contrast with the numerous intelli gent and talented, yet unemployed and underemployed young people I knew in Haydom. In the f ollowing section, I look at two cases in particular , Asha, and George, my The consensus and intervi ew data matched up well with what I observed among my woman, I had more contact with other young, unmarried women and men; without children, I was still a kijana , a young person. The stories of other vijana I knew well are the most compelling to me and best illustrate the most important themes unearthed in this research. In particular, I focus on three principal, interrelated themes in the following section that h ighlight the precariousness of everyday life, and youth, in Haydom: 1) the rapid and widespread changes experienced in and around Haydom, particularly those relating to shifts in livelihood strategies; 2) pressing need to find wage employment now, which is increasingly dependent on being able to access high quality, long term formal education; and 3) the current efforts on the part of the

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150 Tanzanian government to expand and improve primary and secondary education, but currently experiences significant shortf alls, affecting a generation of Tanzanian youth who cannot find stable employment. In the following section, I examine each of these themes in turn, illustrating them with personal stories of friends and informants I believe are most representative. The s tories I heard, and the lives of the people with whom I shared my own over the course of the year, painted a larger, and more detailed, picture of precariousness and endurance. As a mzungu (foreign, white) woman living with a large local family, I felt the constant pressure and burden of kin obligations; indeed, everything did seem to be about money. Th ere was also never enough of it; money was a near constant need. I was frequently asked to pay for school fees for several children, to provide money to buil d houses, to help pay for livestock, food, transportation and health care, bikes, a refrigerator. I was also asked to purchase a solar panel to nostalgic remembrance of the past, more practically it signaled a new requirement to somehow find money. Among several of my key informants (many of whom were friends), finding money t ook considerable time and effort, and many seemed to have little hope. Success in finding employment among key informants also appeared to vary based on age and gender. Older women who did not benefit from more recent expansions in education seemed to have little chance of employment, unless they had familial connections that could get them work at the hospital, for example, or a family business. Younger women, even those who had been to school were still poorly educated, and as a consequence, many suffered from chronic underemployment. For some, sex work was the only option for making a living. For young men, underemployment

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151 nationwide human resources crisis, in Haydom I saw wasted opportunities for developing skills and talent in the youth all around me. Consequently, a few appeared to me to feel hopeless for their futures, overwhelmed by the costs of living and resigned to the limited options they had available to them given to those struggling to make ends meet, or feeling hopeless; vumulia tu , just endure. Wha t follows are the stories of a few individuals whose stories I was closest to, and which illustrate the precariousness, and endurance, of life in rapidly changing times. Joyce Joyce was one heartbreaking case of gender inequality in access to work. The limited options available to some women, however, and particularly those in abusive and ne glectful relationships, were for me most starkly apparent in , and articulated below in the following interview. Of the 200+ interviews I conducted over the course of my months in the field, my friend , Joy ce, was one of the saddest and most difficult to hear. Of all the interviews I conducted in town, it exemplified the precariousness that pervades lives, and the limited options that women have for making a living. Joyce lives on the side of town near Rehem Fieldnotes, 12 April, 2012: Rehema finally showed up around 10, we went out to get house all the time. This interview was particularly depressing; she was very candid, but candid about how her husband beats her, drinks a lot ( pombe ) and smokes a lot of pot ( bangi ). She said one of the biggest concerns was that the price of everything was going up, and things were getting increasingly hard to afford, except for people who have money and salaries.

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152 Her affect changed markedly over the course of the interview, beginning the interview very quietly and hesitantly, shifting over the course of th e hour long interview to more insistent, and surprisingly candid answers in both KiIraqw and KiSwahili when her husband left us alone. She expressed her anger as well as resignation over her position as a woman married to a relatively wealthy husband, but pombe Fieldnotes, 12 April 2012, continued : The woman obviously detested her husband. I was surprised with how candid she was with her answers, about how he would beat her, how he tell or what to do, she just seemed resigned. It was interesting at first too, she was so shy and spoke with a whi sper, and mostly in KiIraqw, and then she deferred the first question to a man who I assume is her husband, a young man who was doing some manual labor around the house. The main house is concrete but poorly built and the o ther couple buildings were mud brick or mud and sticks, also strange for a man who makes Tsh200,000 a month. We were sitting in an awkward line along the wall of what I think was the kitchen, our backs against the cool mud. She was sitting on a bucket, rig ht side up. There were a few kids running around, including one probably about two and a half or three, who she held in her lap most of the time during the interview. But in the beginning she was so shy, when her husband was around, and then once he disapp eared she unleashed she was still pretty quiet and soft spoken, but she is obviously smart, knows Swahili perfectly well though there was some mixing with KiIraqw, and was pretty vocal about many things, including how terrible pombe is lately and how her husband uses it all the time. It was an interesting transition to watch. She said at one point how women who are in bad situations would like to leave their husbands, but without work

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153 and some salary, what can you do? Unafanyaje?, she said. Exactly! What do you do? I have no idea. She does not work herself, and has just one young child. She has little chance of finding paid employment with the little education she completed (primary school only), and like she told me several times in the interview, what d o you do ( unafanyaje ?)? She admitted her alcoholic husband regularly beat her, particularly when there was no food cooked and prepared for him she asked for money t o buy these things food, laundry soap, or medicine for her child who was often sick he would also beat her. Unafanyaje? violent behavior toward her as in part represen people no longer help each other, respect each other, and like many told me over the course of the year, she She would ask her own family members, includ ing Rehema and her family, for help occasionally; and some of her biggest concerns were how to buy the household things she needed, in an unpredictable economy where the price of goods seemed to rise every day. Asha earch assistant after Grace began working full time in the ICU at the hospital. The third oldest of the six girls, she was the first to get pregnant, and had a baby in 2009, a few months before I visited Haydom for the fi was fro m Haydom but at the time was in the Tanzanian army and lived in Dar es Salaam, 18 hours away by bus. Asha dropped out of secondary school for a while, in part to hide her pregnancy from the judgmental and watchful eyes of those in a small town, as well as to care for her son . Once she stopped breastfeeding, she went back to school in the afternoons, determined

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154 to graduate Form 4 and pass her O level exams, which would allow her to go on to university. Her goal was to study laboratory sciences, and then come back to Haydom and work in the few young, single women with babies have the money, support system, and encouragement to return like Asha did. Though technically illegal now, se condary schools in Tanzania commonly conduct pregnancy tests on young women, and kick them out of school if they are pregnant (CRR 2013). A year and a half later, a few months before I left Haydom at the end of my fieldwork in 2012, Asha took her exams, a nd failed, like 65% of her fellow test takers in Tanzania that year. When she found out, she spun a spectacular tale, which I believed for a while, about how the government failed the entire cohort that year as retribution for widespread cheating among urb an students and their teachers. She was likely too embarrassed to admit that she failed, though she had plenty of company. After Asha failed her O levels, Grace told me she was worried that Asha seemed to lose interest and mo tivation to do much of anything . Mama Grace told me that in situations like To retake the test would mean four years of schooling all over again, apparently. A month later, in mid April, my friend Anna told us that Haydom was going to host its first annual Miss Haydom pageant, part of the Miss Tanzania national pageant competitions, ry year. Asha, a town beauty , was immediately targeted by Anna and encourage d to apply to compete. This perked Asha up exponentially; the chance to be a model what many of the pageants are gateways to

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155 Asha was uncertain if her parents Mama Grace and Wilson would approve of her competing in the M iss Haydom pageant. Pageants, she told me, were considered by many to be something that commonly went along with sex work. Wealthy older men, in particular, may court these young, single women and establish a sort of fataki (sugar daddy, loosely translated ) relationship . This view was widespread in town, and perhaps in part because of that view, only three young women competed in the Miss Haydom pageant, Asha and two others, all between the ages of 18 and 22. The pageant was held in the newly built Chama c ha Mapundizi (CCM) political party headquarters in town a large, rectangular concrete room with seats for about 100, including manufacturer, and put on by an entertainm ent company from Babati, staffed with male dancers who would break dance in between pageant acts and frequently yell at the crowd to make noise! or clap hands! The four contestants mostly just paraded around in different outfits to start they all walked around in a circle and dancing, wearing a knee length black skirt and white t shirt, all of them the same, and in bare feet. Then it was the mavazi ya kabila or traditional dress, and Asha wore a beautiful red Datoga gown. The winner was a girl none of us had ever seen before. Asha won second place, however, which also won her a spot in the next pageant for the district of Mbulu, which she went on to win, sending her to the regional pageant in Babati. In early June, Asha, Grace, Paulina, Mama Grace, and I all went to Babati for the weekend to see Asha compete in the Miss Manyara pageant. We left Haydom at 4:45 am, and the Land Cruiser was packed with people I knew going to the pageant, including Anna, who was select ed as a judge, and my friend Petro , an Eng lish speaking safari guide, who went to gawk at with a correct

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156 answer to her final question ( which company is the sponsor of the pageant ?) Asha won third place. With that prize, A sha won a three month scholarship to study tourism management at was in the top group there as well, securing her a spot in the final Miss Tanzania pageant in Da r es Salaam. Ultimately she won one of the smaller prizes in the pageant, winning her the likelihood of a future in modeling after all, and making her nationally famous. Robert, my Tanzanian friend and colleague from the Ministry of Health, even knew her. When I told him that small town girls in pageant circuits , however, can oftentimes end up with fataki in big cities (see also Bulled 2013). George Even if Asha had p assed her O levels, a smooth transition to secure employment would not have been easy. Paradoxically, perhaps, national data show that students securing secondary education and passing O levels sometimes fare worse in the job market, particularly in Dar es Salaam, where 20% of secondary school graduates are unemployed, and in Zanzibar, where 56% of secondary school grads are unemployed. Public sector wage jobs, which many secondary school grads hope for, constitute only 6.7% of the youth labor force (Gaddis et al. 2013). George, George is from Babati, and came to live with the family around October of 2011. Perhaps the most entrepreneurial of the family, George was always looking for ways to make money. Over the course of the year , farm, opening up a small shop ( duka ) on the side of the road by the house, and he had aspirations to be a driver for the hospital, despite not really knowing how to drive. His most bizarre, however, was his most successful the invention

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157 of a tw itchy, middle aged Norwegian doctor with an actress/singer wife, who never ran out of ideas about how to change everything (allegedly for the better). His name was Kjerand, and he at some point had gone to Croatia to learn drum making, with a mind to come to Haydom (which he did frequently) and set up a drum shop for tourists. Kjerand somehow found George working at the farm, and since George spoke very good English and had a good work ethic, Kjerand recruited him for this particular project. George would u se a sisal trunk as the base of the drum, and would stretch and cure goat skin for the top, and tie it all together with very strong Norwegian boat rope that Kjerand would bring down from Norway. That people in the area did not traditionally make or use dr ums seemed to make no difference; tourists spent piles of money on them, and George made quite a bit of money. With the success of his drum making, one day George showed me an email from Kjerand, suggesting that he make and sell these drums at the gift sho p in the large Cultural Heritage Museum in Arusha, for other tourists wanting, and perhaps expecting, African drums. Figure 4 1 : F , crafted by George (2012) . While George, for the time being, seems to be doing quite well ma king a semi precarious living dependent on a consistent supply of boat rope and tourists expecting to buy drums in Africa, his principal wish had been to be a schoolteacher. Like Asha, he was disappointed that he

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158 was unable to pursue it, not because he had he had, he told me but because there was never enough room for his admission to school, and after awhile he just gave teach would have helped to fill a cavernous gap in the educational workforce in Tanzania Tanzania is in desperate need of teachers and health care workers. Formerly considere d the builders of a new nation , teachers and health care workers were once revered for their wor k during ujamaa times, considered the most critical skilled laborers for developing a healthy, productive workforce. Now, as I examine in more depth in Chapter 6 , education and health care are two of the most critically understaffed sectors in Tanzania, wi th disastrous, cascading effects. A failure to support, or perhaps to be able to support, the desires of bright young people wanting to work in these fields is a critical problem in Tanzania today. Seeing my two friends, with intentions of working in these fields but instead being diverted to drum maker and pageant queen/possible sex worker, are two of the most frustrating examples of wasted potential I encountered during fieldwork. When Mama Grace was consoling Asha about her failed O levels, and indeed w hen she you just endure. This phrase for me, in addition to upendo umeisha life here. Of course there were other ways of coping, tha t Mama Grace herself employed hopelessness for the future. Fieldnotes, 13 March 2012 : I hate this idea of just

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159 you get more with luck than effort, because even if you give a lot of effort you can still be failed without doing anything wrong. I feel like I suddenly see this everywhere, you work hard and put forth a lot of effort, and then something like this happens and you either have to go back to Form 1 or 2 and study for 4 more years, an d then the same thing might happen again or you fail or certificate and you have nothing to show for it. And then, even if you do get the certificate ( kusafisha ch eti available for because in Dar everyone is screaming that with patients, schools are overwhelmed with student s, but there is no room for new teaching students, no room for new nursing students etc., everything just gets backed up. And I guess that happens here too Haydom and at the hospital. I t seems such a waste to have so many people, ready and willing to study and work hard, and then even if they work hard something else can, and appears to often do, ruin those plans. Mama Grace suggested to Asha that she goes to get computer training (start with me and then continue on for a cheti somewhere) to get some money, and then go back and try again to get a F4 cheti. For Grace, she says you have to know someone to get work in places like Dar, but break, and people need to look for those op portunities at every turn. Suddenly this makes sense,

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160 that people here constantly asking for money, wazungu are such a great opportunity, an opportunity that is fleeting with every new person who comes along, and you may as well ask. But as far as knowi How depressing. Gideon In a shift of fortune, the people some considered to be living less precarious lives than everyone else were people living with HIV (PLHIVs) themselves. P articularly (and maybe only) for those PLHIVs living near the hospital and benefitting from the excellent, and well funded, care, many in town saw and appeared to resent the extra food PLHIVs would get each month, water filtration systems, the free health care at the hospital, and prioritization for employment and donations from wazungu data that showed PLHIVs could not get much healthier without enough food and a well balanced diet to process AR Vs, without frequent health care that was free, so as to not turn ailing patients away, and without paying attention to the whole person, and not just the disease, for people to truly be healthier (Kalafonos 2010). Many people in town, HIV+ and HIV , also desperately needed food, clean water, access to free health care, however. As mentioned in the introduction, access PLHIVs would receive to these supports. This phe nomenon came to be widespread across the African continent, with many other health care workers and researchers noticing the same things. As Vinh Kim Nguyen wrote in his book about HIV/AIDS care in B urkina Faso and Cote how did a fatal disease be come the only way to s urvive? ( 2010:6) . One of my favorite acquaintances at the hospital was Gideon, who worked as a guard at the gated entrance to the hospital. I would pass him everyday on the way to work, and he always had a big smile and a vigorous handshake for me. He was probably fifty or so, always wore

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161 small, square glasses and h is greenish brown guard uniform . One day I sat down with him for an interview about Haydom and the hospital. He answered each question with an enthusiastic Asante sana thi s endeared me to him even more. But his interview spoke, as most others, to the precariousness and unpredictability of life now, even for him who had full time employment, which by many accounts should have buffered him from hardships in life. Life now is harder than in the past. First, everyone now is looking for development, and progress does not come without money, and money comes from the work, from production. Now if the work does not generate money for example, if today a farmer plows his field, ma ybe he planted a large field and it cost a lot of money, but the rain disappeared and the crops died, instead of because the rains have decreased. Life will be difficult because t he value of the shilling is also decreasing, as I said it's drastic, and life will become harder because incomes weaken. For example, I can, I do, the greatest work of my career, but by my calculations, the salary I received last month is too little, it do es not meet my needs. I cannot even build a house because wages are low and the shilling falls in value; it is a problem, just a problem. In the future, life will collapse, life will be too expensive, and lives will be destroyed, let us perhaps we die. Now for those children who have fathered children, now it will very difficult. improved from a decade ago reduced stigma, improved medications, in addition to more food Gideon was candid about how he perceived their help to be somehow undercutting his own success in life. M M : Do you think life is harder for people with HIV compared with those without HIV? G : Asante sana; for people with HIV infection right now, thei r l ives are much easier than those without HIV. M M : Why? G : Yes, people ... people ... a person with HIV is sure to survive today; though he needs ARVs he is assured to get it, and the help and support the end of the month. He is given food, he is given oil, sugar, soap, he is given a little money, and is still given free medicine. Even if he is admitted to the hospital it is paid for, you see,

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162 but I am not given support, you hear? I am not given the same support that people with HIV infection are given, and so they have a better life than people .... M M : W ithout HIV G : ee, you find even one person with HIV today when a benefactor comes, he sees a person with HIV who has no house and he builds him a house, but I will work from morning until evening an Gideon expressed the sentiments I had heard in casual conversations from a few people, many of whom also felt that life for PLHIVs was easier because of the kinds of support and help that they themselves needed. But he also recognized that PLHIVs oftentimes needed more health care, and lacked the strength necessary for much of the available work, particularly as day laborers in agricultural fields. For me, I felt that PLHIVs appeared to be in particularly precari ous positions, as they were entirely dependent on a steady stream of free and effective ARVs for maintaining their health, which for the time being was funded by foreign aid. The additional support, as I witnessed over the course of the year, was also decr easing rapidly, in step with declining donor funds and shifting donor interests (see Chapter 5 ). But even for those who received the additional food and free care, steady employment like for many people with or without HIV was difficult to come by. Thi s was the central issue for Tumaini, an HIV+ friend Tumaini Tumaini was a relative of the family, Bibi was his aunt; his parents and family lived in Babati, the regional capital of Manyara region, about a six hour bus ride away. He had come to live with Bibi in Haydom to be close to the high quality HIV care offered at the hospital, and because he frequently needed to stay overnight in the hospital to treat recurrent infections and some side effects of th e ARVs he was on. All health care ( matibabu ) at the hospital was free for PLHIVs, paid for by the HIV donor money at the hospital, which Tumaini found critical. Staying

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163 overnight in other hospitals, I learned over the course of the year, and even HLH if yo HIV+, was very expensive (Tsh 20,000 per night for an adult, approx. $13, at HLH). Though I frequently chatted with Tumaini about his life and living with HIV, I officially interviewed him one day as a key informant for HIV care in Haydom. I ask ed him about his experiences living with HIV, his thoughts about the treatment he received at HLH and at the HIV clinic there, and his hopes and worries for the future. The vast majority of his answers revolved around work and money. He attributed his poor health, few relationships (sexual and otherwise, it was implied), boredom, and lack of hope for the future all to having no money, which stemmed from his lack of employment, which he in part blamed on his HIV status. Finding work was particularly difficul t for PLHIVs like him because, he told me, PLHIVs oftentimes lack the strength for hard manual labor, which is what many jobs require. He also raised concerns about a lack of flexible employment that is sometimes necessary when having to seek frequent heal th care and, in his case, spending many nights laid up in the hospital getting blood transfusions and adjusting his treatment. The boredom or idleness that typified his life now, as well as his inability to make money, seemed particularly frustrating. I you stay behind and just sleep. them. He also lamented that having relationships now is dependent on having money. In this case, however, Tumaini seemed to interpret this as sexual relationships, something other interviewees e way life is now, if you don't and his concern about it, was the common thread throughout the whole interview.

