AN INSTITUTIONAL ANALYSIS OF COMMUNITY AND HOME BASED CARE AND SUPPORT FOR HIV/AIDS SUFFERERS IN RURAL HOUSEHOLDS IN MALAWI A thesis submitted in fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY IN ECONOMICS of RHODES UNIVERSITY by SPY MBIRIYAWAKA MUNTHALI December, 2008 Abstract Standard economic models often emphasize inputs, outputs and an examination of the structures in order to conduct an economic performance evaluation. This study applies the Institutional and Development Framework (IAD) in the broader context of New Institutional Economics (NIE) in order to examine the transaction costs of delivering Community and Home Based Care and Support (CHBC) to HIV/AIDS sufferers. For purposes of unveiling the empirical reality guiding decision making processes in the CHBC service delivery, comparative qualitative research techniques of normative variable and concept formation have been adopted to draw out the relative institutional influences from the HIV/AIDS national response partnerships. The study identifies the conflict between the predominantly standardized and more rigid formal management techniques adopted by key members of the national response and the informal cultural techniques familiar to the rural communities, and a lack of motivational incentives in the CHBC structures as the key factors against CHBC capacities to draw external funding for service delivery. CHBCs are also weakened by incoherent governance structures at the district level for facilitation of funding and information flow exacerbating the community vulnerability. Rationalization of the institutional arrangements and a clarification of roles from district to community levels, a shift of focus to facilitation of informal techniques and an integration of performance enhancing incentives are the critical policy insights envisaged to spur CHBCs to work better. Table of Contents Abstract……………………………………………………………………………………i Table of Contents…………………………………………………………………………ii List of Tables…………………………………………………………………………….vi List of Figures…………………………………………………………………………...vii List of Acronyms………………………………………………………………………..viii Acknowledgements………………………………………………………………………xi Introduction………………………………………………………………………………1 Chapter One……………………………………………………………………………...2 Introduction to the Malawi Poverty and HIV/AIDS Situation …………………….…2 1.0 Introduction………………………………………………………………….….…2 1.1 Descriptive Geographical, Administrative and Economic Characteristics…….….2 1.1.1 A Brief on Thyolo and Ntcheu Districts.....……………………………….4 1.2 The Malawi Poverty and Vulnerability Profile …………………………………..7 1.3 The HIV/AIDS Situation in Malawi……………………………………………..11 1.4 Responding to Poverty and Vulnerabilities……………………………………...12 1.4.1 Overview of the Malawi Health Sector………………………………….15 1.4.1.1 Functional Organisation of the Health Sector …………………..…….…17 1.4.1.2 Mainstream Public Sector Approach…………………………………….17 1.4.1.3 The Public-Private Mix…………………………………………………..17 1.4.1.4 The private-for-profit sector …………………………………………….18 1.4.1.5 Distribution of Health Care Facilities…………………………………....18 1.4.1.6 Organization of the National AIDS Response…………………………...19 1.4.1.7 The HIV/AIDS Policy Framework ……………………………………..20 1.4.1.8 Strategies of the National AIDS Response ……………………………...22 1.4.1.9 The Community and Home Based Care Dimension …………………….23 1.5 Statement of the Problem ………………………………………………………..25 1.6 The need for an Institutional Analysis Evaluation ………………………………27 1.7 Summary and Conclusions ………………………………………………….28 Chapter Two……………………………………………………………………...….….29 Theoretical Background to Economic Development and New Institutionalism…....29 2.1 Introduction………………………………………………………………………29 2.2 Background to Development Policy……………………………………………..30 2.2.1 Definition of Development………………………………………………31 2.2.2 Development as Freedom: The Capabilities Deprivation Approach…….32 2.2.3 Growth Oriented Development Approaches……………………………..34 2.2.3.1 Basic Needs Approach…………………………………………………...36 2.2.3.2 Growth with Redistributive Strategies…………………………………...38 2.2.3.3 Poverty Reduction Strategy (PRSP) Frameworks……………………….40 2.2.3.4 Conceptualizing the fight against HIV/AIDS……………………………41 2.3 Institutional Theories…………………………………………………………….44 ii 2.3.1 Defining Institutions……………………………………………………..46 2.3.2 The New Institutional Economics Theory (NIE)………………………...47 2.3.2.1 Justification for the application of the NIE………………………………48 2.3.2.2 The Concept of Transaction Costs……………………………………….49 2.3.2.3 Properties of the Transaction Costs Economics………………………….51 2.4 Approaches to New Institutional Economic Analysis…………………………...53 2.4.1 The Institutional and Development Framework (IAD)………………….54 2.4.2 Insights for Analysis from New Institutional Economics (NIE)………...57 2.4.3 Potential Analytical Factors……………………………………………...59 2.4.4 Examples of Empirical Application of NIE……………………………...61 2.4.5 