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164 MM : So the economy continues to develop, and busi nesses continue to come here, do you think in general this is good or bad? T: MM: Why? T: T he people at the bottom (of the socioeconomic hierarchy) are hurting, some are unemployed, some people do not have any work to do. MM : OK T : So right now as the prices of things continue to get higher, people continue to suffer MM : S T : L ife is hard MM : It is very hard T : V ery hard MM : S o, everything depends on salaried work? T : E for my life right now are broken, as I can see. Because there is no employment at all that I can do, I have no work, and there is no or der in my life in general. At the end of the interview, Tumaini asked my research assistants to leave in order to talk with me privately. I knew what was coming he was going to ask me for money, which he did. he told me. Hi s wife and child were in Babati, and he had not seen them in two years since he had been living in Haydom for treatment. They did not know that he was HIV+, and as far as he knew, had never been tested for HIV. Babati to see his family, and to take them back to Haydom with him, but needed to earn enough money first to do so. He proposed a business plan if I could loan him Tsh 100,000 ($80), he would travel to Arusha and buy a bail of second hand clothes that h e could sell out of his house. If he would be able to work even a little

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165 bit, he told me, it would help he would be able to buy fruit (a reference to diversity of foods PLHIVs are urged to eat), and it may help his frequent dizziness. After listening to his plan, I could feel my cheeks burning, knowing that I would have to turn him down as I was quickly running out of money myself. As he was one of my temporary kin, however, I did feel an obligation to help him, and I told him I would try. Since the begin ning of the year, several people expected me to insist upon, but I t urned that into a sort of revolving pile of money that each person who asked me could have, but it depended on the previous person paying me back. Therefore , for example, I loaned Paulina Tsh 100,000 because she was working without a salary for a couple mo me for the same amount to pay school fees for several of her children. I told her that she could have it, as soon as Paulina paid me back, and so Suma and I were able to actual ly get it back. I told Tumaini he could have that money I gave to Suma, when she had enough to pay me back. On the day I was hoping to tell her to give it to Tumaini when she had the Tsh 100k, her son broke his arm and she spent the day in the hospital. I am certain any money she may have saved look like I was going to be able to loan money to Tumaini. I would occasionally see Tumaini, in the HIV clinic wait ing for his appointment, or at the house, or at his house, etc. One week, however, I saw him nearly every other day, getting more insistent that he needed the money. He looked desperate; I felt terrible. He came over for tea one afternoon to plead with me for the money, but I continued to tell him I needed to get the money

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166 A f ew days later, and about a month after our interview, I heard from Asha that Tumaini had gotten drunk one weekend night and raped a nine year old girl, whom I also knew. The little girl, who was chatty, friendly and well known around the hospital campus (a nd was a favorite friend of many of the Norwegian ex pats), lived with her grandmother just outside of the hospital. One of the Norwegians went to visit her, I heard through the ex pat rumor mill later that and was in pain. The story came out somehow; she was taken to the hospital for care and an HIV test, and the police caught Tumaini while he was playing pool at a bar in town. Tumaini sat in the tiny Haydom jail, while the jailers apparently asked around th e hospital if anyone had food they could donate because they did not have enough to feed him. Marianne, a Norwegian volunteer in the finance department told me that the wazungu apparently concluded. A couple days later Asha told me that Tumaini had been moved to the larger district prison in Mbulu, where he will presumably live the rest of his days I later heard he received a 30 year sentence. As he is HIV+ with many health co mplications already, this effectively served as a life sentence, and no one I asked knew if he would be receiving ARVs or health care in prison. Asha told me he had missed a couple days of his ARVs while in jail, and was already feeling sick. She also told me that if you have enough money, you could usually pay a bribe ( hongo ) to the judge or police in return for a lighter sentence or be released. For rape or murder, crime, otherwise yo u would be hauled off to prison again. Needless to say, Tumaini did not have

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167 that kind of money. Another concern, no doubt, is the vigilante justice that is alive and well in town. In the stories that swirled around town and the hospita somehow released he would be killed. That was the last I really heard about Tumaini. The family, perhaps understandably, did not talk about it much after that, and I would occasionally ask if anyone knew if he was getting his medications, but no one ever seemed to know. He most likely was not I received an email from Grace in early 2014 saying that he died in prison within a year. as the most personally distressing for me. His desperation, his belief me into a lengthy guilt spiral that would reemerge in periodic waves: Fieldnotes, 23 April 2012 ( the day I find out) : This has really messed with my head. What if I had given him Tsh 100,000, would a little girl not be recovering in the hospital right blame, but am I a little bit to blame? Is the global socioeconomic class from which I represent to blame? And me, as their representative here in Haydom, am I implicated in this? little bit, you never hear about things like this. On the surface it appears poor, but happy somehow, like people are just happily, but with some uncertainty, skipping through life, smiling and joking and happy to meet you, the outsider with the white ski n. But underneath, sometimes you get glimpses suffer as they have, are prepared to sacrifice themselves to the whims of the seasons and the rainfall and the decisions of donors and the mood of their husbands and the availability of

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168 alcohol. I feel like people are just blown about with the wind, without agency, which I know is heresy for an anthropologist to say, but sometimes life sucks here and what can people do? So many things are so completely out of their hands, they have to pay bribes to the mayor to even lodge a complaint, pay a health care worker to get along in line at the hospital, starve for January and hope your crops ( if you are lucky enough to even have a farm or a cow or some chickens) 9 year old girl because he was wasted drunk, he felt his life was broken, had no hope for the future, no hope for sex without force (so says Asha), so he forced a little kid to have sex with him. Her parents are probably able to get married, maybe will die young. And does this all come down to me, hesitating and not wanting to give out what amounts to $80? I remember thinking that that is just about the cost of a a pair of Ray Bans ? Is this what it amounts to? I know (rationally) this is in no way about me, but he was obviously getting increasingly desperate for the last week, I saw him three days out of five last week asking about the money and if I could help him. I was obviously his only hope and I just cast him aside, saying to myself I feel like a terrible anthropologist here. How am I supposed to get a job as an anthropologist saying that peo ple here sometimes live a terrible, scary, unpredictable existence? What bright spots have I seen? What have I seen that makes me happily consider the enormous amount of work that women do to take care of their families, with lots of love, or at least as m uch as they can muster? The equally happy, regular bar trips of men getting shitfaced and

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169 like soap to wash clothes they beat the shit out of them, like Joyce? you need. And maybe for a time you give you nice presents and sometimes money, maybe money to go to school or money to buy nice clothes, another wealthy business man, who does the same, and now you have enough money to buy more of what you want, you can dress nicely and get your hair done for seven hours once a week. Why am I judging these women? And when the options are so limited, what can you do? People here have to deal with overwhelming precariousness, a lifetime of just awful shit, and somehow they just keep on. How do people do that? I guess the ma gic question is how do raping 9 year old resiliency, I guess. Who has it? Is it the 9 ye ar old who seems happy and just keeps plugging along, loving and letting some things pass her by but maybe oth perhaps she had links with someone who cou ld pay for h er schooling (Valerie , who worked at Haydom previously ), links with someone wanted to move with the first boy who asked her, and actually told me in 2009 that she never wanted to get married, she wanted to work and earn money. What makes a girl want to do that? And is this desirable, or just me imposing my own values on others?

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170 really trouble lately, and from our interview he definitely seemed to feel like things were not looking o was a child rapist. I remember the last few words we spoke were about my research and him telling me it was very important to do, and I felt happy that he said it, and then started talking more about myself and he cut me off because it was evident that I think it was last Friday actually, and he saw me in the hall and he looked at me expectedly, and I just said hi, and I said hi and shook his hand and then turned away. I feel like such a colossal asshole.

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171 CHAPTER 5 AID WITHDRAWAL : PRECARIOUSNESS IN HEALTH CARE Maria sits down on a wooden chair in my small office, and she looks exhausted. With a check up, and to pick up the free antiretrovirals (ARVs) that keep her healthy, for the most part. She cannot afford the Tsh 6,000 round trip bus fare to ge t here (about $3.75), which a few years to Child Transmission of HIV program (PMTCT), housed within a large, rural hospital in north central Tanzania, Haydom Lutheran Hospital (HLH). I am intervie wing women at the HIV clinic who have participated in the PMTCT program, and my questions revolve around the changes in support they have experienced. Maria has gone through many she has been in the PMTCT program twice, in 2009 and in 2011. The first tim e she received palm oil butter, sugar, peanuts, corn, milk for her child, and bus fare; for the second time she gets nothing, she says, except ARVs. Life is very hard, she tells me, and she has many worries. She is unmarried and lives with her two survivin g children; her mother, who she used to live with, forced her out of the house because of her HIV+ status. To eat and feed her children, she farms an acre of land that she rents for Tsh 20,000 a year, and relies on the small salary she gets as a day labore r ( kibarua) . Neema is another mother in the PMTCT program who comes to see me for an interview, this time in late April 2012. Because she has no job, no money, an HIV+ husband who is too sick to work (and who has never started ARVs), and two living childr en at home, the staff at the HIV clinic do whatever they can to make sure she can continue her HIV care. Unlike Maria and the majority of PMTCT mothers, Neema continues to receive the Tsh 6,000 it costs her to come here by bus, and when possible, a monthly corn ration so her family can eat. The hospital ran out of corn in late February, however, and the money the hospital recently had to fund food support for

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172 mothers in PMTCT has been cut. Another small donor funded NGO that used to send community home base d care workers (CHBCs) to visit Neema and to deliver food, pain medication, and condoms, has also lost much of its funding, and now, she says, they just come salamia tu Neema is visited once a month by Magdalena, one of the CHBCs work ing with Haydom Hospital who goes to town everyday to check in on and counsel PLHIVs from the HIV clinic, particularly mothers in the PMTCT program. Magdalena herself has been subject to the shifts in funding for the HIV program at the hospital. She was hi red in 2003, in the first years of the multi initiative implemented in Tanzania and 14 other target countries that were battling increasingly high rates of HIV/AIDS, in wha prevention, care and t reatment services, supplemented with funds from a Scandinavian donor. Both sources of funds are decreasing annually, even as the number of people who need HIV treatment continues to climb. Up until 2010, Magdalena received Tsh 4,000 a day for visiting PLHI Vs in town, and Tsh 7,000 for outreach visits in the hospital Land Cruiser, in addition to a bicycle and money for bicycle repairs. Today, she receives a salary of Tsh 2,000 a day for either outreach or town visits, which she interprets as a personal insul t, as if the work she does, and the experience she has, is decreasing in value as well. the problems the patients and workers are experiencing due to the cutbacks in the funding. As I witnessed over the course of the year, she feels deeply for her patients and staff,

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173 helping several patients find employment and housing in the community. She tells me that each year the budget gets smaller and smaller, in a proc patients, she says, who are increasingly lost to follow up. The quarterly PLHIV meetings that the hospital used to host she par ticularly misses, not only so clinic staff could educate PLHIVs on ways to adhere to treatment and stay healthy, but because patients themselves could help each other manage their care and act as a support group. Like with some of the other disease speci fic, donor funded programs at HLH that are scaled back or reach the end of their funding cycles, the hospital will work hard to find the resources to fund the majority of HIV clinic staff salaries and services in order to continue delivering high quality c own funding crisis budget) may also cut funding, and actively encourages the hospital to find ways to be more sus tainable. When I left Haydom in June, 2012, hospital administrators were preparing for an uncertain future. In the previous chapter I examined how precariousness is largely a part of everyday life that people endure ( vumulia ). In this chapter I look specif ically at the precariousness of the health care sector, which is in some places (and for some diseases) largely donor funded and governed in part by the whims of those donors, their deadlines, and their own priorities and projects (see also Basilico et al. 2013). I examine these donor and because that is my focus, I cannot speak to the precariousness of public health care, or the entire sector, including public, private and voluntary organizations a limitation in this research of health systems. Within the health care sector, I oriented my focus initially on HIV/AIDS

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174 programs, which within health care broadly, claims a significant share of global donor aid (Ravishankar et al. 2009; Oomman et al. 2007). In addition to HI V/AIDS initiatives, I encountered several similar cases of aid withdrawal and precariousness in other areas of health care. In total, I focus on five case studies in this chapter, organized by level (a roughly global to local direction) and by type I inc lude bilateral and multilateral donor aid for a country; aid for an individual hospital, Haydom Lutheran Hospital; for the MDG 4 and 5 program, a vertical maternal and neonatal care initiative; for PEPFAR, a multi billion dollar, multi country HIV/AIDS ini tiative; and for an HIV/AIDS program, within a clinic funded by multiple actors, housed within a hospital funded by donor aid. I hope to show that each case study is evidence of a larger phenomenon volatility in health care and the foreign aid on which i t depends. I begin at the national and global scale, in part because these high level fluctuations in funding and policy have direct impact on the lower levels, and on some of the cases I present that follow. I track the trends of donor assistance for hea lth to Tanzania over the course of the last 15 years, which, much like in other Sub Saharan African countries, experienced a surge of funding in the mid 2000s and since 2009 has experienced a decrease. Second, I examine the fluctuations in funding for Hayd om Lutheran Hospital itself, and the impending cut back in funds from the Royal Norwegian Embassy in particular. Third, I consider the volatility of another form of funding that for a large scale vertical program addressing maternal and neonatal health, that mothers in labor in order to deliver at the hospital. This program also provided funds for the to Child Transmission of HIV (PM TCT) program as well. This program had a five year timeline, and came to an end in early 2012 while I was living in Haydom. I examine the impacts the program ending had on both maternity care at HLH, as well

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175 as the end of one of the several funding streams for PMTCT. Fourth, I look at PEPFAR itself, also a principal donor of HIV care and treatment at HLH, in addition to PMTCT support. I I collected with PEPFAR administrators and NGO partners who remember the initial rollout of services in the early 2000s, and how this surge has hamstrung the building up of sustainable HIV/AIDS care and treatment now. I include data other anthropologists and health care workers have collected from countries in Sub Saharan Africa experiencing more dramatic cutbacks in HIV/AIDS funding and support, to illustrate the impacts on programs and patients these funding cuts can have. Finally, I write about the PMTCT program at HLH, and in particular how small pieces of the program have eroded over time, to go from a well funded, well attended program that provided comprehensive support to one that lost significant funds in a short time. Patient attrition has resulted, at the same time as a surge of interest in following one faith healer in particular Babu Loliondo who claims to cure chronic diseases. Because of the variety of cases of aid exit, I sought out and collected interviews with diverse informants: administrators, policy makers , health care workers and volunteers actively working within the health system and encountering problems associated with aid exit and crafting plans to relieve them. In total, I collected 32 semi structured interviews in Dar es Salaam and in Haydom, relate d specifically to these larger scale processes and problems. In Haydom, I also sought to better understand what the patient experience might look like, going through a T program as a case study within the PEPFAR transition, I conducted 75 semi structured interviews with mothers who had, at some point in the past nine years, been enrolled in the PMTCT program at HLH and could comment on the care and support they received and are

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176 currently receiving. My research assistants and I made concerted efforts to get a representative sample each day in the clinic, all women identified by clinic staff as present and former patients in the PMTCT program were asked to participate. In the end, we were able to interview 22% of the total sample of PMTCT mothers, 75 of 343. Principal themes were elicited from interviews and field notes, using in vivo coding aided by MAXQDA text analysis software. Aid Exit Aid exit is usually conducted in a stepped or graduated process over time in which fewer and fewer aid dollars are disbursed to the country over a period of years. Much of aid exit research and policy strategizing is focused at the national and international level including the philosop hical arguments about how effective foreign aid is at reaching its broad development goals, the ethical issues of inadvertently (or advertently, depending on whom you ask) cultivating aid dependency, and expanding capitalist interests globally (Easterly 20 07; Moyo 2010; Sachs 2005); to practical concerns about how best to manage aid exit without undermining previous successes or causing damage to future country development (Slob and Jerve 2008; UNDP 2011; Tandon 2008). Fears of entrenched aid dependency an d the erosion of state capacity for sustainable development motivate many arguments for aid exit and improved aid effectiveness. A principal argument against the use and proliferation of foreign donor funded NGOs for the provision of social services is tha t, unlinked from the state, these institutions are undemocratic, principally conceived as apolitical, and lead recipient states and citizens to lose power in making demands on the state for services that most fit their needs and interests (see Ferguson 199 4). In practical terms, the proliferation of NGOs delivering services can also lead to increased fragmentation and duplication of those services, decrease coordination among actors, and contribute to what many anthropologists of global health have recogniz and Walt 1997;

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177 Janes and Corbett 2009). Most critically, however, is the widespread inequality among people and social services that follows alongside neoliberal mechanisms of social service provisioning. Global health is, a bove all, a quest for equity in health care worldwide (Farmer et al. 2013a; work in anthropology, and in African contexts is perhaps best outlined by Ferguson (1994 ); Ferguson and Gupta (2002); and Piot (2010). As outlined in Chap ters 2 and 3 , an outcome of the neoliberal geometry of health care is neglect (Ferguson 2005; On g 2006; Tsing 2000; Catterson and Lindahl 1999). This patchy landscape has a temporal aspect to it too. Green zones can easily become brown and vice versa, develop go, leading to a perpetually unpredictable health care system. Like Char les Piot (2010: 164) observed in Togo, t, slithering snake used to be able to count on things, knowing that if you did this you would get elopment Efforts to rectify these issues have taken shape in a series of aid effectiveness forums organized by the OECD. At the Second and Third High Level Forums for Aid Effectiveness, the OECD developed The Paris Declaration on Aid Effectiveness (2005) and the Accra Agenda for Action (2008) to improve aid effectiveness and accountability among donors and recipients (OECD 201 3). The Paris Declaration built on the First High Level Forum in Rome (in 2002),

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178 1. Ownership: Developing countries set their own strategies for poverty reduction, improve their institutions and tackle corruption. 2. Alignment: Donor countries align behind these objectives and use local systems. 3. Harmoniz ation: Donor countries coordinate, simplify procedures and share information to avoid duplication. 4. Results: Developing countries and donors shift focus to development results and results get measured. 5. Mutual accountability: Donors and partners are accountable for development results. From OECD (2013) of the Paris participation, and delivering results (OECD 2013). Both of these declarations, while inspiring a brief change in the way aid is delivered, have had limited ef 2013). As I discuss in this chapter and the next, many lofty goals for changing the way aid is controlled and distributed, changed and changed back in the 2000s and early 2010s in T anzania. This is likely in large part because of the 2008 financial crises (less money available for foreign aid) and ensuing political upheavals (to more conservative governments), but also due to evidence of widespread corruption in Tanzania unearthed in sources such as wikileaks. What resulted is a continuation of a predominantly neoliberal model of aid and global health, with a of medical insecurity for a moment if we follow the FAO definition for food insecurity, medical insecurity is a distinctly personal, and perceptual, experience of ongoing phenomena. Health care precariousness can relate to the overarching phenomenon its elf, the sovereign appearing and disappearing as Piot put it, and the attendant

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179 unpredictability of care. Throughout this research and writing, I tried to keep a focus on both nomenon. In the following case studies, I take both levels of experience and phenomenon into account. Case Studies o f Aid Withdrawal The following section examines five ethnographic case studies of aid exit and withdrawal I encountered during the course of my fieldwork, which illustrate how aid withdrawal is a complicated phenomenon that emerges and affects people and institutions on mu ltiple levels. In the first case, I look at the international level and fluctuations in foreign aid and donor funds for health care in Tanzania from individual countries and international organizations bilateral aid and multilateral aid which changed s ignificantly after the 2008 financial crisis. Second, I examine precariousness at the institutional level, at HLH itself, in its struggles to find a steady stream of donor funds as well as dependence on foreign volunteer doctors and donated equipment. Thir d, I present the what happens at the tail end of a maternal and neonatal care program, and the worries and fears of mothers and health care workers about trends in hospital deliveries after it is no longer subsidized. Fourth, I look at fluctuations in indi vidual programs or initiatives that are often implemented in part within institutions, for example PEPFAR funded HIV clinics. Finally, I examine changes within one program over time, in this case, the PMTCT funded HIV clinic. F or each case study, I present empirical data of the nature and extent of health sector volatility, and reflect on the consequences of that volatility on the health care system writ large. I discuss some of the ethnographic data I collected about the patien ts who must negotiate these changes, and on the health care workers and administrators, who, while operating at the point of articulation between the system and the patient (and more broadly between the global and the local), draw on perceptions complicate d by multiple fields of vision. I argue it is not necessarily

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180 this highest level kind of aid exit, but the constant upheavals in the system, and the constant threat of aid exit, the precarious nature of aid in general and the essential health care that is in (very) large part dependent on it, that is a site of anxiety, power and action. #1: Bilateral and Multilateral Aid in Tanzania: Rapidly Shifting Donor Funding and Policy Official Development Assistance (ODA) per capita to Tanzania has decreased signif icantly in the past few years, from USD $67 per capita in 2009 to $53 in 2011 (World Bank 2013e), though it swings wildly from year to year, between $38.6 in 2005 and $68.6 in 2007 (see Figure 5 1 ). From 2000 to 2010, however, total ODA to Tanzania increas ed from US$1.6 billion in 2000 to US$3 billion in 2010, or 14% of the total GDP. Figure 5 1 : Official development a ssistance to Tanzania. World Bank (2013e) Forty donors contribute funds to Tanzania, but five of those donors contribute 54% of total O DA the International Development Association of the World Bank (IDA) (20%), the UK (10%), USA (9%), Japan (8%) and the EU (7%). General Budgetary Support, or GBS, became a favored aid modality in Tanzania after the Paris Declaration, which is essentially writing a check

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181 to the government, and the money can be used wherever the government sees fit. GBS is the preferred modality for aid effectiveness because it promotes country ownership and decision making about where in the government budget aid money goe s, reduces transaction costs and bureaucracy, promotes efficiency in public expenditures, and helps improve coherence and coordination of aid and public funds for social services (Mutalemwa 2009:1). In Tanzania, the eptional, among resource poor countries (Agha and an exemplary case that, according to the Paris Declaration, best implemented the goals of ownership, alignment and harmonization (Appolinario and Locher 2009). licy, GBS as a percentage of aid to Tanzania (36% of total overseas aid in 2009) has been decreasing over the past several years, with several donors decreasing funds or shifting focus to the two other principal aid modalities: basket funds (18% of total a id) and project support (46% in total aid) (Mutemwala 2009:6). Basket funds are a sort of middle ground between GBS and individual project support, where donors can designate which y) the government has discretion over which services within the basket to fund and promote (Agha and Williamson 2008) . Health has it s own basket, for example, as does primary education development in Tanzania; others include water and sanitation. As researchers at the Overseas Development Institute note, baskets often function like large scale projects, which promote parallel and fragm ented national systems, undermine the strengthening of public sectors, and continue the donor directed, instead of recipient directed, nature of aid (Agha and Williamson 2008). The

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182 projected proportion of GBS in Tanzania among total aid for 2013 decreased to 25% (KEPA 2012). International Development (DFID) was the principal contributor to the GBS that year, and as several informants told me, were the principal advocates of GBS con tributing Tsh217.9 billion, or 25.46% of the total GBS budget (Tsh 856 billion in 2008/09). The World Bank was second, providing 23.25% of the GBS budget, with the African Development Bank a distant third with 12.87% (Mutalemwa 2009). By 2012, however, the Netherlands and Germany had backed out of GBS, and DFID had scaled back their contributions to GBS and the basket funds considerably, choosing inst ead to support programs. Table 5 1 outlines the quick rise and fall of GBS support. Fieldnotes, 22 February 2012 : friend difficult to sit down with someone who will talk with me. But for a bit we were discussing hire all British people and British companies to do the work, but they do get favorable trade concessions donor country, and trade is does appear to be lots of volatility. Anjali told me that DFID used to provide 97% o f their funds to the general budget (GBS). A few things conspired to change their focus back to program funding, however,

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183 including problems with accountability and corruption within the Tanzanian government. The 2008 financial crisis however, provides imp ortant context the shift from GBS to vertical programs and program support was orchestrated by the increasing conservatism of the UK and shift to programs came a wealth of employment opportunities for expatriates, for which Anjali was jetting all over the world to recruit for. Fieldnotes, 22 February 2012 , continued: With the increasing number of programs, Anjali (part of the Human Resources Department) was on a recruiting tear there are a lot of vacancies for program people at DFID right now she is always traveling recruiting people for these new jobs that opened up coming with the shift in funding programs, they now need people to run the programs. DFID was with Tanzania. The Dutch, Germans and Norwegians were also in the process of shifting their donor plans, in part because of changes in political climate in donor countries an d new political parties (many more conservative in Europe after the 2008 recession). One afternoon I sat down witnessed over the past year. M M : Last time you were sa ying that funding from Norway was going away or being cut back or being redirected. Cut completely. E : They have, I think, $6 million that was in the health basket that they've redone their strategy and they've prioritized, I believe, climate change. So NORAD through Oslo will be still programming from internal health; they're traditionally a very strong partner for that. And they also have an Eastern Africa region Open Health Initiative and I believe they're a member of the global health alliance as well so they still have vested interest, but I think here specifically is a bilateral M M: And then the Germans and the Dutch are also pulling out too? Is that what you said?

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184 E: Mhmm (yes) M M : C ompletely? Or the Dutch are pulling completely out of health? E: Mhmm (ye s) M M : And so is this common? Do countries sort of come and go all the time based on political climate? E: Yeah, could be. Or, you might see variances in countries, but this is a larger scope and scale across multiple countries than I've seen before. DFID was the big shocker when they pulled out and also changed their management platform. M M : I heard they're now funding more programs. E: They are. They're kind of back in. DFI D not being in the basket, to me, is bizarre. They were probably one of the biggest supporters of the basket approach. Table 5 1: Changes in c ontributions to Tanz ears . KEPA, Policy Brief 03:2012 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 Disbursed GBS (USD) 605.930 776.106 737.781 766.763 534.317 597.047 496.000 Disbursed GBS (constant 2006 USD) 605.930 731.092 694.989 722.290 503.327 562.418 467.232 In an analysis of decreasing levels of GBS amo ng principal donors (see Table 5 1 ), myriad factors: insufficient progress in poverty reduction and good governance practices in Tanzania, and changing politic al and donor priorities among bilateral partners (2012:7). Counter grants shows that donors are increasingly earmarking their funds and channeling them to sp ecific areas, rather than letting the Government of Tanzania choose where to invest the aid money in

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185 2008 that impacted on GBS funds. The first was the food, fuel and financial crisis, which motivated donors to pay their 2010 aid commitments in 2009 to fill the gaps, leaving subsequent aid shortages for the following years. Additionally, wikileaks documents exposed the External Payments Account (EPA), in which USD $131 million had been paid out to 22 (allegedly fictitious) local companies in 2005 and 2006 (Semberya 2012). Another corruption scandal rocked Tanzania in 2010, when national and international newspapers repor ted the government contracted the US based company Richmond Development to provide emergency electricity in Dar es Salaam, which they did not do despite paying the c ompany USD 100,000 per day (BBC 2008 ). Many government officials were found to have special interest in the company, leading to the resignation of Prime Minister Edward Lowassa and two other government ministers. Fueling these corruption allegations is the failure for the phenomenal economic growth in Tanzania over the past few years between 6% and 7.8% every year since 2004 to reach the general population and make any dent in the high poverty rate (World Bank 2013). Several benefits for the majorit KEPA 2012:8 ). This allegation, that the government is ufisadi , one Tanzanian friend told me) was alleged on so ro bust and well Tanzania as a bastion of good governance, is still perhaps not entirely true (KEPA 2012:8; Hermitage 2013). The shift back to program support, however, is proble matic for all the reasons that inspired the Paris Declaration. It is more difficult to harmonize with the health sector, to align

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186 and coordinate with other institutions, and when principally organized and implemented by donor agencies, such as DFID, true o wnership of the program is in question. Additionally, the unpredictability of funding, both long and short term, was a principal concern of my informants in administrative positions, and impeded long term planning for health care in general. One informant , Anne, who worked at one of the large, international NGOs in Dar, told year year program contract, she must reapp ly creasing, we already know Health Initiative, which broadens the scope of care from HIV to include other health programs, must stay nimble. #2: Haydom Lutheran Hospital Funded Hospital Health care institutions must also stay nimble, as HLH learned as it faced potentially , and featured Rosa, a German pediatrician who arrived in October 2011 for a two year stay. The film narrative illustrates how much the hospital depends on Rosa and others like her young, foreign, short term volunteer doctors that the hospital could not function without, and how much the hospital

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187 The film opens with a young woman in labor in the back seat of a Land Cruiser, with a midwife and another nurse attending t o her. When the car arrives at the hospital, after sloshing through mud and rain, she is wheeled into the maternity ward, where after a minute or so of pushing, the smiling nurses gently hand over her healthy baby. The next scene is much more harrowing a bus has tipped off the narrow bridge at the base of the mountain on which Haydom sits, with fifty to sixty people inside needing immediate medical attention. They are rushed up the mountain to the hospital to receive emergency care. Stitching, bone settin g, and surgeries are all bloodily captured on film, conducted by Tanzanian and foreign volunteer doctors alike. Several doctors tell the camera how lucky it was that the hospital was there s for if it was not, the passengers would have had to travel the 300 kilometers or so to the next nearest hospital. These two scenes set up the purpose of the video to warn against what would have happened to those people on the bus, or for the young mother perhaps, had the hospital not been without opening titles, may soon lose the funding of its major donor the Norwegian government in everyday, again, is one day closer. So we have 300,000 people in this area that are depending on no health care. This means that with just a little bit of malaria or whatever, you will suffer and get an idea of what might happen if funding for the hospital ended, and how those dependent on that

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188 support could manage or cope without it . What I discovered over the course of my year there was that, while this sort of large scale aid exit rarely happens (and it likely will not happen at Haydom either, I was assured by many), it does happen in varied, small and ubiquitous forms everywhere. While my initial research questions led me to look at aid exit in two principal contexts within a Prevention of Mother to Child Transmission of HIV program at Haydom Lutheran Hospital, and among PEPFAR funded HIV NGOs in Dar es Salaam b ut notice small examples of it everywhere, first within the hospital itself, and from that, within like to fluctuations in available health care services and quality , such as when a health care program ends, when a key volunteer leaves, when services are scaled back or when an international health initiative reaches its deadline and donors lose interest. This spatial and temporal patchwork of services creates a highly unpredictable, and precarious, foundation for health care. Conducting long term ethnographic research at a principally donor funded hospital allowed me to see many of these fluctuations and changes HLH experiences over time. It also allowed me to see how people thought about it, and the rumors that circulated to help people understand it, and perhaps make it seem more predictable. Debates circulated about whether or not aid exit or withdrawal actually happens, and the circumstances under which it occurs. For example, at a security briefing at the US Embassy in Dar es Salaam, I met Sarah, an American woman who worked for the Tanzanian PEPFAR office, who became a dear friend, a candid informant, and an important link to other key informants in the foreign ai d world. One of section of the northern peninsula of Dar es Salaam where many expatriate aid workers live. At

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189 frican woman working for one of the big international NGOs in Dar, and talked with her about my plans for researching aid exit and sustainability, and how patients and organizations cope with losing care and funding. She there were always other donors waiting on the sidelines to fill in the gaps, or to step in and provide funding if the funding might be cut. Especially for good projects with good reputations, she said, donors are always looking to fund those. Others echoed this same sentiment over and a sort of wholesale, pick up and leave nothing kind of aid withdr awal rarely occurs. In Haydom, where in two years this wholesale withdrawal of donor aid was potentially on the horizon (as the film followed), Theodor, a Norwegian research administrator for the hospital explained why, for HLH at least, this was unlikely here and visit, and it makes them feel good about themselves, to feel like they are making a positive impact in the worl HLH is currently funded by the Norwegian government, through the Ministry of Foreign Affairs and the Royal Norwegian Embassy (RNE), in five year funding cycles. During every cycle, the RNE commissions an audit of the hospital to account for the funding , to monitor the successes and challenges facing HLH, and to evaluate hospital progress in achieving and Mwisongo 2009). The hospital itself produces annual reviews as well, both for the RNE and its own internal monitoring, and to put on its website for donors and interested parties former volunteers, and donors from the active Friends of Haydom charity organization to review (HLH 2005; 2008; 2014). Toward the end of every five year funding

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190 cycle, HLH is required to submit a new request for funding, and the RNE either approves it or not. In the two most recent funding cycles, however, the RNE has been increasingly vocal about the need for HLH to be more sustainable, understood in this context as more self sufficient, to find ways to at least better supplement the funding received by the RNE. At Haydom this has meant employing a variety of tactics to get more money soliciting from a wider pool of governmental and organizational donors, instating user fees, revamping the website t Tanzanian doctor in the video said, and what I heard echoed the entire year simama kwa miguu yetu ). The truth is, as many people told me, rural hospitals caring for the rural poor will always need donor, or outside, funds, in Tanzania or anywh ere. The majority of patients at HLH are cash, and cannot easily pay user fees. Health insurance schemes hold more promise (Sekabaraga et al. 2011), but are still slow to catch on in Tanzania, though there have been successes in implementation among salaried employees accessing private insurance, government employees (with the National Social Security Fund), Community Health Funds (CHF) and proposals for expanding a ccess to non wage earners. Additionally, the annual cost of running HLH, compared with other large hospitals, is relatively inexpensive. As many advocates for continued funding from the RNE noted, the cost of running HLH for an entire year is equivalent to the cost of running one of the largest hospitals in Norway for one day.

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191 All these things factor in the political pressure put on the Norwegian government to keep funding the hospital, which is ultimately what is the most powerful, Theodor thought. Defund ing HLH would not be popular, especially in the heavily Christian southern part of Norway, where the founding family came from, where the Friends of Haydom, a private donor organization is based, and for whom Haydom is largely synonymous with Tanzania (Hay dom IS Tanzania to those people, a Tanzanian friend told me). Part of the political back and forth, some Norwegian friends told me, is around the place of faith based organizations (FBOs) in the Norwegian foreign aid philosophy. Currently the country favo mentioned above, is a form of development practice which allows recipient governments to dictate where funds go, instead of following donor demands (Mbacke 2013; Agha and Williamso n 2008). The previous Minister of Foreign Affairs, they said, was a Christian, and many volunteers from Norway expressed their own concern that the new Minister would align more closely with this more secular Norwegian foreign aid philosophy and drop HLH f rom its funding plans. Corruption at HLH Adding an additional layer to the problem of long term funding at HLH are the periodic waves of rumors about corruption and mismanagement of funds that plague the hospital, and perhaps with increasing frequency si nce PEPFAR funds rolled in. When I arrived at HLH in the beginning of July 2011, HLH had just implemented a suspension of salaries for all hospital workers. As central as the hospital is to the economy in Haydom, this suspension affected a wide network of people and businesses in town. Rumors in town about the cause of the interruption in salaries were widespread, and all centered around corruption in the hospital, which many allege had been going on for a long time. Particularly after the former, long term hospital director died,

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192 and before the new director, his son, was instated, people told me stories of hospital equipment being carted off in rented trucks and millions of S hillings going missing from hospital coffers. This time, rumors were that the inter ruption in salaries was because the RNE caught operating budget. They put a stop to all money going in to the hospital until the people stealing from the hospital were c aught, fired, and the money paid back. My friend Emmanueli, explained the situation to me one day at the hospital: Fieldnotes, 19 August 2011 : I went back to the hospital for an interview, and while I was waiting I sat outside on the rocks lining the road heading over to the library and admin building. Emmanueli saw me and walked over to talk for a bit. I asked him how he was doing in the finance department have caused a lot of problems. Everyone knows who did it but no one wants to bring charges against them because they feel there is not enough evidence to charge them the only negative consequence is getting fired, but how is that really bad? They just steal they see the money there, and it always just sits there. A nd then you think you can just take it and A friend of mine in town, an older man who relished discussing controversy and corruption, told me that despite what people in tow n were talking about, he had heard from someone higher up that the delay in funds came about because of a reporting error. I had heard of and overhearing them arguing on the phone with gaps in funding,

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193 differences in funding cycles, or what processes organizations need to go through in order to release the next round of funds. On one of my trips back to Dar that year, I sat down with Malaik a, a Tanzanian who worked at the Royal Norwegian Embassy (RNE) for an interview, and asked her about it. This complicated process funding organizations engaged in seemed destined to create occasional gaps in funds, and in this case, Malaika told me, it was just a reporting problem. Once the hospital fixed the reports, the RNE would release the funds. RNE : I think the main challenge that Haydom runs in to is more of a cash flow issue, then a real funding issue. Like I think that they have funding but a lot of times we can't release it until we get the reports that we need, or you know we need to see another report, we need to see your plans, we need to know what you're going to do, and if you cannot tell us that then we cannot give you money, that's part of the grant rules M M : W as that what happened last summer? RNE : Y eah M M : O kay, because rumors were rampant that it was you know, it's corruption, and the Norwegian government is angry about (corruption), and then one person was like it was, no, it was just a reporting issue RNE : Y eah M M : T hat just lit up a firestorm of rumors RNE : Y eah, there were a few issues at that time. There was a change in the Norwegian a registered entity in Norway, it's a registered entity in Tanzania, so they didn't have this registration number. And when the law changed the bank couldn't find a registration number, so put it on the director's personal name, so they changed the bank acc which we were like, we can't disperse money to a personal bank account, so that got us stuck for a little while. And then he had to run around and get that changed, and that had to happe n in Oslo. And then the other issue was the reporting we hadn't received sufficient quality reports as well, I mean we got them and then we sent them back, and back and forth, and it went on for awhile. There were three issues, anyway, but those were th e two main issues, so when we finally got that done, then we released all the MDG 4 and 5 money in the summer last year. And then also one block grant disbursement I think it was in September, and then the second block grant it was

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194 in November, so then the y could pay off their debts and all their salaries and everything and then we had a very good instructive conversation at that time about how we can speed up the process so there was there was a there is an annual meeting that needs to be held once we get all the reports then we hold a meeting shouldn't run into too many financing problems, and then if the government comes in with their staff grant then it should become a bit mor e stable. But yeah, there are risks when you're so heavily dependent on one donor, so that's quite a big challenge. a year later, when I was discussing some of these issues with one of the newer accounting volunteers Marianne a development economist from Norway. Fieldnotes, 13 June 2012 : Had lunch in the guesthouse with Marianne and Rosa. Marianne told me that the RNE said in a meeting with her a couple months ago that they are defunded with the new government in Norway not wanting to fund faith based organizations (FBOs) fired: the old guard were all Christians who worked in development, and now they are mostly non So she says she really does think that HLH will be defunded in 2014. Her and Rosa were also talking about how Karl was working on making the hospi tal more of a medical center, with three wings res earch , curative (HLH) and education (nursing school), and then having directors for all three areas work together, so Jostein would be the head of the curative part only, and not of the whole thing. They said that the hospital was getting just too big for a single entity, and that it would work better as a center somehow. She (Marianne) also said that if/when the funding gets cut they will have to downsize, because the hospital and everything is just too b ig for the money.

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195 (Lange 2013:viii). Four accountants were fired that month at H LH, including the Head of Finance I had interviewed in 2009. In addition, evidence showed that there was a significant Mæstad and Mwisongo 2009 ). The new financial directors who came after this were all European volunteers or paid expat workers first Karl, and then Joost, the Dutch man from the documentary. The people in between who h term bases were all Norwegian volunteers, and in some cases, volunteers with very little accounting experience. As for whether HLH would lose funding, Malaika told me on the record that they could make no promises, and would make a decision about funding in the coming year. After the official interview was over, however, we discussed at length the ethical issues involved with ceasing funding, and the moral obligation the RNE felt they had to continue funding care at HLH. Fieldnotes, 1 March 2012: Just had an amazing interview with Malaika at RNE most were talking about the RNE leaving and the panic that surrounds it and she said that RNE does have a mor enough money to fund it, and she brought up the example of the Irish and Irish Aid after the

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196 fundraising scheme, asking for different organizatio ns to fund $1 million from one organization at what point does something become so large (like PEPFAR) that it ceases to be an issue of moral obligation and begin s to be a question of tenability? Maybe this is why Haydom is a special case ve worked with for decades, and know well? Aid withdrawal and moral o bligations In addition to the five reviews particular projects and special funds such as the MDG 4 and 5 program (discuss ed in more detail below) and staff and block grants all of which are publically available. Because of problems experienced at HLH in developing more sustaina ble health care. In these requisite and Mwisongo (2009) at CMI outline many of these push and pull factors for funding the hospital. The ethical dilemmas RNE contend with as it contemplates withdrawing aid each granting ro und are also explained here (perhaps as much as they can be publicly). The sense of moral obligation, as Malaika put it, pervades these reports by CMI: Given the long term support from the Norwegian government to the hospital, it can be argued that it has become a duty of the RNE to continue its support at a has arguably entered into an implicit social contract with the people of the long as the RNE wants to ensure cannot exit (Mæstad and Mwisongo 2009:37). the number of beds increased f rom 250 (officially, 400 unofficially) in 2005 to 429 beds in 2009 2012; and the number of outpatients increasing from 57,896 in 2009 to 70,151 in 2012 the increase in salaries

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197 for health care workers, and increasing number of services, maintaining fund ing to support these services is particularly problematic (HLH 2005; HLH 2014). To support these services and fold just in the past decade. In 2004, RNE funds accounted for 48% ; in 2006, 59%; and peaked in 2008 at 70% of total funds (Mæstad and Mwisongo 2009). In the past year recorded 2011 the hospital relied on RNE funds for 59% of its funding. The desire to continue current levels of care, and the desire to withdraw funds , is an impossible equation, CMI writes: Future support from the RNE seems to have been guided by the dual objective of 1) maintaining the operations of the hospital, and 2) the gradual exit of RNE support. These objectives have turned out to be internall y inconsistent, and are likely to remain so in the future. The RNE therefore needs to state more clearly what their primary objective is (Mæstad and Mwisongo 2009:xiii). HLH has been part of the Tanzanian national health system since 1967, and in 2010 bec ame a Level II referral hospital and is attempting to become a teaching hospital as well (Mæstad and Mwisongo 2009; HLH 2014). Increasing integration into the Tanzanian health system, not only for providing services but to receive state funds for operation s, is considered a 40% of all health services in Mbulu District, but receives only 17% of its total funds from the government (HLH 2014), approximately 12 13% of funds from the Tanzanian health basket (Mæstad and Mwisongo 2009:35). Advocating for an increased share of the basket funds to match the percentage of services provided is one avenue HLH is pursuing, though CMI suspects, as written below, that the governme nt is playing a game of chicken with donors: The problem appears partly to be caused by policy regulations from the central government (or lack of such) and partly by lack of political will to coordinate local administrative units, or maybe a game in whic h local governments are trying reflects an attitude that seems to be present all the way up to the ministry level, that the voluntary agencies are able to make their way through support from

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198 foreign sources, so why should the government take financial responsibility? ( Mæstad and Mwisongo 2009 : 35). Finally, depending on expatriate volunteer MDs is another way in which HLH depends on unpredictable and foreign assistance. For much of the time I was staying in Haydom, the hospital had no full time MDs on its regular staff. The few MDs who were on the regular staff were gone for much of the year getting specialist training, some others were busy with administrative tasks, and the maj ority were the ten or so medical school interns from Dar es Salaam who were there for their year internship before taking on a government post somewhere doctor, J akob, that I began to understand how dependent the hospital was on volunteer doctors to Norwegian volunteer doctors, Camilla and Hilde, were discussing how to reorga nize themselves and the few other volunteer doctors to make sure that each ward had a MD to care for the patients. Jakob and Camilla each manned a wing of the general medical ward, Jakob on the male side and Camilla on the female side. With Jakob leaving, and few other new volunteer doctors coming for several months, covering each ward with an MD was, for the time, impossible. Three weeks later, in mid December, I caught an early morning ride to Arusha en route to the coast for my own Christmas vacation. As the Land Cruiser passed by the hospital to pick up more passengers, a friend climbed in and sat next to me. She told me that all the interns had left for their medical school graduation that morning on the bus, and all the other volunteers were headed to Zanzibar for vacation before leaving for home for Christmas. Not a single doctor, she told me, was at the hospital, save for the Medical Director and Assistant Medical Director, who rarely treat patients and whose positions are almost entirely administrati ve.

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199 While this situation was exceptional, it illustrates the trouble with depending on professions students and clinicians who l hours and time off to ensure that the wards are staffed at all times (Wendland 2012). Weekends were particularly empty, especia lly as two and three day safaris to the nearby national parks, Serengeti, Ngorongoro, and Lake Manyara would regularly lure away many volunteers. Despite this, the doctors self regulated their vacations and times away, making sure to keep the hospital sta ffed as best as they could. Several volunteer friends of mine felt immense pressure to do so. V olunteer doctors were typically tasked with working Monday through Friday, 9 to 4 or 4:30, sala eeting to discuss cases and treatment strategies. M any were on call whenever they were staying inside the hospital compound, however, and worked weekends as needed. I n many cases , volunteers ended up working essentially all the time. This burned a lot of p eople out, and with the additional burden of patients asking them for money who could not pay the fees for tests, treatment, a hospital stay or food, the pressure could be overwhelming. HLH also relied in part on the revolving cadre of expatriate voluntee r MDs to step in and help with training and supervising Tanzanian medical interns alongside the other Tanzanian doctors. But with a growing interest in global health in Western universities as well, more and more medical students on global health rotations require their own supervision, and stretch limited time. This contributed to some resentment toward foreign students to teach Danish, Norwegian term

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200 at all except for in this moment. Supervising and teaching Tanzanians, who will stay here in the #3: Millennium Development Goa ls 4 and 5 Program: The Tail End of a Vertical Program Another variation of aid exit can occur among health care programs or initiatives, which are often vertical, multi year, and of limited scale, targeting a specific disease or health outcome for a given period of time. Programs are often housed within hospitals such as HLH, and/or rolled out among many health care centers in the country (and world). The MDG 4 and 5 program at HLH was one such program and was replicated across Tanzania from 2008 2012 (L ange 2013). In 2007, Norwegian Prime Minister Jens Stoltenberg announced the Global Campaign for the Health MDGs, providing five years of funding and support for the 4 th and 5 th Millennium Development Goals in particular, maternal and child health (NORAD 2 011). This program was implemented in five countries, of which Tanzania was one, and provided a significant amount of financial assistance for services such as antenatal and hospital care and immunizations (Kloster 2012). In Tanzania, maternal mortality is quite high 460/100,000 but has been dropping, down from 578/1000 in 2005 (UNICEF 2012; WHO 2013). Maternal mortality is most often associated with home birth, unsafe abortions, obstructed labor, as well as infections, hemorrhages, and hypertensive dis orders (WHO 2013). in hospital births among women in the immediate catchment area, from 2,843 in 2007 to 4,558 in 2008 (Lange 2013:4), and about 90 95% of the nearby population (personal communication, town, was the free ambulance transpor t to the hospital, but also included all payments fo r delivery and hospital stays, C sections if needed, tests, treatments, medications, and the like.

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201 The program at HLH was intended to be for women experiencing problems with delivery, or identified as hi gh risk during antenatal care, though it eventually turned in to one used by many women regardless of risk. The program funding ended at the end of March 2012, though HLH continued to fund it out of its already stretched general hospital budget, keeping th e program running more or less true to its original form. With the laboring mother in the ambulance as one of the first scenes in the HLH documentary, the MDG 4 and 5 program became an important example of the care the hospital can give, and a compelling c ase for donors to open their wallets (mothers and babies always are) (Deloitte 2010). Most women in town (and surrounding villages) appeared to know about the program and made good use of it, especially as they knew the program was slated to end sometime i n the near future. I frequently heard women discussing the ambulance program when planning for their deliveries, and heard a few discuss their fears over what would happen when it was fini shed. In an interview with Maggie , a nurse in the maternity ward, sh e expressed great concern for the coming end of the program, at that time expected to happen in just a few months. Because the program was officially designated as a program for high risk pregnancies or women encountering problems during delivery, she was concerned that without the ambulance program, and free transport and care that comes with it, those women would not be able to make it to the hospital, would likely deliver at home instead, and maternal and newborn death and morbidity would increase signif icantly. Grace was a nurse at the hospital and had many stories to tell of the women coming in to give birth during the time of the program. Because the services were free, she told me, women would call the ambulance to come in whenever they felt any pain , even if it was in the 6 th , 7 th , or 8 th month, to check and make sure everything was fine. Most memorable for me were the stories

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202 of the few mothers who would ask the ambulance to idle in the driveway as they finished cleaning up their houses and getting their kids taken care of before they left for the day or two in the maternity ward. These stories, to me, hinted at two notable thi ngs I recognized about the program: first, these mothers were most likely not the ones the program was, in letter, trying to reach (see also Lange 2013:vii). The hospital staff made use of a vertical program like this one, meant for a narrower population o f women, to extend it to as many as possible, a trick I saw many health care workers employ in other health programs as a way to care for as many people as possible. Secondly, when given the opportunity for free or low cost deliveries, most women in the ar ea will choose a hospital birth over delivering at home with a midwife or traditional birth attendant, even when experiencing few or no complications. In a discussion over dinner one night with Anke, a European obstetrician and researcher who had just ret urned for a few week s to visit, problems with the actual running of the program came out. Having worked for a year in the maternity ward already, with several follow up visits in the meantime, Anke saw that with everyone women of high and low risk, with problematic and problem free deliveries were coming to HLH to deliver the influx of laboring women was overcrowding the wards and overextending the already burned out health care workers and midwives. This overextension, she believed, meant that the wo men the program was initially intended to reach were not receiving the attention in the hospital that they needed, and because of that, the health outcomes of the program were not as promising as she had hoped. A final report on the program indicates that 13,892 made use of the free ambulance services over the course of the program years, a significant increase in numbers than before the program began 177 used the ambulance services in 2007, while 3,206 used it in 2011, the peak year (Lange 2013:3 4). Th is is likely the major reason the program went over budget, Lange

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203 writes, as each trip cost approximately Tsh 70,000 ($50). There was little increase in the number of C sections except for the final year, however, which the auditors write may indicate the deliveries were largely for uncomplicated births, and not as intended (Lange 2013:vii). When the program ends, Anke believed, demand for services in the maternity wards would decrease, as fewer women would come to the hospital to deliver. Those who needed care the most, and made it to the hospital, would get more attention, resulting in better health outcomes for women presenting at the hospital. While the hospital was able to increase the number of nurses in the maternity ward from 17 to 27, it was still not enough, she felt, to contend with the increase in numbers of laboring women. She told me that there are many cases where women in the maternity ward are just forgotten one day she went to the labor ward to check on another patient, and spotted another women who she thought was in respiratory distress and that. This story illustrated anothe r two points I would like to make about vertical programs: the overextension of health care workers (burn out is particularly bad in maternity wards) is a critical issue that underlined nearly all of my encounters with Tanzanian health care, and undermines most every vertical or higher up attempt at improving health care. Finally, within the confines of cases, improving the health outcomes of a narrowly defined populat ion within the vertical program may take precedence over the health of those people who do not fit the criteria for inclusion. These two points, health care worker burnout and the evaluation of vertical programs, are critical challenges in promoting the su stainability of health care, and will be addressed in more detail in Chapter 6 .

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204 #4: PEPFAR in Tanzania: Fueling the Golden Age of Global Health The largest vertical donor program PEPFAR experienced cutbacks in aid itself after 2009. The impacts of thi s funding cut on patients will be examined in more detail in the fifth however, briefly examines the structure of PEPFAR and consequences of its aid withdrawal broadly. In m y interviews, several NGO administrators reflected on the beginning of PEPFAR in Tanzania in interviews, remarking that despite these significant achievements, the initial emergency phase of the PEPFAR rollout was so large, and was conducted so quickly, th at it informant remarked that the fire hose came off when PEPFAR started, and establishing long term effective care. A nother respondent, remembering his own experience as a program officer in Guyana said, country program funding plans were announced. And a fourth respondent candidly noted that for PEPFAR officers, the early days inspired a somewhat cavalier attitude than they knew what to do with Henry, an administrator at one of the global health NGOs in Tanzania, explained that this early focus on emergency rollout engendered an ill conceiv ed focus on quantitative targets, rather than establishing high quality HIV care, which he said hindered retention in long term care for PLHIVs today:

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205 It was not realistic that you could spend so much money, because the absorption capacity of Tanzania is reach your targets. We went too much for quantity, and now we see the results, attrition rates are very high, we still lose a lot of people to follow up, lost to follow up is very high because it was always quantitative targets, quantitative targets, we have to reach so many people, quality was not mentioned. Bush PEPFAR appear, hopefully with PEPFAR III we will get away from these targets sickle cell whatever treatment we have available; or for cancer (where) not realist ic. Put (focus) a little bit more on quality, and a little bit less on quantity. Our health system is not fully ready to implement this over night, and if you do it you will lose quality, you will kill people. As treatment for HIV improves and PLHIVs live longer and longer lives, the total number of people living with HIV (the prevalence) increases as long as the incidence rate (the total number of new infections in a given time) continues to increase or holds steady. Without an HIV vaccine or widespread ac cess and acceptance of effective prevention methods, new HIV/AIDS cases will create increasing, and perhaps untenable, demands on health systems (Garrett 2009). Even with a continued rate of rising HAART coverage, HIV/AIDS is projected to be the 10 th leadi ng cause of mortality in 2030 (WHO 2008). The burden of disease from HIV/AIDS without rising coverage, or with dramatic cutbacks in treatment and funding, will be significantly higher. increase, particularly as HIV prevalence climbs (Whyte et al. 2006). The provision of free ARVs in many PEPFAR countries may similarly be scaled back or eliminated. Medecins sans Frontieres (MSF) reported in 2009 that in the wake of th e global crises, HIV+ patients are increasingly being turned away from health clinics, and doc tors and health care workers again have and Maclean report that:

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206 Some implementers have been told that they must cease enrolment immediately, others that they must initiate new patients with caution, and still others that they the death or loss of patients already receiving treatment (2009:7). Whyte et al. (2006) also write of drug rationing, treatment inaccessibility, and methods of o and health care workers determine who will be recommended for treatment. The blanket sign is a of a patient based on the quality of bed linen and other supplies they bring to the hospital (patients in many East African hospitals are required to bring in sheets and blankets, food and other supplies when interned). Patients with higher quality linen, food and supplies are considered more able to afford life long treatment and more likely adhere to complex drug regimens, and therefore will be recommended for treatment (247). Families are also sometimes faced with difficult decisions about who m in thei r family to treat if multiple people are infected, and what the long term family priorities are (Whyte et al. 2006). Whyte and colleagues interviewed a o you pay for ARV medicine for a sister forever and give up paying school fe and Maclean (2009) report that family members sometimes share ARVs if they cannot afford additional treatment, decreasing the effectiveness of the medication, increasing disease progression and potentially accelerating drug resistance. Finally, PLHIVs who are unable to support themselves likely understand the enormous burden they place on their families if they cannot access free health care. Whyte et al. (2006) families and friends for complex and expensive medical care (252). Others may interrupt their own treatment to save money,

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207 stopping and re Trust in biom edical care and health systems, and hope in the possibility of life long care may also be sacrificed with cuts to HIV programs (Biehl 2009 ). Trust and hope can be some intangible outcomes of efficient and accessible health care, and are powerful motivators for hope that HIV is manageable, and may further motivate patients to adhere to treatment regimens, or to form support groups or cooperatives. Seeing that their chi ld does not get HIV when enrolled in HAART through a PMTCT program may inspire hope that women can have more children. Hope in ARV effectiveness and HIV treatment is also shown to decrease stigma, as HIV becomes increasingly viewed as a chronic disease rat her than a death sentence (Castro and Farmer 2005). This hope in successful treatment may also increase voluntary counseling and testing uptake among general populations, increasing the number of people who are treated and therefore less likely to transmit HIV to others (Castro and Farmer 2005). Alternatively, losing hope in care and treatment, or the predictability, availability and accessibility of ARVs, negatively affecting adherence to treatment regimes. It may also decrease the number of people willing to be tested, influence PLHIVs to not disclose their status and increase social stigma. In these conditions, HIV may more easily continue its inexorable spread. Both these patterns loss to follow up and decreasing testing and treatment appear to be ha is explained next. #5: PMTCT at HLH: Decreasing Enrollment and Loss to Follow Up After Funding Rolls Back Another kind of aid exit can happen within the confines of a vertical program as well, as gradually parts and pieces of a program can be scaled back as funding slowly diminishes, or as

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208 clinic as a whole, was the end point for all the other forms of aid withdrawal described above it all came to a head here, at the HIV clinic at Haydom. Funding for the PMTCT program at HLH came from three sources: PEPFAR, which was experiencing decreasing funds as described above, and via two funding streams from the Royal Norwegian Embassy through the MDG 4 and 5 program, which ended in early 2012, and end in 2014. Over the course of my research, I was able to see how decreases in donor aid from these sour ces were experienced on the ground, and particularly by those most vulnerable to decreases in aid rural HIV+ women. In 2009 when I arrived in Haydom I met Carolina, a Norwegian PhD student and PMTCT researcher who graciously agreed to take me under her wing, show me around, and shadow her for the six weeks I was there conducting feasibility research. She also introduced me to Mama Danieli, the head nurse of the PMTCT program and the CTC in general, who took as excellent care of me as she did her patients . In 2009 the PMTCT program at HLH was like a little oasis of health care it was so well funded that one of the health care workers came out of retirement to work (for a higher salary) for the program, and while the clinic was frequently crowded with peo ple, no one seemed particularly burned out or as exasperated as I had seen others in other wards. As a part of this program, more accurately called PMTCT+ because of its additional supports beyond just ARVs for mothers and babies, mothers received a lot of help, beginning with ANC at the hospital. In the kliniki ya wazazi (clinic for parents, or reproductive health clinic), all pregnant women are offered an HIV test, which most agree to, and if they have a positive diagnosis, this is where PMTCT really begi ns. First, they are referred to Mama Danieli

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209 in the CTC to begin ARVs, which at the beginning is directly observed by one of the nurses, usually Tabitha, who most often sits in the CTC dispensary and counsels patients on ARV adherence, managing side effect s, etc. All new CTC patients are observed taking their ARVs everyday for the two weeks, not only to help them get used to the routine necessary for effective treatment, but also to make sure they are given the most effective ARVs with the fewest side effec ts. After two weeks, the patient receives monthly supplies of ARVs, but must return each month for a check up and CD4 test, and a new prescription or refill. PMTCT women follow this routine as well, but when the program was in its heyday, they also receive d food support if After the baby was born, mothers were instructed to exclusively breastfeed for six months, and k (subsidized by HLH), which is safer when introducing other foods. Additionally, they would receive more food support for them (and their families, inevitably), home based care, bus fare to come back to the CTC once a month, and meetings once every three months with other HIV+ mothers in their area (traveling meetings) where nurses would talk about how best to do adhere to treatment, changes in treatment guidelines, and to act as support groups. Together, all these components reduce mother to child trans mission considerably, and at HLH, reduced transmission from up to 50% (the statistical mean, globally, with no intervention) to just a little over 4%. In wealthy countries, such as the US, transmission hovers around 2%, but that includes routine C sections and exclusive formula feeding, the latter of which puts babies at at much higher rates than HIV (WHO 2009).

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210 Like I outlined in the introduction, the progr am at HLH was so exceptional that Carolina needed to seek out other PMTCT programs to get a better idea of what PMTCT care looked like for most Tanzanians, and ended up going to the government Regional hospital in Babati. My original research plan focused on this PMTCT program. As mentioned in the introduction, I intended to follow women as they transitioned out of the two year program, tracking their health and observing how they coped with the loss of PMTCT program support. But I did not predict that the program would be dismantled during the year and a half between pre dissertation fieldwork and my return. From my fieldnotes in 2009, I observed a PMTCT program in enviable health, providing the supports outlined above. When I returned in 2011, the situatio n looked quite different, as detailed in the introduction. I conducted 75 structured interviews with women at the CTC who had, at some point in the past nine years, been enrolled in the PMTCT program at HLH. The interview questions walked respondents throu gh their experiences in the program, the kinds of support they received, what they felt was most important and useful, what was less important, how they keep their families healthy without support from the program, who m they may be able to seek other help from, and so on (see appendix C for interview questions). Over the course of these interviews, the fluctuations in the program emerged. Women in the PMTCT program at Haydom Hospital, like Maria and Neema, reported considerable variation in the care and su pport they received from the CTC over time, which followed the 2009 appeared to be the best years for getting the most support from the program, which were also the p eak years of funding for PEPFAR programs (PEPFAR 2013a). The care women received also depended on how many times they had been treated through PMTCT the first

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211 time going through PMTCT, women received as many services as were available and were prioritize d by clinic staff. The second time, or any times beyond that, services were cut back. Despite these scaled back services, most women I interviewed were still quite happy with the care and support they received. ARVs, medications to treat opportunistic infe ctions, and hospital care, were, and currently still are, available for no cost to all PLHIVs at Haydom Hospital. What was also becoming apparent through these interviews was a patterned way of how eem to expect a lot, and were thankful for whatever they could get from the hospital, though this could be because they did not know me very well. The program support a majority of women missed was the money for bus fare, which for some women living far aw ay can cost upwards of Tsh 10,000 (or about $6 7), which is 1/10 of the monthly salary for a day laborer. Many also missed the food support, and asked me for money for food, or to talk with HIV clinic staff to make an exception for them and provide an extr a sack of corn. Mama Danieli, at one point, urged me to plead with PEPFAR administrators for more money for food provisioning, as she felt overwhelmed with people in need. As I learned through the village interviews I conducted, however, many patients wh o sought health care at the hospital did not feel like they could complain about unsatisfactory care or services, or if they encountered negligence, corruption or malpractice. This is in large part because many felt that lodging any complaints could negati vely impact their quality of care, particularly in a rural area, and for patients needing long term care. I suspect this could have occurred in these interviews as well, as most clinics and dispensaries in the immediate area refer PLHIVs to HLH for ARVs an d care, so there are no other options for care should problems with health care workers arise.

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212 Many women I interviewed, however, sought out alternative treatments for their HIV in indigenous and faith healers, who often claim to be able to treat, and some say cure, HIV. Twenty two of the 75 mothers I interviewed (29%) in the PMTCT program went to see one faith healer in particular a retired Evangelical Lutheran pastor, Ambilikile Mwasapile, known affectionately as Babu Loliondo (Babu: grandfather in Swah ili). Loliondo region is in north west Tanzania, where he lives and performs his healing, and as of 2012, had allegedly seen four people would wait up to a week to see Babu, and to drink a cup of his tea brewed from the black currant tree, locally known as mugariga ( Carissa edulis ) for Tsh 500, or about 20 cents. Reputed kikombe is believed to be particularly powerful in healing five principal chronic diseases: HIV/AIDS, cancer, diabetes, asthma, and high blood pressure. Absolute faith in the power of drinking from the cup is essential for the full ikombe is incompatible with any None of the mothers I interviewed appeared to have stopped their antiretroviral therapy, despite seeing Babu. Many of the others who did not go wanted to, but could not afford the trip; round One woman told me she sold two cows to pay her way; it cost her Tsh 350,000 ($215) in bus fare for her and one of her children, and for food along the way. Another told me the trip took a week of driving and waiting in line to take the cup, during which she sat in a bus the whole time. Many other PLHIVs at the clinic did appear to stop taking their ARVs Mama Danieli est imated that about 10 15%) were lost to follow up in the

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213 precipitously from a high of 65 in 2011, to a low of 42 in 2012, or 35% (see Figure 5 2 ). Figure 5 2 : Number of women enrolled in PMTCT, 2008 2012. care workers, NGO leaders, and interested participants went to see Esther and another NGO was a foregone conclusion Health for All is critical, though we should still not lose sight of HIV care and opinions that it was the result of widespread distrust in t he Tanzanian health care system, and perhaps biomedicine in general. One outspoken Tanzanian critic of the public health care system told the group that he thought the low supply of good medical care drives the low demand for services, and Babu was an outc ome of this. In the final weeks of my time at HLH, as I was scrambling to gather up all the reports I

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214 for 2010 d as a funding source beyond 2013. PEPFAR, up to then, was the major donor of HIV care at HLH. Soon after, I interviewed one of the accountants for the hospital, who told me that PEPFAR would no longer fund staff salaries beyond 2013, though there would be some money for supplies, and ARVs would still be free from the government (via The Global Fund). Conclusion These several cases of aid withdrawal paint a picture of overall precariousness in the health care sector, and the medical insecurity experienced by patients, that pervaded nearly every level I encountered during my fieldwork. At the same time, however, there was widespread acknowledgement of this and concern for rectifying it, in policy if not quite yet in practice. These policies were largely disc following chapter. The most important outcome to note during this expansive process of aid withdrawal, however, is the dramatic increase in PLHIVs who were lost to follow up (10 15% , per Mama (from 65 to 42) during the same years of the steepest funding decreases. At the same time, the ntion, and particularly his advertising of a cure for chronic diseases, including HIV/AIDS. Unlike depending on unpredictable funding streams for essential ARVs, a cure is forever. I did not follow faith healing or the contemporaneous rise in chronic disea se faith healing closely while in the field but I feel deserves further research. It could indicate an important, but in some cases perhaps life threatening, coping strategy to managing the overwhelming feelings of uncertainty that accompany the precarious nature of HIV/AIDS programming and funding.

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215 CHAPTER 6 HEALTH CARE SUSTAINABILITY : PRIVATE ORGANIZATIONS AND HEALTH SYSTEM STRENGTHENING IN TANZANIA Many Tanzanians I worked with over the course of my fieldwork experience wide ranging insecurity and u npredictability throughout their lives. Even those with formal employment in the health or NGO sectors that I knew well, their livelihoods depended on the large foreign aid apparatus operating in Tanzania, an apparatus that could change dramatically and ra pidly, as I described in the previous chapter. Many people I encountered in my fieldwork patients, PLHIVs, and health care workers are largely unable to depend on long term donor funded health care. This is in part intentional, perhaps, because per the (Swidler and Watkins 2009), resource on anything. So instead of providing the materials and resources that are so often lacking in clinical settings, donors overwhelmingly s upport mechanisms that are intended to discourage principally, workshops and using volunteer labor (see also Maes 2012). k projects that (donors believe) recipients will be able and willing to sustain after the donor and Watkins 2009:1184). The result is a largely ineffectual and paradoxical system of aid and care. Not only does effects on local communities and actors community members, patients, NGO volunteers, and Swidler and Watkins keeping talented volunteers working for little or no salary in the hopes of eventually finding employment, and to keep donor dollars flowing to projects that make claims of sustainability (however d istant from reality). In the absence of many long term

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216 proven or disproven. In the meantime, national elites and ex pat NGO workers keep their jobs like Ferguson found in Lesotho in his early work The AntiPolitics Machine (1994), the intentions of NGO programs may not always be forthright. As I describe in this ch apter, program functions, sustainability strategies, and objectives can at the same time undermine the functioning of the health system already in place. Most detrimentally, perhaps, it can encourage an internal brain drain of government health care worker s to more highly paid NGO desk jobs, and can take health care workers out of the clinic on workshop and training circuits (see also Sherr et al. 2012; Manzi et al. 2012). I also examine the strategies that programs and institutions enact to pursue their ow or self sufficiency, which can in turn result in increasingly limiting services available to patients and populations by scaling back the services that are available, or increasing the cost of care. I highlight the impacts the se processes have on health care workers in particular, as the human resources crisis is the biggest hurdle Tanzania must overcome to put in place an effective and efficient health system. This chapter examines these processes and outcomes using the large global health initiative PEPFAR and the donor funded health institution Haydom Hospital as principal case studies, as they try to establish sustainability in a context of potential or expected aid exit in Tanzania. In the first part of the chapter , I focus on the shifts in policy, programming, and funding a global health initiative like PEPFAR undergoes over time as it works to transition from an emergency initiative to become more sustainable. I begin with an examination of the emergency stage of the PEPFAR rollout and its transition to building a sustainable country program, and how this transition was operationalized. Next, I examine outcomes of the

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217 implementation of PEPFAR and its transition in Tanzania: the contributions PEPFAR and other vertic al program funds and programs have had in building up the health sector, and the internal brain drain they have in part caused. e and independent from Norwegian aid, which included implementing user fees and relying on volunteer labor, to prevent the scaling back of services. I conclude with an preliminary examination of how health care workers conceptualize sustainability in healt h care contexts, which map on to the contours of the health care system in Tanzania itself vertical programs on the one hand, and the health sector on the other, with the principal goal sustainable good population health a still distant imaginary, an d believed by nearly everyone to be impossible. Methods Data from 32 semi structured interviews in particular are presented in this chapter, including those conducted among health care workers and administrators who were affiliated with PEPFAR in some way , or familiar with its transition to sustainability within the Tanzanian health system. Twenty of those interviewed were administrators with PEPFAR or other US government agencies, and present and former employees at implementing partner agencies. The rema ining ten, along with those former employees of PEPFAR agencies who had moved to new jobs, worked as health care workers and administrators in HIV, maternal and child health, family planning, intensive care, hematology and tuberculosis clinics and programs . Most informants were Tanzanian (21, or 70%), four from the United States (13%), four from Europe (13%), and one from Ethiopia (3%). Only two informants were employed by the Tanzanian government or worked exclusively within the public health sector . Most others (80%) worked for Tanzanian and

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218 international NGOs that integrated services with the public sector, such as the PEPFAR implementing agencies, or at Haydom Hospital, a donor funded mission hospital. Interview questions focused broadly on sustainabili ty in health and health care, and more various stakeholders. I sought to better understand how people working in health care in Tanzania conceptualized sustaina bility as it relates to health and health care, and asked questions like, and what were the principal challenges impeding a sustainable health system and the stra inquiry, I was able to witness these processes in action, and document how multiple stakeholders adapted to budget cuts, and planned and implemented strategies to bui ld more sustainable programs. Human Resources, Capacity Building and Health System Strengthening: Fun damental Barriers to Building Sustainable Health Care in Tanzania de velopment assistance for health, which translated into dramatic improvements in global health, and 2) rise in the number of NGOs implementing global health programs and services, and their emergence as critical stakeholders in funding and programming (Mess ac and Prabhu 2013). The in 2000, with a focus on ending poverty via eight principal goals four of which are explicitly health related eradicating hunger, reducin g child mortality, improve maternal health, and combat HIV/AIDS, malaria and other diseases. The golden age was also marked by a surge in donor assistance for health, from 5.59 billion in 1990 to 21.79 billion in 2007 (Ravishankar et al. 2009). A principal reason for this increase in funds was to combat the HIV epidemic, which was

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219 (PEPFAR 2009). This funding increase came from many sources, including the Gates Foundati on, the WHO, the UN through the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and through ever PEPFAR was established in 2003 by President Bush, with $15 billion dedicated to its rollout. The scale up of PEPFAR was impressive as well by 2010, $46 billion had been committed to HIV, as well as in much smaller part to malaria, TB and maternal and child care. T his increase in funds played a significant role in getting millions of Tanzanians on ARV treatment, which remains free to all those who need it in Tanzania. year strategy focused on the transition from an emergency response to the promoti on of sustainable country programs. To do so, PEPFAR and each target country created a Partnership Framework (PF) that outlines how a sustainable HIV response can best take sition an emphasis on country ownership, capacity building, and health systems strengthening, which falls in line with the recommendations of the OECD through the Paris Declaration and Accra Agenda (PEPFAR 2009, 2010; OECD 2013). an existing Tanzanian NGO that can take over service provision for the regions the Track 1.0 partner manages, or to create a new NGO. Those that started their own Tanzanian NGOs were MDH which created Management and Development for Health; ICAP established Tanzania Health Promotion Support (THPS); and EGPAF started the Ariel Glaser Pediatric AIDS

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220 Healthcare Initiative, or AGPAI. AIDS Relief chose to work with the already existing Christian Social Services Commission (CSSC), and FHI chose numerous small NGOs already working in HIV care. The Track 1.0 and Tanzanian partner NGOs were all in varying states of transition in 2011 2012, with one American NGO preparing t o give over all operations to their Tanzanian partner, a few slowly handing over responsibilities on a district by district, and region by region, basis, while a couple others were just in the beginning stages of mapping out their transition strategy. I di scussed these processes one day with Eric, an American who worked with PEPFAR in the country office in Dar es Salaam. For the time being, he told me, Tanzanian partner NGOs were funded predominantly by the US government through the CDC, Department of Defen se or USAID. A separate PEPFAR funded project, the countrywide blood safety program, was the closest to being transitioned completely, and that was being handed over to the Tanzanian government. This program was ready for transition, Eric said, because the program is: at a maturity level, and the government is at an investment level, where they can that strictly government funded. But you know, Tanzania does not have the resource s that a lot of other countries do. So for some of the middle income countries, the transition plan is much more condensed. But for Tanzania, the timeline is much more spread out, because we recognize that the resource pool Informants disc ussed with me their perceptions of the potential for PEPFAR to develop sustainable country programs. Regarding the transition in general, one respondent noted that as an emergency intervention, PEPFAR and is currently that the differen be sustainable were discussed at length among the partners as well. Those who chose to start

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221 their own Tanzanian NGO were sometimes criticized for adhering to the letter, but not the spirit, of the transition. Because many of those newly created NGOs were staffed by people who had worked for the Track 1.0 partners for years, and in at least one case just moved to a new cubicle ew NGOs were, or if they were just the same American NGO, but run by and the relationship of the names of the Tanzanian NGOs to their American partner NGOs o ne recognition among the global health community as being affiliated with that particular American partner. Additionall y, in a health system already populated by numerous international and Tanzanian NGOs, adding more NGOs into the mix was seen to be further complicating an already complicated, disjointed, and largely parallel health system, a charge many other anthropologi sts have laid against PEPFAR NGOs (Pfeiffer 2013; Mbacke 2013). Nevertheless, the newly created NGOs were staffed and administered by Tanzanians, who were very well trained in HIV care, treatment, policy making and programming, and were especially qualifie d to head up an HIV NGO. Not having to pay for expatriate staff and outside consultants, as the Track 1.0 partners did, also saved considerable money, informants told me. Laurie Garrett estimated that anywhere from 30 60% of a PEPFAR t goes to overhead, on average (Garrett 2008). Overall , because of these similarities and continuation of business as usual, one informant told me not to be fooled, that One organization, however, was considered by s everal observers to be conducting the -

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222 step plan for transitioning program operations to a Tanzanian NGO. First, they told me, their organization worked to ide ntify NGO partners they could most effectively work with, and second, conducted several internal and external evaluations of those NGOs to assess their ability and readiness to take over HIV care, treatment and prevention services. Third was the developmen t of comprehensive capacity building plans with the new partner or partners, and on a district by district basis, with the ultimate goal to hand over respons ibilities for entire regions to these Tanzanian NGOs. In this case, however, the CDC urged the organization to transition more quickly to their partner NGOs. As Anne outlined, So instead of three districts, we have to transition a whole region, which is a third stage of our plan, capacity building, is absolutely critical. And so, we found ally good at putting plans together, but not so great at following you need to build your capacity so you can be doing holding. Health System Strengthening Like Anne noted, capacity building is a critical, but also extremely difficult, step to promoting sustainability in health care. For successful implementation, the initial rollout and scale up of PEPFAR needed to accompany efforts in health system strengthening (HSS), which many recognize as becoming even more important now in a trans ition to sustainability (Pfeiffer et al. 2008; Goosby et al. 2012; Palen et al. 2012). Section 204 of the PEPFAR 2008 reauthorization legislation specifies that combating HIV, malaria, and TB hinges on Institute of Medicine emphasizes less direct support

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223 of PEPFAR (IOM 2013a). Ap proximately 10% of the annual PEPFAR budgets were allocated specifically to health system strengthening in PEPFAR II, including funds for laboratories, strategic intelligence, and systems development, which include financing, capacity building, and supply chain management (PEPFAR 2012; Palen et al. 2012). As noted above, HSS also typically includes: investments in infrastructure building, equipment procurement, and in human resources for health; expanding primary care; improving medical education and skills training; establishing a range of financing strategies; and improving service delivery, information systems, reporting, monitoring and evaluation (WHO 2007; USG 2008). These tenets underline some core principals of the US ative (GHI), of which PEPFAR is now a part, which expands the focus from an HIV specific initiative to include other important health goals, including improving maternal and child health services, and programs to combat seven of the neglected tropical dise ases (GHI 2013). Clara, an administrator at a newly created Tanzanian HIV NGO with almost a decade of experience working with one of the six original implementing agencies, commented at length about several benefits PEPFAR in particular had on improving t he health sector. Improved management of care, particularly for chronic diseases; monitoring and evaluation of health programs; and the expansion of infrastructure, commodities and equipment, she mentioned in particular. Clara also noted that the HIV speci fic model of care that was implemented in the early years of PEFPAR broadened over time with GHI, and as policy makers heeded the advice of Tanzanian practitioners.

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224 A strategy many administrators employed, with some limited success, was the use of diagona l programming. specific results important strategy for continuing to treat and prevent HIV/AIDS, as well as improv ing country level capacity and health systems management in the context of HIV/AIDS. Integrating HIV and primary care health services, further, may be an important first step to developing more easily accessible, sustainable health care systems (Pfeiffer 2 010; Bendavid and Miller 2010). Price et al. (2009) and Pfeiffer (2010) both write of how diagonal HIV programs and services improved other primary health care services in Rwanda and Mozambique, respectively, by integrating HIV and primary health care serv Lucia, an MD, and medical school professor at the national hospital in Dar es Salaam, diagonal program at their hospital: HIV patients are not just isolated , they will have complications, so outpatient clinics should be outpatient clinics for everyone , don as the HIV money goes down whatever other funding that comes up will still be part of the whole system. You have to strengthen the whole system. And we have a national lab now! And my colleagues, when they come, they are envious, and even (those) from outside (countries), they are envious of that lab Internal Brain Dr ain While PEPFAR contributed to infrastructure and management development, monitoring workers from the public health sector in Tanzania to the private NGOs imp lementing PEPFAR

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225 programs (see also Pfeiffer 2008; Sherr et al. 2012). This internal brain drain, many respondents noted, is particularly damaging to the health sector in Tanzania, which has a severe shortage of health care workers, and presents a critical obstacle in building up a sustainable health care system. The internal brain drain happens in two principal ways in HIV program contexts, Clara told me. First, health care workers from primary care centers or other vertical programs or wards are recruite d to work in HIV clinics, providing treatment, counseling and prevention services for a growing number of patients, leaving fewer doctors practicing in primary health care centers. This was an outcome of the HIV epidemic itself as well, however, as the inc reasing number of patients with HIV presented in hospitals and clinics, and the increasing number of health care workers with HIV limited staff available to care for them (Iliffe 2006). What Clara regretted in particular, however, was that this tends to le ad fewer doctors to aspire to work in primary care in general, which she believed to be essential to the functioning of the health care sector. Secondly, and what many informants considered particularly corrosive, is the recruitment of practicing health ca re workers, particularly MDs, from the public sector to non practicing (or infrequently practicing) desk jobs at NGOs. Esther, a Tanzanian OB/GYN and former medical school professor herself, and Lucia spoke at length with me about the internal brain drain and its effects on the Tanzanian health system. Both believed that the internal brain drain was crippling any effort to create a sustainable system, let alone an effective one at present. As Lucia said, the thing that makes me weep every month, without a doubt, is the good people we lose to NGOs. T he internal brain drain is bigger than the external brain drain re not working at (the national hospital), so not working in

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226 Esther speculated that international NGOs actively recruited Tanzanian doctors in part to push through their desi red changes in medical treatment and treatment guidelines, which they felt would be more palatable to the Ministry of Health and Social Welfare coming from a Tanzanian. At one particular (non trea there is The brain drain leaves its mark on medical schools, too. Despite the current push to educate a legion of health workers in Tanzania as part of health system strengthening efforts, the overstretched medical school faculty members are seeing some of their most promising colleagues leave for the private sector or to go abroad, taking with them their years of specialized training. Lucia was concerned for the future of her university when the head of her department all the people he has trained are inishing the chances that his students will be around to, in turn, train the next generation of doctors. To help fix this problem, Esther recommended that NGOs work with the public sector in a partnership sharing health care workers. In her vision, health care workers who work for NGOs are posted in public hospitals and clinics to treat patients part time, leaving the rest of their time to do policy work and program planning with the NGO. This way, NGOs would be contributing to health system strengthening in its most needed form supporting health care workers in the public system. Medical Education And Accreditation A fundamental strategy to building health care capacity is expanding medical education, supervision and training for all health workers, and improving the quality of education for all Tanzanians across the board. With the increase in the number of medical students, however, the

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227 student to teacher ratio is significant there is an estimated 74% shortage of staff at health training institutions in Tanzania (URT 2008). Lucia and Esther believed this shortage led to poor training and medical school educators stretched very thin. As Esther told me, E : S o the thing that we lack, is protected time for teachers to teach, where they're not expected to do something else, like research or exams, or something like that. So when you doing clinical work, it's a full time job. And then I'm expected to teach 6% of the time because about 6% is clinical teaching but it overlaps with the time of clinical service s provision because there's not enough of clinical service provision. So if a ward round is not run by a specialist, then the teaching doesn't happen for senior residents. Now in (three Dar es Salaam) hospitals, they have only AMOs, they do service ward ro unds so interns don't get taught. So when I was being trained, I had two people, and there was a senior resident with us, and we have ward rounds. So there was constant teaching, constant teaching so when we finished we were really competent. But right now the senior resident is so busy doing service provision because he has no one else and he is also missing out on teaching because he's missing the person above him. M M : S o they're doing clinical work, just having students watch and is that pretty much it? E: Y eah, and there are too many (students). Because the government has increase (the number of students), we need more doctors, so we (the government) increased it by 400% M M : D id you say that you have 12 students yourself? E : Y eah, and then how can you start doing demonstrations and one on one, and maximum you do and bedside teaching is six, maximum! And we are doing 12. You know, and so then and then you have a queue waiting outside so it's just not conducive. So we are compromising the quality of t he product and after that, so we have hospital M, which is the best; the interns I see at hospital A and hospital MW are from private medical schools, Intu and Kyruki, they don't have a clinical background. So they are even less exposed. An additional pro blem Esther mentioned was the lack of accreditation, particularly from these private medical schools, and of continuing medical education, which also contributed the poor training, and poor practice, of Tanzanian doctors. E: We don't have a system of acc reditation, and we have certain people that can pass through the gaps. [For example], we have an intern from Botswana, and another

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228 one who trained in Russia, and I asked her, you know so you know how to do (?), "No, we were never taught that" M M : T aught w hat? E: H ow to do basic midwifery when you are in the labor ward, (she said) "oh we were never taught how to measure contractions, and we were never taught C sections, your students are so lucky!" and I said "what would you like to learn?" But, how do you start? She's actually the one running the ward when I'm not there, making the decisions, and she doesn't know the basic skills! So it's quite scary. Trainings One principal strategy for sustainability and capacity building in particular, is the implemen tation of off site training for health care workers. Currently, poorly planned NGO trainings have populated the health system, taking the already too few health care workers out of the clinics and hospitals and placing them in what can end up being a never ending revolving cycle of trainings in various new skills and with various new technologies. Manzi et al. (2012) conducted an assessment of 24 dispensaries and clinics in five rural districts in Southern Tanzania, looking to document staff levels and prod uctivity. Among their findings, they discovered that on average 38% of available staff were out of the clinic or hospital for seminars and long term trainings. In addition to those on leave and those out of the office on official travel, clinics were on av erage staffed at only 44% capacity. When I came to Tanzania in early March 2011, Esther was just starting to coordinate and plan curriculum for a series of maternal and neonatal health workshops for nurses and midwives in the government clinics and hospita ls in Dar es Salaam. The goal of the workshops were to bring people up to speed on the current guidelines for safe deliveries and emergency care to help bring down the still high maternal mortality rate ( 460/100,000) , and target skills for particular perva sive negative health outcomes, like preeclampsia, fistula, and post partum hemorrhage

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229 (UNICEF 2012; WHO 2013 ). Part of the problem, Esther explained to me, was that many of the nurses and midwives at the lower in maternal and neonatal care in years, and did not have the confidence in their skills to deliver babies safely, like believed, women in labor who present at the clinics are most often referred to the hospital to deliver there instead regardless of how labor is progressing, causing serious overcrowding in the l argest hospitals . trict Medical Office and another large, international NGO to run the trainings. I sat in on several days of these trainings, . W e sat around a large con ference table, looked at a few P owerpoint slides, and someone at nearly all times manned a large flip chart at the front of the room, writing out important notes that we would tape to the lengt hy new guidelines written in complicated, English medical jargon. Nurses from each clinic were responsible for reporting to the group the results of their internal monitoring of the guidelines; most did not speak English very well, and I suspect a few spok e very little at all. The woman running the workshop, a Tanzanian working for the international NGO, spoke in English almost entirely the first few days, despite the obvious language difficulties. Esther would interrupt her frequently The daily workshop schedule included tea around 10:00, a large lunch, and then an afternoon snack before breaking for the day. Every participant received per diem, enough for a hotel, money to buy dinner, with a significant amount left over, I imagine . Like Esther explained, most people participating in the training live in Dar anyway, so they just pocket the money or

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230 stay with relatives. Per diems are a critical part of the training culture, and are arguably the principal reason people participate (se e also Swidler and Watkins 2009). Trainings are conducted for a variety of reasons, perhaps most importantly to serve as continuing medical education Additionall y, trainings fill gaps in medical school curriculum and quality. In service trainings are popularly promoted by donors and popular culture (Swidler and Watkins 20 09). Some of my informants outlined another critical problem with the paid training model, beyond taking clinicians out of the clinic. Because the allowances and per diems for trainings are y thought that people would not update their medical skills themselves without it, leaving what one NGO administrator said many everyone, considerable competitio n arose over who went to trainings, and who stayed behind to work in the clinic or hospitals. Another friend and informant, Robert, worked as an MD with the Tanzanian government, and was vocal in his interview with me about the deplorable state of trainin gs, and salaries as I can't train everybody. Now the problem is if you train just a few, the rest who have not been trained will say 'no, I'm not doing it workshop). Additionally, he said, Health care workers spend two to three months moving from one training to another. One of the things which has really affected the health sector is all these trainings, because people have been moving so much, they don't stay even in the hospitals, sometimes they move from a TB training to an HIV training, and then from there they go to a laboratory HIV training, and then from a laboratory HIV training they go to a pharmaceutical HIV training.

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231 This fear was also supported by a story related to me by Esther, who, in addition to training trainers in maternal and child health workshops, visited hospitals and clinics for in service training in the maternity wards. S he related to me that considerable resentment was and thus those who learn the guidelines, and receive per diem, and those who stayed behind to work in the hospital, without a pe r diem. What shocked her was that some health care workers who stayed the implication that they were not their responsibility to carry out, because they were not paid to learn th em. She also told me that because she herself was conducting a revolving cycle of trainings in different hospitals, she could not enforce the new guidelines in any way, or supervise practitioners for any length of time to ensure the new skills were correct ly employed. One trainee Esther encountered doing what we always In a lengthy critique of the training model, Robert explained to me that he thought the expectations for Tanzanian doctors should be much higher, and being paid to do something that should be a regular pa like staying up to date with continuing medical education was at the uni versity, I used to have a professor for internal medicine, a very well known professor in Russia. He used to tell us, 'when you're a medical doctor, every single day of your life, you have to read. At least ten pages of something new, at least! Ten pages o f something new in the medical field. Whether it's a then you learn new stuff every day in your life. So imagine, you know, that is the spirit of other countries! But here, every year, or it's like every six months, you have to be trained to do your work. But that's wrong!

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232 Salaries Nonetheless, Robert and many other health care workers I interviewed explained at length that the work they were asked to do was not nearly compe nsated enough (see also Bech et al. 2013; Sullivan 2011). As higher salaries offered to staff at NGOs fueled significant internal brain drain, the staff practicing in the health sector were increasingly overburdened. Over time, the topic of salaries, and p erceptions of value tied to salaries, generated heated interviews and strikes erupted over the course of several months toward the end of my fieldwork, fueled principally by anger over low salaries, few allowances for housing and transport, and stoked by continuing deficiencies in equipment and resources . During these strikes, however, patients and communities were hit hard as hospitals effectively shut down a nd patients needing immediate care were turned away. Robert, himself a Tanzanian MD and administrator who works in the public system, discussed some reasons behind the strikes, and the diminishing morale doctors in particular are feeling: Most of the doct the least paid! All these other students who were mediocre performers (in school) ecause they are working in another system, like the private sector or a bank. Doctors are not paid commensurate to their job demands and need for continual education and training as well, he believes . Everyday new things come up. But you do all these new things and the salary is less. When you are a specialist and at the end of the day you are earning $600 (a In response to these concerns, doctors went on strike once in January, and again in June and July 2012. The doctors on strike (of which Robert was not part) made several demands: a

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233 starting salary of Tsh 3.5million a month (about US$ 2,150) for new doctors (current starting salaries are about Tsh 950,000 or about $600), a ris k allowance of 30% of their salaries, a housing allowance of 30% of their salaries, health insurance, an increase for on call allowances, and an allowance of 30% of their salaries for transportation. In a televised speech , addressing doctors and the public these demands, a new doctor will be earning TSh 7.7m (about $4,800) per month. As a result, 2 012a). A few months later, frustrated with the persistent strikes, President Kikwete noted that twice as much as graduates who start employment in the civil ser 2012b). ong the Tanzanian public. In an opinion article, published in mid "I will cross to some other professions such as Marketing and do my MBA so that in just one year I can earn thrice o r twice what a medical doct or who is a specialist can earn " (Tanzania Daily News, patients waited, with many dying in empty hospital wards. The leader of the Medical Association of Tanzania (MAT) was kidnapped and tortured, allegedly by the Tanzanian government itself, which President Kikwete vehemently denies (TDN 2012b).

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234 In addition to continued frustration over low salaries and faulty equipment and transportation is no doubt in part an outcome of the large population of expatriate NGO worker s who regularly receive all these things. Working side by side with Tanzanian doctors earning significantly less, with little or no supplemental income for housing and vehicles, seemed to have numerous effects. First, the inflation in housing costs, parti cularly in the ex Tanzanians out of those neighborhoods. Desire to live in these neighborhoods is high, yet largely remains aspirational, as these neighborhoods are regularly exempted from scheduled, revolving brownouts; experience less traffic; and have more paved roads; and are largely safer. Second, prices for everything are increasing, not only housing, but also for food, gas, and schooling, requiring much more money, which salaries did not adequately make up for (Figure 6 3 : NBS 2013; World Bank 2014b). Figure 6 1 : Tanzania consumer price i ndex (CPI), January 2000 January 2014 (NBS 2013) Despite the impressive investment by the government in the educational system, quality lags behind the quantity of schools (World Bank 2012; Lee and Morisset 2012), and many

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235 Tanzanian professionals I met believe that a good education necessarily involves pricy private education. Third, many people equated salary with perceived value which appeared to me to be the mo st offensive and hurtful to my Tanzanian informants. Esther, who was having a bad day after an argument over her salary with her boss, said that seeing how little she was being paid which she explained as making often reminded of the undercurrents of racism that pervade much of international health efforts, she and Lucia lamented how Tanzanian doctors were perceived by the global health community to be resource country means a low These feelings of hurt and offense were widespread among health care workers in general, not only doctors. In the current shift toward sust ainability, many health care heavy workload. As Swidler and Watkins (2009) note, many people volunteer with NGOs because of the possibility of recruitment an d advancement to more highly paid employment with an NGO. Kenneth Maes (2012) has also written much about how community health workers in h HIV patients, which he believes is a powerful tool used by NGOs to get many people to work for nothing. In a global health culture devoted seemingly entirely to cost effectiveness, where absolutely everything is about price, it is telling that the only f actor exempted from this calculation is the salaries for local health care workers (see also Basilico et al. 2013).

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236 One informant and friend in Haydom, Magdalena, spoke at length with me one afternoon about her job as a community home based care worker (C HBC) with HLH. Over the course of a two hour interview, she discussed in detail the requirements of her job the heavy workload and how her salary went from what she perceived to be a living wage in the heyday of the HAVACOP), to so little salary that she and some of her distant towns in the catchment area that they felt took too much time and for which they received too litt le compensation. Mag : I refused (to go on outreach) because there was funding and there was a donor, MM : Why? greed about .... Mag: The greed of the director, I say MM : Why? Mag : Yes, because we are paid two thousand shillings per day! You come by car you may go to Iramba, very far M M : Y eah Mag : You may go to Dongobesh, you may go to Eshkesh, you may go to Yaeda Chini, and for two thousand, really! It is tough, as CHBCs, we say we do not go M M : Y eah, Mag : Yes, and CHBCs do a better job because we are going to remote communities, and we are going to educate, we take care of the village office, and you might go jobs have just a small allowance now. villages and we work to people living with HIV, in palliative care, and go around to the villages without relying on cars we go on foot and s paid, it hurts. You have a family, you have kids, you have a husband, you have a farm, now you are going to volunteer to work? Really, I think, ah I do not know.

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237 Few avenues to complain about their salaries were particularly aggravating to her. As a witness to the inner workings of the hospital and donor funded projects for a decade, she resented her diminishing salary, while she believed ample donor funding still flowed through the hospital. Mag : ogram in the mid 2000s) we were CHBCs, why do they not consider it heavy? In Tanzania there is money here I do not know why they do not want to pay people wages, I am sad. Citing Mag: We are expected to work for free, especially us volunteers... I read that sustainable development policy transforms wages, (even though there is) more money for the whole project ... (it transforms) volunteers from working people, to MM : T he staff work for free? Mag : ( W e work) for free, yeah, who in the world works for free except in Africa, as projects from other countries who make funding dependent on people, particu larly in Africa (there are people) working for free, this is bad Mag : Y sad. I am the secretary of CHBC, and I say we do not work in this way. We wanted to see the director, but we failed. We wanted to see him to increase our salaries even slightly, because we work a lot, but we were unable to reach the director, down here the y say there is no chance to see director Uzembe and Rushwa Another common thread weaving throughout many of my interviews with health care uzembe or negligence am ong health care workers overall. In a countrywide report on the Tanzanian

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238 health system, Musau et al. (2011) found that health care staff morale had decreased considerably in the past ten years, and like for Magdalena, was a result of heavy workloads, and include washing and dressing patients, providing medications and injections, and counseling patients. These jobs now predominantly fall on relatives, in additi on to the provision of food and basic care they are already expected to do in most (if not all) hospitals. Corruption and bribery (rushwa ) that go on within hospital and clinic halls were also commented on widely in interviews both in Dar es Salaam and in Haydom , in addition to the burnout staff feel with rapidly increasing demand for health services and too few people to help ete shift in attitude T hasis on a materialist approach . As mentioned in the previous chapter, people in Haydom reported to me many experiences of corruption at Haydom Hospital. These typically included paying small fees to employees to exped ite lab tests or to jump ahead in line. The expectation of needing to pay a bribe to get service was widespread. Bribes, many patients reported, could be used in many ways, but most popularly was to cut in front of long lines waiting for services, and to g et lab house for a couple nights while waiting). Many people used the expatriate volunteers to help them through; a couple people asked me to stand with them in line, or to go ask a doctor about something or other, thinking they would get faster service and more attention (they were probably right). One volunteer doctor from Norway, and friend of mine, Jakob, told me that one old man refused to give any Tanzanian s money for services except him, because he thought the

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239 Tanzanian health care workers would just steal it. In one village interview with another old man, he told me similar things heart ( moyo ) compared with the Tanzanians who worked in the hospital. Other researchers (Sullivan 2011) note that bribes in health care contexts are often considered by workers to be essential supplements to their inadequate salaries (as described above). Additi onally, on a larger scale, c orruption ( rushwa ), and the expectation of corruption, is institutionalized in Tanzania in many respects. Amidst the corruption scandal at Haydom well used strategy to getting ahead, Samueli told me one day. As we walked past the mansion of one of the previous hospital administrators one afternoon, he told me that o f course he stole millions of S Having connections to health care workers was also important if you knew someone who worked at the hospital, Tanzanian or expatriate, people reported that you could typically get a better room and faster care, and for unmarried women, access to birth control (though technically illegal in Tanzania, several young women told me that most health care workers would refuse them birth control if they were unmarried). considered by many to be culturally prohibited in greater Tanzanian culture. Many community members I interviewed who used health services at Haydom felt that if they complained about someone or something, they would be denied treatment, g iven worse care, or forever blocked from receiving treatment, as spiteful health workers would take their revenge in powerful ways, in a rural part of Tanzania with few alternatives for biomedical care.

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240 The expectation of corruption was widespread in the villages surrounding Haydom as well. During a visit to Hayderer, an outlying village within the catchment area for Haydom, I interviewed the clinical officer at the village dispensary, along with several others in town the mayor, the primary school teach er, one of the major business men, and several farmers to get a better idea how health care was changing for their town. I was introduced to many of these informants through my research assistant, Rehema, whose brother, Pius, lived in town and knew just about everybody. Sitting on the back of his motorcycle as we crisscrossed town, passing down on rushwa rushwa happens in health clinics. The government thinks that if they give the CO a farm, they Robert told me that in order to truly build capacity and keep good do ctors in the public sector (and in the country), the government needs to invest more in doctors, by both paying them more and giving them more support to do their jobs well. Of particular concern for many, he outlines, is being stationed in the vast rural stretches of Tanzania, where the services needed to raise a family are either non existent or under resourced, and oftentimes of low quality. The system as a whole, he believes, is largely ineffective and sets doctors up to fail. You know, we're in an en vironment where first of all it's not paying much, and life is expensive, sometimes you have to make a choice, yeah? You want to work just for the sake of working, or you want to work to make a difference, but otherwise just become a (aspiring?) doctor, yo u don't have any equipment, you

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241 don't have anything and then they put you in a village where there's no school for your kids. So it's like your sacrificing your life you know! If you really do what the system wants you to do, then you lose. User Fees Anot her strategy the hospital instituted to be more self sufficient was to introduce user patient income accounted for only 11.2% of incoming funds in 2012. Consider ing user fees a potential avenue for increasing hospital revenue, a nominal charge of Tsh 500 (about 20 cents) to register, and another Tsh 500 consultation fee, was implemented in 2011, whereas previously, most services were free. Fees for more involved s ervices were more expensive to stay the night in the hospital was Tsh 20,000 ($13) for adults, and 10,000 for children, medications were also extra. When these fees were first instated, people around town whispered to me that they suspected it was corrup tion, and the 500 Tsh notes were being pocketed by staff at reception. I assured them it was not the case, and that they could get a receipt if they wanted to, but some were still suspicious. User fees as a strategy for recouping funds, or for a strategy for recruiting patients, was a topic several of my informants in both Haydom and Dar mentioned as important for saving money and more judiciously distributin g resources. James, who worked i n social marketing for an international agency in Dar es Salaam bel ieved that by charging a fee, it would reduce the amount of freely distributed health materials people took from free campaigns, as well as encourage adherence to long term care: M M : A lot of people have said that paying on a sliding scale or something is going to need to be essential. What do you think about that? J : I would much rather have a conversation with the folks up in Haydom about I need your 100 shillings and I'm gonna give you this, as opposed to here you go.

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242 M M : Is thinking that the 100 sh illings will offset the cost? Or is it that with the 100 shillings, you're not getting something for nothing? J : Don't take it if you don't need it. It's more expensive to give away a free condom than it is to sell a social marketing one. And the huge difference there is not the 100 shillings. The difference is somebody who needs it, takes it. M M : I've heard that a rgument several times and I didn't really understand why. J: It's a good amount of money, but I think to me the largest point is the philosophical one of its like you know if you get into Tanzania, I don't know how long you've been here, but if you walk up to any old lady in the village and basically said buy this or give me money for that, there isn't anybody out there who completely changes the way they look at you when they say "what's in it for me? Is this any good?" Even if I am poor, it's a question of quality, it's a question of service, do I want it, and can I afford it, and where am I going with this? I will have that discussion with somebody any day of the week. I think that's true pretty much everywhere I work in Africa. M M : So it that propose d for most health care systems? J: Yeah, we're giving away HIV/AIDS care in Tanzania. My first job was in TB, and we had a real problem with people falling out of TB treatment, this was back in Congo, back in the old days. And so basically what the hospi tal worked out, was that people paid a deposit on their cure. And so it's like, okay, you're TB positive, you're spitting bugs, you're going to contaminate everybody in your house, I've got the wherewithal here to treat you, and to make you feel better if not cure you. You put 50,000 on the table, and we will start that treatment. You finish that treatment and I will give you 40 back or 20 back or 30 back or whatever it was. We had spent a lot of time on that formula. You disappear from that treatment and y ou're going to eat that, I'm going to eat that 50,000 and I'm telling you right up front, you don't come back for your medicine, you basically don't do what the protocol, the program has to be, that 50 is mine. We didn't need the 50,000, we did need to hav e that conversation. Why are we not having that conversation with people about HIV/AIDS treatment? They have absolutely everybody, assumes that their investment is the fact that you will save their life by giving them ARVs. ...When you're out of country ru n out of ARVs? Why are we not having that conversation? Say ok I can come up with this you can come up with that. I don't know? M M : So if that worked with the TB program in Congo, why did it go away? Or did it not go away with TB J : It didn't go away !...But when it came to HIV, why did we lose that mentality? I everybody. Blame it on CDC, I don't know. Blame it on the stupid mentality that you can't talk money with poor people, it is just nonsense. Poor people will end up

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243 paying more for their health care than rich people do. Rich people know where to go! are selling it the same way you're selling air ti me for cell phones, or selling cell phones. Saying 'hey, this is going to save you money. We can work something out as to how much you pay during the year, maybe I'll take it during harvest season or when you sell your cows, or whatever it happens to be, b ut it's just like let's get in to the cash economy, and basically work some of these schemes out. And I think people aren't spending enough time sitting on the street, watching everybody going by and seeing how much they have in their pocket. Or having tha t discussion that says 'what have you got?' 'What do you need, what have you got, how do we work something out here? M M : So, how do you fix something like that? Or is this the perfect time when it's transitioning from an emergency to a is this one of the key strategies do you think, for a sustainable program? J: this being an emergency and we had to do this, and I mean nobody really ever hunkered down and then of course you know, is the ministry here really any better informed about this any better than the folks up in Haydom? There's a set of preconceptions here that are as equally obtuse as the ones we have in Washington. And I think that's the kind of st uff that we had with social marketing that made a big difference too, is you know what, we got rid of a lot of those preconceptions and then we went out and we tested this stuff with people and said 'what are you going to buy? What do you like, what don't you like, what are you going to buy?' and spent a lot of time basically harping everybody on doing your research to make sure your product goes somewhere. Sustainability at Haydom Lutheran Hospital While I was in Haydom, the hospital was working hard to secure new donors, and new donor dollars, to make up for the money that may be cut entirely should the Norwegian Embassy decide to stop funding HLH. The Royal Norwegian Embassy commissioned the external auditing firm, Deloitte, to research and propose fund the expected gap of

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244 2014 (Deloitte 2010). The principal cause of the rise in operating costs are due to the increase in personnel costs and salaries, with an 18% expected increase in rates for the peri od up to 2014 (from 2005 does not find new sources of funding, the current activity level cannot be sustained. The the largest segment of the addressable market, although the corporate segment is the fastest a shift from general budget support and baskets to more direc ted program support (Mbacke 2013). During the time I was there, the hospital quickly and thoughtfully implemented several competition for funds among the differen a marketing and public relations strategy was considered to be essential for continuing to attract donations and grants, and the report recommends hiring a PR person for fundraising. Advertising and social media campaigns were recommended to attract individual donors, and the h ospital in response developed a new English language web site and maintained the Norwegian website addition to a new German Friends of Haydom donor site (www.haydomfri Finally, as

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245 introduced in Chapter 4 Other strategies were outlined in the report, particularly th ose related to the position of HLH in the government health care system and its potential for garnering government grants and support. As a newly minted referral hospital, HLH may have better access to reimbursements from the government for services provid ed to the community (service agreements), may be open to more grants by becoming a teaching hospital, or by breaking ties with the Evangelical Lutheran Church of Tanzania (the current owners) to become a foundation, which some believe may attract more dono rs (2010:7). As a faith based hospital, HLH receives funds from the Tanzanian funding agency the Christian Social Services Commission (CSSC), which Deloitte Finally, as an increasingly large research station in a remote area (a nd a medical research post for the Tanzanian government), the possibility of collecting fees from researchers and research projects was also raised. Discussion howeve r, the health system is fragmented; divided among multiple stakeholders from multiple different funders, organizations and governments, culminating in what several informants called a series of parallel systems, or as Buse and Walt (1997) famously put it an unruly mélange. Within this fragmented context, sustainability goals, objectives and strategies are fragmented themselves, as each piece of the fragmented whole must be concerned principally for its own

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246 different programs contend for the same donor dollars. Ideally, sustainability would contribute to objectives c ontribute perhaps to further fragmentation, and may ultimately undermine the efficient running of a health system (Farmer et al. 2013b; Pfeiffer 2013). Sustainability conceptualizations and goals largely fall along the structures of the health system itse lf vertical programs, which may comprise a significant part of health systems, and the health system itself. Vertical programs, as noted in Chapter 3 , are those targeted at a specific disease, a specific health outcome, or a specific population, to the e xclusion of others, and often provide much better care and treatment to these specific people than the care afforded others. A health system, alternatively, is the entire (typically government funded and constructed) apparatus devoted to improving or maint aining the good hea . It has many different parts public, private, and voluntary organizations; primary, secondary and tertiary care workers and facilities; and can also include environmental health protections like water treatme nt and sanitation, etc. A fundamental problem with translating sustainability policies into practice is how as I also discovered over the course of this research. I asked informants to explain what they understood sustainability to mean, both in general in regards to health care and health systems, as well as how their programs put sustainability into practice. Taken together, their answers largely conflicted, illuminating perhaps critical underlying impediments to achieving sustainability. Many described an aspirational sort of sustainability that closely ali gns with goals of either sustainable development including broader environmental, economic or social goals; or cited

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247 asked more specifically how they would operation alize these strategies, the first hurdle was always financing. In the case of PEPFAR and many other vertical programs, sustainability depends principally on financing, usually international aid, to fund salaries of local staff and expatriate technical ass istants and consultants, operating costs, vehicles, fuel, medications, consumables, etc., and for the most part is determined by the ability of the host country to maintain similar services after the donor or NGO leaves. For example, in an assessment of th e PEPFAR services after financial, managerial, and technical assistance from the United States and other al. highlight this among their concerns for the use of the term sustainability. Advocates of sustainability in global health, they write, originally sought to find a way to overcome the profusion of short term, emergency aid that had little investment in l ong proved difficult, leading t o the undefined and inconsistent application of the term (see also Basilico et al. 2013). Today the focus has shifted to a vertical program centered idea of sustainability that prioritizes longevity of program operations, regardless of its contribution to the health of the population (Yang et a. 2010:130). This program centered definition of sustainability adheres to a neoliberal philosophy regarding health and health care, Kenneth Maes (2012) argues, and is rooted historically in the International Monetary

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248 Chapter 3 (Pfeiffer 2012; Brown et al. 2006; Basilico et al. 2013). L ike Yang and colleagues observed, over the course of my fieldwork and series of interviews addressing themes of sustainability in health care, it became apparent to me that ideas about what sustainability is, and how it can best be achieved, are fundamenta lly different for external donor funded vertical programs, and for those ideas and strategies an entire system requires, for sustainability. Further, the strategies to sustain vertical programs can, and perhaps often do, undermine the sustainability of the entire system. As vertical programs attempt to integrate into the health system, however, these ideas and strategies mix and sometimes clash, with some unintended good and bad consequences. The PEPFAR programs in Tanzania are a good example of this clash, come to represent the friction of more than ideas about sustainability, but identify the dynamic nature of health care and the political and economic underpinnings of global health programs and policy making. A health system centered conceptualization of sustainability, with a strong foundation in universal primary health care, is widely considered to more successfully create an effective and sustainable health system (WHO 2007; Chan 2008; Farmer et al. 2013; Pfeiffer 2013). A care in Alma Ata, USSR (now Kazakhstan), policy makers and health care professionals are angling for a reorientation of research and funding to horizontal or diagonal programming, health system strengthening and capacity building, in addition to primary health care (Chan 2008; Garrett 2009; Lancet 2008). As described in Chapter 2 , WHO Director General Dr. Margaret Chan declared that returning to Alma Ata objectives was paramount among her goals f or her tenure at the WHO.

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249 Health systems strengthening is the goal of the WHO Six Building Blocks model, which includes: 1) effective, safe and quality service delivery; 2) a well performing health workforce; 3) effective health information systems; 4) equitable access to quality medical products, vaccines and technologies; 5) a good health financing system; and 5) effective leadership and governance (WHO 2007). M any informants identified the WHO building blocks as key guidelines for their conceptualizat ion of sustainability, along with similar health system primary care a nd health system strengthening (WHO 2007), and increasing the number of health care workers and managers (Musau et al. 2011). Others identified goals for a sustainable health system that more closely line up with broader sustainable development goals (SDG s), such as those that are currently being worked out in UN open working groups to be unveiled in 2015 as the next generation of development goals, following the MDGs (UN Sustainable Development 2014). From this perspective, informants identified sustainab ility in some way or another as resting on a solid foundation of good primary and secondary education, basic health services, roads and infrastructure, electrification, access to safe water, good governance, and a healthy enough economy that could provide for a good tax an integrated effort toward advancing 1) social welfare and inclusion (of which health is subsum ed), 2) economic development, and 3) environmental sustainability (IOM 2013b; Sachs 2012). When it came to individual vertical programs, however, sustainability appears much more like financial survival. At ground level many health care workers and adminis trators, in

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250 Haydom particularly, lamented the fact that sustainability is a long term goal, and could only be met after the short term survival was assured. Being on the brink of financial collapse was an all too frequent occurrence at Haydom while they re main overwhelmingly dependent on donor funds in an increasingly precarious aid environment. These ideas and concerns emerged when people in both Haydom and in Dar addressed how they would put more abstract ideas of sustainability into practice, of which fi nancing was always the most critical issue at hand. In Haydom, this indicated expanding fee based services and other strategies to integrate privat e companies and partners, like X trata Nickel. User fees was a topic that came up frequently among Haydom admi nistrators, as well as health insurance plans, scaling back services, attracting new patients with niche care markets, and using more unpaid, expatriate volunteers. For the foreseeable future, all believed the bulk of financing for these vertical programs (like HIV) and donor funded projects and institutions (like Haydom) would continue to come from international partners. Diversifying funding sources was a top priori ty, as some were fearful of depending entirely on a single donor (like PEPFAR), and perhaps particularly on the US government, which is notoriously fickle. Building capacity in this respect, through grant writing iewed as a critical skill that was currently neglected. The most common definition of sustainability I heard among Tanzanians in Haydom in simama kwa miguu yetu circulated a lot among hospi tal administrators at Haydom in particular, as did the English translations to be self sufficient, which is commonly used in the periodic hospital audits and Mæstad and Mwisongo 2009 ). I met up wi th an academic colleague in a hotel bar in Dar es Salaam and discussed this common phrase

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251 the hospital used briefly with him. He was incredulous PEPFAR and Sustainability PEPFAR contributed to reducing HIV incidence, HIV related mortality, expanded antiretroviral use, helped to improve infrastructure and instituted a culture of reporting, monitoring and evaluation. In its prog rammatic transitions, however, it came up against significant barriers already in place a critical shortage of health care workers; and contributed to others increasing an internal brain drain, and perhaps furthering a loss of morale among less well pa id public sector and the Tanzanian health workers. Translating sustainability policies into practice also proved a persistent problem, with many informants expressing frustration with the progress of the transition, while also noting that maintaining and s ustaining the HIV response in place would continue to take significant funds the Tanzanian government did not yet have. limited. The way the system is set up now, financing for much of the PEPFAR funded operations in Tanzania largely bypass the state, though they coordinate with stakeholders in the Ministry and with the Global Fund, who do finance government health programs. PEPFAR funded HIV treatment programs are instituted via non governmental channels, something James Pfeiffer writes is one of the most critical, yet overlooked, parts of PEPFAR legislation (2008; 2013). private partne rships as one of their six central purposes. The legislative documents expressly indicate : The purpose of this act is to strengthen and enhance United States leadership and the effectiveness of the United States response to HIV/AIDS, tuberculosis and malaria pandemics and other related and preventable infectious diseases as part of the overall U

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252 expansion of private sector efforts and expanding public private sector partnerships to combat HIV/ (2008). Funneling aid dollars via NGOs and bypassing the state, is something Pfeiffer (2013) and Cheikh Mbacke (2013) in particular mention as a critical oversight in the study of PEPFAR, and a critical barrier to building sustainable health systems or sustainable HIV country programs. This pattern is replicated elsewhere as well, and overall the pattern of diverting aid to private and voluntary sectors follows the ideals of expanding neoliberalism in health sectors, . Further, this practice explicitly goes against the two principal aid effectiveness agreements the Paris Declaration and the Accra Agenda that were implemented to ensure more government control over donor aid. As Mbacke (201 3:3) writes, Although international support for health has increased substantially in recent years, there has been a continued focus on disease specific initiatives. Much donor support is funneled through international organizations, and country support c ontinues to flow mainly to non governmental organizations. The guidance of the Paris Declaration and the Accra Plan of Action are being royally ignored with more than two thirds of donor assistance for health bypassing government. Figure 6 2 : Percent of donor funds bypassing the state. F rom Mbacke ( 2013 ) . 0% 20% 40% 60% 80% 100% 1995 2004 2010 % GOV'T % NGO

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253 Conclusion In this chapter, I examined some of the consequences of fluctuations in aid policy and programs. In particular, I outlined many of the outcomes health care workers and administrators have ob served over the course of the past volatile decade in global health with decreases in funding for health and HIV and efforts to establish a more sustainable health care system. Some outcomes discussed in this chapter include perceptions of competition an d inequality among community members for the benefits of aid; and competition for health care workers between NGOs tasked with rolling out HIV care, and other institutions within the larger health care system. Finally, those most intimately experiencing th e volatility of aid, the patients themselves, return to a routine in which accessing care and support is increasingly difficult. Health care workers in turn are asked to do more for their patients with decreasing support as well. However, there are some br ight spots on the horizon. James Pfeiffer who has worked with PEPFAR brought about by PEPFAR has dramatically altered the calculus and sense of possibility in global health broadl major progress and innovation are possible but only if we maintain a focus on the resurrection of a public Pfeiffer notes that by us ing this money a phenomenal amount of funding dedicated to specific diseases and putting it toward a project like health system strengthening through the public sector, it would contribute considerably to building up a foundation for sustainable health care (2013). Some other methods such as implementing user fees or scaling back services; and outcomes such as the competition for skilled health care workers fueling an internal brain may also ultimately work to undermine the sustainability of the health system. One example of the effects of this is the

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254 extensive use of health care volunteers. As Kenneth Maes (2012) argues, when health programs are influenced by the continued macroecon omic policies of neoliberal institutions such as the IMF and World Bank, keeping a program afloat is much more difficult in practice. Using he IMF discourages governments from raising public health payroll expenditures, and simultaneously discourages donors from funding payroll expenditures, paying to thread this needle is to invest heavily in recruiting and training volunteers who agree to work for free for a period of 18 months. This may result in program sustainability, but few would argue this would contribute to the sustainability of a health sy stem, not only because it expects people like Magdalena to work for nothing or very little, but also because it reduces the tax revenue the state can depend on to fund public services. In the following chapter, I take a broader view and consider some of t he principal lessons learned from my fieldwork and engagement in global health and HIV/AIDS programs. I consider issues principally of sustainability per the original intent of the word establishing long term, high quality care that can be as dynamic as epidemics are volatile. The question of temporality particularly interests me, which many other anthropologists consider has changed considerably in flexible and fast passing of time, rather than taking a long term, longue durée view and scope of Sustainable Development Goals (SDGs), set to unveil in 2015.

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255 CHAPTER 7 DISCUSSION AND CONCLUSION The original goals of sustainability in health were to find ways to overcome the profusion of short term, emergency aid that had little investment in long term care, and to focus attention on addre al. 2010:129). These intentions have been shaped and formed since then in multiple ways to suit the structure of increasingly privatized global health care, with donor d ollars flowing to non governmental and private organizations (Mbacke 2013). Through interviews with several informants, this process appears to further fragment the Tanzanian health system, making it more unpredictable, unstable, and inefficient. My data s uggest that overall, the long term objectives and future orientations that used to imbue the meaning of sustainability itself has been twisted, to be limited to the sustainability of this present fragmented system, with its focus on non state entities and be argued that the structure of health care, particularly for HIV/AIDS care and treatment, is systems strengthening and universal primary health care are considered the best and most important ways of developing sustainable health care. In this discussion and concluding chapter, I review the history, theories and principal findings from my research on the volatility in global health aid and policy, and the efforts underway to correct for that volatility, under the aegis of sustainability. I also incorporate other works, particularly those that deal with the shifting temporalities of aid and global health, to better work through some of these findings. In particular, I reference works on humanitarianism driven culture and foreign aid (Ho 2009b and Guyer 2007); and

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256 the unique power that may be afforded to donors and organizations that hold services hostage and people in p erpetual limbo in the time of the almost exit, that can span decades. In this which care and other social services are batted between powers, seeing who will flinch first and end up footing the bill, and what changes are put in place to further the perhaps more concrete long term goals of extending the reach of privatization and deregulation. Meanwhile, what many outsiders may see as volatile the constant churning of NGOs and donors, pet projects and moral missions may be just another part of a predictably unpredictable life for those who depend on that care for their health and well being (see Swidler and Watkins 2009). I conclude with some evidence that these tr ends and processes underway are slowly being recognized and corrected for, and in the meantime, buttressed by the love and dedication of many health care workers in Tanzania. With new political will behind the advancement of the Human Resources for Health campaigns in Tanzania, salaries are beginning to rise for health care workers in government positions (Songstad et al. 2012). More support for these workers will likely have spill over effects into other parts of the difficult equation corruption, briber y, and burnout may decrease as people are paid better, paid on time, and have more colleagues to work with to care for the increasing numbers of patients. Finally, as James Pfeiffer (2013) has written extensively, this current moment in global health is a n opportunity to make the best use of the still impressive amount of funds dedicated to it. Using PEPFAR as a principal example, Pfeiffer argues for the importance of pressing legislators to redirect the money dedicated for NGOs and expanding the private s ector for global health to building up public sectors essential for sustainable health care (2013; see also Weigel et al. 2013; Farmer et al. 2013b).

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257 Privatization, Time, and the Humanitarian Mission humanitarian crisis of a magnitude never before faced in modern history ever global health initiative initiatives was dedicated to combatting the HIV epidemics in 15 focus countries, which has now expanded to 35. The second iteration of PEPFAR, which began in 2009 and came to a close last ting sustainable country also retract, forcing cuts to health and development initiatives around the world (Garrett 2007). This follows a cyclical pattern in global health that stretches back at least a half century, following other larg e scale international vertical programs, like malaria, polio, guinea worm and others before it (Basilico et al. 2013; Greene et al. 2013). And indeed, as HIV slowly slides off the emergency agenda, materna l and child health is taking it s place, or what my informant This transition from emergency to sustainability became a principal topic for my own research in Tanzania, somewhat accidentally. The PMTCT program I began studying for a few mo nths in mid 2009 lost a large amount of PEPFAR funding within a year, and was scaled back considerably by the time I returned to continue research in early 2011. While I stayed to document how women served by this clinic experienced cuts to HIV care, I exp anded my research to include interviews about health care sustainability with health care providers, program planners; donors; hospital administrators; and policy makers at the national and

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258 international NGO level, as well as at the patient, clinic, and ho spital levels. The data I presented in this dissertation included the difficult work of discerning what sustainability actually means to coming, and what challeng es we are up against when we say we want to create more sustainable care. The precariousness of everyday life I encountered while working with people in Haydom and Dar es Salaam provided an important anchor in reality, while policy makers and global health programmers choose how to best adapt to funding changes and donor demands. Privatization and Global Health in Tanzania With neoliberalism, the idea that social services such as health care would more effectively (and more cheaply) be delivered via select ive primary health care, or via the private sector, forced the widespread scale back of health care services throughout Sub Saharan Africa (Walsh and Warren 1979; Easterly 2007). In Tanzania, Benson (2001) notes that once structural adjustment policies (SA Ps) were adopted, the number of private clinics escalated in wealthier, urban areas. Public clinics closed, and as a consequence, the vast majority of the country rural, poor farmers and pastoralists were left out, limiting (or eliminating entirely) th eir access to care (see also Pfeiffer and Chapman 2010). That this happened at the same time as the HIV epidemic in Sub Saharan Africa took off is perhaps, some note, not a coincidence (Comaroff 2007; Basilico et al. 2013; Pfeiffer 2013). As John Iliffe w rites in A History of the African AIDS Epidemic (2006), growth and medical advance in most regions for thirty years after the Second World War, the actly with the transformation of HIV into an epidemic disease eavily indebted regimes seeking international support had to accept structural adjustment programmes demanding still further economy on services, including use r fees at medical institutions that did

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259 less to raise money than to deter the poor from using them. In Zambia utilisation of urban health In this dissertation I presented several theories anthropologists of global health have us ed to help explain how health care is being adapted in our current era of neoliberalism and which capitalist organizations divest citizens of their rights to s ocial services to accumulate processes of privatization and deregulation could be a pri vate clinic or hospital, or an NGO a government run and funded maternity ward, where sometimes up to four women labor in bed at the same time. There is a temporal aspect to this patchiness of the globa l map as well, where a space of social abandonment can become a green zone of prosperity in a short time, in many cases dependent largely on donor interest and international pressure. HIV/AIDS is an excellent example of this US funds for HIV/AIDS increas ed from 300 million in 1997 to 8.9 billion in 2009 (Oomman et al. 2007). This temporal shift the increased speed in which green zones and brown zones can emerge is likely a consequence of the rise in philanthropy, and humanitarianism in particular, th at is principally short sighted. Over the previous thirty years, we have come upon a principally

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260 those interventions that are expensive and long term focused, and may not deliver immediate spectacular results to show donors or stockholders (Basilico et al. 2013). Additionally, and perhaps more powerfully, the rise of emergency interventions and humanitarianism have come to dominate global health and development, and explicitly focus on the immediate present (Calhoun 2010:54). This temporal frame dominates global health care now, and is, as I have shown throughout this dissertation, one of the principal hurdles to developing sustainable care for the long term. Progra ms which in Tanzania have become a principal mechanism for delivering health care are usually short term, selective, and when rolled out via NGOs, can contribute to further fragmenting the health care system in Tanzania (KEPA 2012). Popular critiques a bout the delivered care perhaps best exemplify this. Competition for donor funds also takes up valuable time and resources for these NGOs, and since the 2008 global recession, more donors in Tanzania have shifted their efforts toward programming rather than general budget support, the latter of which is considered to be more in line with the Paris Declaration (Mutalemwa 2009; KEPA 2012; see also Grépin and Sridhar encies that may not really be prominence in the last t H e attributes this to great social change and not, in reality, an increase in actual emergencies. drives advertising, and persuades everyone potential donors and volunteers alike that they can easily t ake part in the moral mission of saving people (see also Richey and Ponte 2010).

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261 This shift to a humanitarian focus (instead of the longer term view of development, or the even longer view of sustainability), Calhoun writes, further relieves actors from l ong term political or economic obligations, or work to change the structures under which emergencies that progress will ever come. The emergency has become def initive because it is understood to pose immediate moral demands that override other calls for a humanitarian his 1994 book The Antipolitics Ma chine, humanitarian and development projects can obfuscate the political foundations of the global economy that causes widespread poverty, and in many cases serve as a short term Band Aid at best. Implementation of global health programs and policies in th is short term, emergency frame is set up to work against the things that are necessary to build up strong health systems. Like one HIV program administrator told me, as an emergency intervention, PEPFAR and is current ly With donors it is difficult to plan for the long term, since the majority of the funding for the long term is presently coming from donors focused on the short term; investment in the long term can informant told me, to keep up with donor interests and demands. With this nimbleness, however, comes the sacrifice of those things that need long term support, and must alwa ys be a part of an effective health system a good health work force, highly educated, with stable funding, in order to be effectively responsive to the dynamic nature of population health. These important components may also buffer the extent of emergenc ies when they do happen.

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262 This temporal aspect has been written about in other ethnographies of time, and most live and die by the shifts in the market that come down to milliseconds. She references the l functioning of companies, but makes for dramatic unpredictability in the short term. She writes ely helping to shape a world Ho cites the example of AT and T under the guidance of Morgan Stanley to illustrate her point, which was touted by bankers as a short term success story, generati wealth for shareholders primed to cash out during the short this process, however, like other corporations Ho observed, employees were laid off, hareholder value over a longer time health care puts health care under the same stresses, and as I outlined throughout, experiences similar detrimental outcomes .

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263 time, and the collective focus on the immediate present and the fantastic future, Guyer writes, is politically and socially powerful in neol iberal contexts (2007:411). This presentist focus, which we live the structure of the systems of donor funds, UN deadlines, cost effectiveness assessments, and cycles of monitoring and evaluation, the latter of which, oddly (or perhaps intentionally) rarely evaluate anything beyond the outcome (or exit) evaluation at the end of a program. Power at the Almost Exit The intent of this dissertation has been to show the lived experience of those who are living through rapid social and policy changes, through predictably unpredictable events; those whose lives sometimes very much depend on the whims of sometimes fickle foreign governments, and in one case, PEPFAR via t he US government. But the uncertainty of the funding leaving could have interesting effects. Many people in Haydom, and even those unfamiliar but with experience with donor aid and NGO health care in Dar, did not really believe e is always money for well As Sharon Abramowitz (forthcoming) writes, NGOs operating in emergency contexts can particularly during tim es at which the state has diminished ability to do so, such as in a litany of factors over which they have little control, including donor interest, political will, as well as local security conditions and the approval of host countries. At the time of exit, however, rule right to disregard local staff and

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264 beneficiary will, local health concerns, epidemiologic bu rden, and the economic implications of In the case of Haydom, or for PEPFAR organizations, the time of the almost exit the liminal period of will they or they may be a principal time frame in which NGOs or do nors wield power. The time during which an organization or a donor threatens to leave and therefore potentially dissolves critical services to a population and the oftentimes indeterminate point when NGOs or donors actually do leave, what strategies, p olicies, or practices occur within this space? What patterns emerge? In other, non health related contexts, we see this power wielded often, particularly when companies threaten to move locations elsewhere or offshore, or lay off hundreds of workers, unle ss tax breaks are levied, or workers agree to lower salaries, contract work, or the dissolution of unions. in which the promise of rights, and becoming rights bearing individuals, but always too i mproved behavior by threatening to withdraw their means of survival. Although they are supported by expert rationales, from the perspective of the victims, these regimes differ little from the despotism of sovereigns who can take away life and liberty upon

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265 I encountered a similar temporal space during this fieldwork most everyone threatening to leave, or warning that others may leave has not yet materialized, but it did so in some that CMI referred to repeatedly can be illuminating: setting up the RNE and government in continued existence, they are thus trapped in a game where they cannot exit ( Mæstad and Mwisongo 2009 :38). The problem appears partly to be caused by policy regulations from the central government (or lack of such) and partly by lack of political wi ll to coordinate local administrative units, or maybe a game in which local governments are trying Mæstad and Mwisongo 2009 : 35). ct those on the ground in many ways, during this period of the almost exit. HLH launched a campaign to become more self sufficient, which meant more user fees and relying on volunteers, as well as courting new donors via social media and appealing to corpo rate social responsibility like t o Norwegian nickel corporation X trata Nickel. Like Bech et al. (2013) write in their history of the socialist experiment followed by the neoliberal experiment both of which have failed upendo , and the sense of competition among people in Haydom could have been a consequence. Like the fictional person people I encountered in fieldwork did appear to believe that ac netting paid employment with an NGO could be a stroke of wild luck (see also Piot 2010). The capricious nature of aid and on whom it is bestowed appeared to create divides among people

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266 work day and night and I , Gideon told me) as well as perhaps a e Samueli told me on two separate occasions, , and As Swidler and Watkins (2009) note, however, the unpredictability and uncertainty of aid in aid depen dent countries like many in Sub Saharan Africa has come to be just a part of life the uncertainty is certain and so many people may take periodic aid to be a nice, occasional iken accessing care from donor funded care and opportunities that occasionally supplement their more regular, but marginal, subsistence living. Just as the weather is unpredictable, the price of tobacco or cotton rises and falls, and other resources come and go, so also do the resources provided by more frequently, are promised but never materialize. This is a wor ld a modern American consulting firm, or someone trying to pitch scripts for TV shows in Hollywood might recognize. But it is far from the coherent, modern, rational self reliance the sustainability ideology intends to produce. Indeed, it engenders somethi ng closer to hunting and gathering, a kind of unpredictable supplement to the marginal subsistence agriculture that sustains daily life. (Swidler and Watkins 2009: 1188 ). Another outcome could be the rise of expectations to come from donors and programs, p administrator called them. These programs are typified by creating a sort of vibrant green zone, in which the best of everything is poured into a single vertical program or initiative, with little a Cadillac program, because for a brief period of time the program was very well funded and comprehensive, all the pieces were (mostly) th ere to provide mothers with food, transport, and

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267 all their health care needs that could be met by the hospital, including free ARVs. Once those extra supports were cut back, however, most mothers I talked with expressed some concern for getting to the hosp ital in particular, and particularly during early 2012 when the harvests had not come in, concern with getting enough food. Toward the end of my fieldwork in Haydom, in early April, I was feeling the weight of my many months away when I went for one of my of the day. Distressing me most, and what had been brewing in my subconscious for months perhaps, was my obsession with my bicycle pale green, increasingly rickety and rusty, with failing brakes that eventuall y forced me to give it up for good after I determined I was not skilled enough a rider to not injure myself seriously. On this long walk however, I determined that my experiencing with the donor culture and aid exit, and the rise of expectations, and demands, that so often accompany it. Fieldnotes, 4 April 2012 : One of my most exciting first purchases in Haydom was a bike. I felt that a bike would give me freedom to roam around my new home for the next year, help me roam farther and to more remote parts outside of my remote town, either to get lost faster but to return faster too. During my first venture out looking at bikes with Valerie , another mzungu researcher, th e guy took one look at the color of our skin and quoted us one million Tanzanian shillings, which is about $625. You can buy a motorcycle for that price, and we both bei ya wazungu T anzanian friends some money to find a bike, and ultimately they came back with a used bike in need of repairs, which total cost about Tsh 200,000, or about $125. Still a bei ya wazungu , but whatever.

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268 Fieldnotes, 4 April 2012 , continued : The first couple months began a sort of love affair with the bike. I did find more freedom with it, errands which would usually take 30 minutes (mostly because it cut down on the time stopping to talk with everyone who I passed, who were moderately surprised to see a whit e person walking around so far away from the main hospital compound and wanted to greet me) now took about ten minutes, and I explored all sides of the importantly, I could and meeting in time. This satisfied me immensely. It also felt like a marker to me that I lived here, confirming that this was my home. I was not a temporary visitor, too tempor ary to bother with buying a bike when walking was still completely enjoyable, and completely fine for a month or six weeks. A bike was an investment, in the thing and in the place. Around this same time, my research assistants and I began the first in a s eries of semi structured interviews with people in Haydom town, and in five of the surrounding villages that removed to have their own distinct economies and life styles. The content of these interviews were wide ranging, but mostly touched on changes in health and political economy; we asked questions about which diseases and illnesses were increasing and decreasing and why; how the crops were doing; if and how wor k was harder or easier than in the recent past; what changes in road construction, education, water projects, and development projects they had seen; and changes in the economy, like the price of goods, the cost of sending kids to school, hiring day labore rs or house help; and more broadly, how people help each other and how these helping patterns had changed in their memories. This final question unleashed a torrent of bitter stories,

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269 observations and accusations, the gist of which was that in Haydom today , the love is gone, and money is everything to everyone. These observations follow a pattern common to many similar countries and communities undergoing a market transition in the recent past, in recent memory, life was easier, more stable, and more lov ing. Discussing these memories, and the perceived danger of the times they live in now, unearthed profound displeasure and fear, and fantastic glorifications of the past. Principally, people remembered neighbors sharing food; if as a child your mom cooked something you did not like for dinner one night, you just took your plate next door and got a pile money for everything. Somehow, the bike became the focal point fo r me of the clash of cultures and for the sharing of things. Fieldnotes, 4 April 2012 , continued : We all found we could not live without the bike. I became irrationally angry over not having my bike in time to go the morning prayer meeting or around in the afternoons and early evenings to go explore and for exercise; my house father lost the ability to leave for work on time and so would ride the bike with one kid on the back to ride it r (mama mdogo) needed the bike for much of the day to cart around sisal trunks and goat skins for his newly formed drum making factory; the kids used it primarily for playing in the yard, but also to haul dried beans from their farm a few towns away and to run errands throughout the day. It became indispensible. After the first round of semi structured interviews (from Chapter 3 ) we conducted a consensus analysis among 64 people in Haydom and three of the surrounding villages, about the

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270 skills and material kuishi maisha bora). From the answers from the first initial interviews, as well as many months of ethnographic data and a few free lists, we came up with a list of 55 things and skills one would need to live well. The things people determined most important from the consensus analysis were not surprising: it was universally noted that having a farm was of paramount importance, as well as having respect in the community. One old ma n was particularly verbose and explained in detail why he chose what he chose, and his answers started to strike home without it, so for him, it was indispensible . If someone else does not have a motorcycle, they needs it as much as he does. Fieldnotes, 4 April 2012 , continued : It is the having of the thing that ma kes it indispensible. And suddenly not having the thing after having the thing is a fate worse than never having the thing in the first place. People may be jealous of the status that having a bike or motorcycle can bring a person, but perhaps more importa ntly it is stressful learning of all the without have been written about extensively in social science, particularly with the rise of globalization and the spread of Western media. Seeing the lifestyles of the rich and famous or of the American middle class and un notable realized as much before, how much wealth is in t he world, and how truly spectacular wealth is effectively made invisible. (Conversely, truly abhorrent poverty is perhaps more often now being uncovered, though to various ends whether it be to send money to humanitarian

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271 organizations or witnessed on a multiple kinds of aid exit, and the everyday violence it causes, the smaller scale effects of rising when NGO workers disappear to the next post, can be erosive over time as well. A s I search to find a silver li ning somewhere in these narratives, perhaps being exposed to wealth in general, and to wealthy world health care in particular, can be a critical first step to advocating for more equity in global health, that is, after all, a paramount goal. Seeing, having, and then demanding care if or when it goes away may be part of what i s needed for sustainability of health care . I t may be a critical part of conferring agency to vulnerable people, and contribute to the advancement of local participation and ownership of care that is urged within aid effectiveness policies (Foucault 1995). Several of my informants, across different settings, voiced their an ger and indignation over what they perceived to be unjust outcomes of the volatility of aid Magdalena in particular threatened to stop working because Haydom lost based care workers. Salaries for community hea lth workers, in particular, are some of the first budget items to be cut in the wake of funding of the MDs I worked with Esther and Robert, for example als o expressed deep resentment over the inequalities in salaries for Tanzanian and expatriate health care workers, that were made Second, as Farmer and colleagues (2013b) highlight, the exceptional s uccess of the global HIV/AIDS interventions the surge in political support, donor funds, and moral activism (also Messac and Prabhu 2013:130; Greene et al. 2013). The overwhelming evidence that

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272 something believed at first to be too expensive and intractable the continued spread of HIV/AIDS across the African continent and ensuing mass death can now serve as precedence for other global health issues curren conditions ripe for capital accumulation among pharmaceutical companies were curbed in favor of stopping a global health emergency; cancer in resource poor countries, for example, may be targeted next for the unfair distribution of health resources (Farmer et al. 2013b). As Messac and y to that (Greene et al. 2013). Lucia, the medical school professor in Dar es Salaam, and Magdalena, the CHBC in Haydom, both underscored their vitriol over decreasing salaries and eroding health programs Finally, a principal role of ethnography in this case then is to expose the vulnerability of people who live particularly precarious lives, in order more effectivel y work to solve new problems that arise with changes in global health and HIV/AIDS care, treatment, and funding. attention to the humble, the mund ane, the little shifts in our ways of thinking and understanding, the small and contingent struggles, tensions and negotiations that give rise to In this period of financial crisis and brinksmanship, new measur es for social protection must be enacted. Historically, HIV/AIDS care has served as a moral guidepost, and perhaps it can do so again as Julio Frenk (2006)

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273 been 2013b:337). A Look Ahead Many of the interviews I conducted involved a n aspirational vision of a sustainable future, which included the development of all interconnecte d sectors that would contribute to sustainable good population health, in particular infrastructure (buildings, roads, electrification), education (primary up through medical education and training), and increased governmental people would talk about it at length. Several informants noted that there were some significant improvements to the health system in Tanzania, however, including the improved management of h ealth programs (especially for chronic diseases), improved routine monitoring and evaluation, and contributed to infrastructure development and equipment procurement. As mentioned in Chapter 4 , PEPFAR has been instrumental in managing the HIV epidemic, and putting millions on ARVs. An important question now is how to leverage the successes of the HIV response into building a more sustainable health system, instead of just one, disease specific program. To do so, there are many significant challenges to over come currently in the Tanzanian system. First of all, as mentioned above, it is important to more clearly define what is meant by health is typically divided up into two categories financial assistance and technical assistance sustainability in health care can be envisioned along those lines as well: financial sustainability, and technical sustainability or the sustainability of a competent workforce, infra structure and equipment. Financial sustainability, he thought, is impossible right now international donor organizations will be essential in funding health care in Tanzania for the foreseeable future.

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274 Building up and sustaining a local workforce with te chnical expertise, however, may be possible The Tanzanian government in particular is working to build capacity in multiple ways. In the last decade, Tanzania has increased by 175% educational funding per capita, and overseen a 290% increase in secondary school enrollment (Lee and Morisset 2012). They continue to improve roads and infrastructure, and it has a national economy growing at about 7% a year, one of the highest in the world (World Ban Strategic Plan (HSSP III), Tanzania is working to extend primary health care services to all Tanzanians within the next decade. Extending health services, particularly in rural areas, is a keystone to Tanzanian Ministry of Health and Social Welfare estimates that to do implement the HSSP III, it will need to add 88,829 health care workers to staff the additional 5,201 he alth facilities it intends to build, in addition to the 90,722 health care workers already needed to shore up health Health Strategic Plan, only 35,202 health care workers staff both public and private Tanzanian health facilities Tanzania will need a more than five fold increase in health care professionals to meet HSSP III goals. Health care workers like Lucia and Esther, however, are finally getting more support from the government with a series of salary increases that is slowly making up for the years of salary freezes. Health care workers like Lucia and Esther, I believe, are the key to building a sustainable health system. They know the system much better, le t alone the culture and language, and perhaps most importantly, they are staying for now, providing care for patients as well as educating a new crop of doctors.

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275 Despite employment opportunities in the private sector or in the UK or USA where they could e arn significantly more, Esther and Lucia stay in Tanzania, and work hard to provide good care to their fellow Tanzanians. I asked them why they stay when so many others are leaving, and their answers ranged from a deep love for their country and fellow Tan zanians, to feelings of But they also cited the shortage of human resources as critical to their decision to stay. o India, we'll just be another doctor in a 100 doctors, and I'll be contributing valuable services, and doing a valuable thing, but there will the US, where she ve to know for five years after I've left, things will continue. And if they will continue for another 20 years, the Contributions of the Dissertation I had three priorities in this dissertation. F irst, to examine aid withdrawal , healt h care fu nding and volatility as a central point, instead of as a tangential phenomenon that is either brushed off as inevitable or considered beyond the scope of any one project or program evaluation. This instability in health care funding and availabili ty became evident over long term ethnographic research in two related sites, where I could witness the vast changes that occur over short periods of time , particularly for essential health care. I conducted multi sited research at Haydom Lutheran Hospital and in Dar es Salaam, looking at the many levels of care, practice

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276 and policy making that impact directly on program implementation . This included the experiences and opinions of patients, health care wor kers, administ rators and policy makers in clinics, hospitals, and regional NGO offices. Doing so, I was able to discover how these levels intersect and interact, and most importantly, how they affect the health and well being of the people these programs are intended to help. Exposing the spatial inequalities and temporal instabilities, alongside the variations that occur across different levels, allowed me to create a more nuanced estimation of HIV/AIDS programs, funding and policies over time. My second priority was t o document the everyday lived experiences of this instability and volatility. I used the conceptual frame of precarity to k ey in to other works that circle around the anxiety and uncertainty people are increasingly exposed to dispos in neoliberalism (Muehlebach 2013 ) . Critical here is the inequality in exposure to precariousness; overwhelmingly, those who experience it the most are vulnerable to many other risks that also contribute to poor health outcomes. Most w ork in precarity, however, centers on the European experience of draconian austerity measures eroding the established welfare state, particularly post 2008. Importantly, African populations have rarely if ever been included in t hese conversations and calcu lations of precarity . Current d iscussions of precarity , therefore, principally highlight the experiences of those who have until now only ra rely experience d precariousness, leaving out large populations of the global poor and a large part of the picture of how precarity is experienced throughout the world . Engaging the experiences of precarity from some of the most precarious people people living with HIV/AIDS in rural Tanzania, therefore, is important for understanding the range of expe riences of it . For example, those of us wazungu (white foreigners) who lived and worked in Haydom during this time felt that the potential termination of funding from the Royal Norwegian Embassy was nothing short

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2 77 of a catastrophe, even though we would not be directly affected by it; the Tanzanians who lived in Haydom felt much differently something would work out, people told me, Mungu akipenda (if God wishes it). This experience, for me, suggests that for those people who only rarely are exposed to this sort of precariousness (us wazungu in this case), feel it more harshly than those who experience it often. Precariousness is perhaps experienced as less severe when subjected to it all the time, and like many of the people I worked with over these years, h ave developed a resiliency to it. However, like Muehlebach (2013 ) warns seem to be telling themselves a soothing story: the poor are strong (no matter how often we batter them); they can withstand (no matter how much we exploit them); they will bend and 301). Keeping mindful of both the a gency exhibited by people in the face of precariousness, an d the various forms of structural violence that impede agency, is an important contribution of anthropology in global health. A third priority of this dissertation was to critically examine the effor ts of administrators and policy makers to make health care more sustainable, and to see how those efforts were playing out on the ground. Perhaps unsurprisingly, most informants believed the policies in place have had little positive impact on the sustainability of the Tanz anian health c are system itself. Efforts so far have largely failed to strengthen the health system and overcome the human resources for health crisis that emerged during structural adjustment. The human resources crisis was exacerbated by the proliferation of NGOs and other private institutions contributing to an unruly mélange of health care delivery, operating what many believed to be a fragmented health system (Buse and Walt 1997). The internal brain drain of health care workers, additionally, from the public to pr ivate sector, is also undermining sustainable care in Tanzania.

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278 James Pfeiffer and colleagues ( 2008 ) recognized these barriers to sustainability in health brought publi c systems and promoting local leadership and talent. Findings from this dissertation can add to this code of conduct . For example, workers hired by NGOs to work part time in the public sector can eas e the burden placed on clinicians working in the understaffed government hospitals. O r , for the promotion of more diagonal programs that use donor funds to build up capacity and services that are related to vertical program s bu t expand them to be made available to more people. Finally, i f sustainability is the primary long term goal, as outlined in countless global health policies, disease specific programs will need to be better integrated into the public health system in Tanzania . T aking seriously the concerns and recommendations of Tanzanian health car e experts and patients is also critical. N ot only are they frontline observers and astute critics, they speak the language, best understand the culture, are linked up with i mportant networks, and have lived through extreme precariousness that can pervade dai ly life, and particularly the precariousness that is, for now, an integral part of health care in Tanzania. As the Sustainable Development Goals rise to the top of the glo bal agenda , addressing many of these issues of health care delivery and volatility outlined in this dissertation are essential precursors for establishing true sustainability in health care, particularly in don or dependent contexts such as contemporary Tan zania.

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279 APPENDIX A SEMI STRUCTURED INTERVIEW QUESTIONS FOR WOMEN IN PMTCT Basic Demographics: 1. How old are you? (una umri gani?) 2. How many children that are living do you have? (una watoto wangapi walio hai sasa?) How many children of yours have died? (U na watoto wangapi waliofariki?) What did they die from? (kama watoto walifiriki, nini ilisababisha vifo vyao?) 3. Are you pregnant now? (umjamzito sasa?) 4. When was your last child born? (mtoto ya mwisho alizaliwa lini?) Are you enrolled in the PMTCT program no w? (unashiriki na programu ya PMTCT sasa hivi?) What years were you enrolled in the PMTCT program? (Lini ulishiriki na programu ya PMTCT? Miaka ipi?) 5. Where do you live? (Unaishi wapi? Kijiji gani?) Do you come to HLH every month? (Unaenda hospitali ya Hayd om kila mwezi?) How do you get to the hospital when you come? (Unatumia usafiri gani kuenda hospitali?) 6. Are you married? (Je, umeolewa?) Mjane, hajaolewa, bado mdogo, ameachana, talaka) 7. Have you disclosed your status to others? (Umewahi kuambia ndugu zak o kuhusu HIV yako?) Semi Structured Questions: 1. Why did you choose HLH for your HIV care? Kwa nini unachagua HLH kwa matibabu ya ukimwi? a. Have you ever gone to another health center for your HIV care? Umewahi kuenda kituo cha afya kingine kupata matibabu ya ukimwi? i. If yes, where? Kama ndiyo, ni wapi? ii. Why did you decide to come here instead of the other center? Kwa nini uliamua kuja hapa badala ya kituo kingine? b. If you needed to choose another health clinic, you would choose to go where to get care? Ungehi taji kuchagua kituo cha afya kingine, ungechagua wapi ili kupata matibabu ya ukimwi? i. Kwa nini? 2. When you were enrolled in the PMTCT program, how was life? Was it easier or harder? Why? Can you give examples? (Uliposhiriki na programu ya PMTCT hapa, hali yak o iliendeleaje? Maisha ilikuwa ngumu zaidi kuliko na sasa, au rahisi zaidi? Kwa nini? Unaweza kutoa mifano? a. What sort of support/help did you receive from the PMTCT program? (help with food, help with transport, help with medications, help with ante natal care, delivery, and post natal care?) (Ulipokea msaada gani kwa programu ya PMTCT? Ulipokea msaada kama chakula, pesa kwa kusafiri, msaada na dawa, matibabu kwa wajawazito na akina mama?) i. What helped the most? Why? Can you give examples? (Msaada/misaada ga ni ilikusaidia sana? Kwa nini? Unaweza kutoa mifano?) ii. What helped the least? Why? Can you give examples? (Msaada/misaada gani hajakusaidia? Kwa nini? Unaweza kutoa mifano?)

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280 b. Did you receive the same kinds of help the whole time you were enrolled in the prog ram, or did it change? How? Why? When? (Ulipokea msaada sawasawa kwa muda mzima uliposhiriki na programu ya PMTCT? Au msaada ilibadilika? Vipi? Kwa nini? Lini?) 3. Before you were enrolled in the program, how was life? Was it easier or harder? Why? Can you gi ve examples? (Kabla ya ulishiriki na programu ya PMTCT, hali yako iliendeleaje? Maisha ilikuwa ngumu zaidi kuliko sasa, au rahisi zaidi? Kwa nini? Unaweza kutoa mifano?) a. Did you receive any help or support before you started with the PMTCT program? Like wh at? From who? (Ulipokea msaada kabla hujaanza programu ya PMTCT? Kama nini? Ilitoka shirika gani?) i. What helped the most? Why? (Msaada gani ilikusaidia sana? Kwa nini?) ii. What helped the least? Why? (Msaada gani haikukusaidia? Kwa nini?) 4. After you finished th e program, how was life? Were you able to manage? Was life easier or harder? Why? Can you give examples? (Baada ya ulishiriki na programu ya PMTCT, hali yako iliendeleaje? Kwa nini? Unaweza kutoa mifano?) a. Did you receive any help or support from the CTC or another organization after you finished the PMTCT program? Like what? (Ulipokea msaada na CTC au shirika nyingine baada ya ulimaliza programu ya PMTCT?) i. What helped the most? Why? (Msaada gani ilikusaidia sana? Kwa nini?) ii. What helped the least? Why? (Msaa da gani haikukusaidia? Kwa nini?) b. Do you still receive any help or support from the CTC or another organization other than ARVs? What? Why? Are others receiving similar support? (Hata sasa, unapokea msaada na CTC au shirika nyingine, siyo dawa kwa kurefush a maisha? Kama nini? Kwa nini? Watu wengine wanapokea msaada kama hii pia?) 5. What are some of the most important ways you and your family try to stay healthy? How are you able to do it? (Unafanya nini kuhakikisha familia yako kubaki au kuishi na afya njema? ) a. What are some of the biggest challenges you have in maintaining your health? (Changamoto zipi unazopata sasa kwa kubaki/kuishi na afya njema? Kwa nini? Inawezekana kufanya nini ili kurekebisha afya yako? b. What could the hospital or CTC do to make it easie r for you to stay healthy? (Kuna vitu vyovyote kwamba hospitali au CTC itaweza kufanya kurahisisha kwa wewe kubaki au kuishi na afya njema?) 6. Does anyone from the hospital come visit you? How often? For what reason? (Je, kuna watu wowote wa hospitali/kijiji ni wanakutembelea wakati una shida? Nani? Wahudumu wa PMTCT au wahudumu wa kijiji (VHWs)? Mara ngapi? Kama ndiyo, wanakupangia msaada gani? 7. Do you hope to have more children? Why, why not? (Unatumaini kutawa na watoto zaidi? Unapanga kuwa na watoto zaidi? Kwa nini?) 8. Have you ever gone to Loliondo? Why or why not? Would you recommend others go? Why or why not? (Umetembelea Babu wa Loliondo? Lini? Kwa nini? Je, unajisikiaje sasa kuna badiliko lolote? Lipi? Je, utashauri wengine waende kupata kikombe pia? Kwa nini?) a. Have you tried other traditional medicine to treat your HIV? Why or why not? (Umejaribu dawa mengine kutiba HIV yako? Kama nini? Kwa nini?)

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281 9. be able to get them? Why? (Umewahi kulikuwa na shida kupata ARVs? Kwa nini? Umewahi kuwa na wasiwasi ?

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282 APPENDIX B SEMI STRUCTURED INTERVIEWS, HAYDOM Demographic I nformatio n 1. Umri (age) 2. Jinsia (sex) 3. Elimu (education) 4. Kijiji/Kitangoji (city, district) Semi structured Questions : 1. Unafikiri magongwa yameongezeka au yamepungua siku hizi? (do you think diseases have increased or decreased these days?) a. Kwa nini? Aina gani? (why, what kind?) b. Unaonaje magonjwa ya watoto siku hizi? (what kinds of diseases do children have these days?) c. Kwa nini? (why) d. Unaweza kutoa mifano? (can you give examples?) 2. Je, ukiwa mgonjwa, utachagua wapi ili kupata matibabu? Kwa mfano, hospitali ya Haydom, h ospitali ya Mbulu, Mewedan, Labay? (if you were sick, where would you cho o se to go to get health care? For example, HLH, Mbulu hospital, Mewedan dispensary, Labay dispensary?) a. Kwa nini? (why) b. Ukihitaji kuchagua kituo kingine, utachagua wapi ili kupata mati babu? (if you had to choose a different clinic, where would you ch o ose to go to get health care?) i. Kwa nini? (why) 3. Unafikiri kuna tofauti gani kati ya miaka iliyopita na sasa? (do you think there are many differences now compared with previous years? this is in reference to the hospital, using the times of the previous Medical Directors of the hospital as guides) a. Katika kipindi cha Dr. Olsen, maisha ni vipi? (during the time of D r. Olsen, how was life?) b. Katika kipindi cha Dr. Oystein, maisha ni vipi? (during the time of Dr. Oystein, how was life) c. Na kama sasa, maisha ni vipi? (and now, how is life?) 4. Katika swali hili, tunapenda kujua juu ya hali ya maisha yako na ya jamii kwa mia ka kumi na tano iliyopita. Kama hali ya mavuno, ugumo wa kazi, hali ya maendeleo, hali ya elimu, na hali ya uchumi. (in this question, we would like to know about the state of your life and that of the community during the past 15 years. Like the state of crops/food, the difficulty of work, the state of development, the state of education, and the state of the economy). a. Kwanza, unaweza kueleza mabadiliko yalitokea ndani ya miaka kumi na tano ya hali ya mavuno, kwa ujumla? (kama katika 1990s? early 2000s? mi aka tano

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283 iliyopita?) (first, can you explain changes in crops/food that have happened within the past 15 years, in general?) i. Unaweza kutoa mifano? (can you give examples?) b. Unaweza kuelezea mabadiliko yalitokea ndani ya miaka kumi na tano ya ugumo na kazi, kwa ujumla? (kama katika 1990s? early 2000s? miaka tano iliyopita?) (same question, difficulty of work) i. Unaweza kutoa mifano? c. Unaweza kuelezea mabadiliko yalitokea ndani ya miaka kumi na tano ya hali ya maendeleo, kwa ujumla? (kama katika 1990s? early 200 0s? miaka tano iliyopita?) (state of development) i. Unaweza kutoa mifano? d. Unaweza kuelezea mabadiliko yalitokea ndani ya miaka kumi na tano ya hali ya elimu, kwa ujumla? (kama katika late 1990s? early 2000s? miaka tano iliyopita?) (state of education) i. Unawez a kutoa mifano? e. Unaweza kuelezea mabadiliko yalitokea ndani ya miaka kumi na tano ya hali ya uchumi, kwa ujumla? (kama katika 1990s? early 2000s? miaka tano iliyopita?) (state of education) i. Unaweza kutoa mifano? 5. Kwa kawaida, watu husaidiana katika maisha w akati wa uhitaji, shida na furaha. Je, unaweza kueleza jinsi watu waivyosaidiana: (Usually, people help each other in life during times of need, times of problems and times of celebration. Can you explain how a. Katika uhitaji? Kwa ni ni? Kwa mfano? (during times of need?) b. Katika shida? Kwa nini? Kwa mfano? (during times of problems?) c. Katika furaha? Kwa nini? Kwa mfano? (during times of celebration?) 6. meaning a. Je, kuna tofauti kati ya ufadhili na msaada? (is it different from help?) b. Unafahamu watu au taasisi/mashirika iliyopokea ufadhili? Kwa mfano? (do you know any people or organizations that have received aid? For examp le?) i. Kama katika hospitali ya Haydom? Kama nini, kwa mfano? Ufadhili unafika mwisho? Kwa nini? Kitu gani itatokea? (like in the hospital? For example? Has the aid come to an end? Why? What happened after it ended?) ii. Kama katika kijiji? Kama nini, kwa mfano? Ufadhili unafika mwisho? Kwa nini? Kitu gani itatokea? (like in town? Has the aid come to an end? Why? What happened after it ended?)

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284 iii. Kama kwa mtu binafsi? Kama nini, kwa mfano? Ufadhili unafika mwisho? Kwa nini? Kitu gani itatokea? (like for individuals? Like what, why? Has this aid come to an end? Why? What happened after it ended?) c. Je, kuna hasara yakupokea ufadhili? (does any loss/damage come from aid?) d. Je, kuna faidha yakupokea ufadhili? (does any profit/good come from aid?) e. Je, umeon a ufadhili iliyofika mwisho? Kulitokea nini? (have you seen aid come to an end? What happened?) 7. of corruption? Can you explain it?) a. Aina ngapi ya rushwa? Unaweza kueleza? (wha t kinds of corruption are there? Can you explain it?) b. Kuna rushwa katika jamii? Hospitali? Kijiji? Ofisi ya kijiji? Polisi? (Is there corruption in society? The hospital? The town? Local government? The police? i. Kwa nini? (why?) ii. Unafikiri watu wanapokea ru shwa kwa nini? Unafikiri watu wanapokea rushwa zaidi kuliko na zamani? Kwa nini? (Why do you think people accept bribes? Do you think that people receive bribes more than in the past? Why?)

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285 APPENDIX C SEMI STRUCTURED INTERVIEW QUESTIONS, HEALTH CARE WOR KERS AT HAYDOM LUTHERAN HOSPITAL Basic demographic information 1. Job title and description (Jina la kazi husika; wasifu wa kazi) 2. Date started working at HLH (kwa muda gani ulianza kazi katika HLH kwa ujumla?) 3. Any previous jobs at HLH before the current one? (Ulikuwa na nafasi/kazi yeyote katika HLH kabla ya nafasi/kazi uliyonayo sasa?) Semi structured interview questions 1. What changes have you seen at the hospital in the past 10 years? (Unafikiri kuna tofauti gani kati ya miaka kumi iliyopita na sasa katika hospitali?) a. In your department/ward specifically? (katika wardi yako?) b. What were some positive changes, negative changes? 2. Have you worked with any specific programs that (were donor funded and) had a beginning and an end, like the ambulance program or the food for work program? (Umewahi kufanya kazi na miradi yoyote uliyopokea ufadhili kwa nchi nyingine au shirika nyingine?) a. What services did it provide? (Mradi hii ilipokea misaada gani?) b. Who funded/organized it? (Kama masharika yapi?) c. How did it change your job? (Kwa jinsi gani miradi ilmebadilisha kazi yako?) 3. What have been some of your greatest successes/accomplishments in your job? (Ni mafaniko yeno ni makubwa kwa kiasi gani?) a. How were you able to achieve them? (Kwa jinsi gani ulifikia?) 4. What are some of your current challenges in your job? (Changamoto zipi unazopata sasa?) a. Why? (Kwa nini?) b. What can be done to improve them? (Mnaweza kufanya nini ili kurekebisha?) 5. What will happen if much of the donor funding ends? (Unafikiri ufadhili una fika mwisho? Kwa nini? Kitu gani itatokea kwa hospitali kwa ujumla? Kwa wagonjwa?) a. How will your job be affected? (Kitu gani itatokea kwa k azi yako hapa katika hospitali?) b. How will your department be affected? (Kitu gani itatokea katika wardi yako kwa ujumla?) 6. When you think of Norway/the Norwegians, what do you think of? (Wakati wa unafikiri kuhusu WaNorway, unafikiri nini?) 7. What do you thin k about the volunteers who come here? Do they help? How? (Unafikiri nini kuhusu washiriki wanaofika hapa? Unafikiri wanasaidia hospitali? Kwa jinsi gani?)

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314 BIOGRAPHICAL SKETCH Meredith Marten was born and raised in Mi chigan, and received her BA in a nthropology from Michigan State University in 2002. She began her graduate education with a focus in maritime archaeology , and conducted research on the Mediterranean coast of Turkey for her thesis. She completed an MA in a nthropology from Florida State University in 200 5. After that, and received an MPH in international health and d evelopment in 2008. During this time, she completed a field course in HIV/AIDS programming in Kenya, and an internship in adherence and psychosocial s upport at an HIV/AIDS NGO in Dar es Salaam, Tanzania. She returned to Flori da in 2008 to begin her PhD in medical a nthropolog y at the University of Florida, conducted fieldwork in 2009, and 2011 2012, and received her Ph.D. in August 2014.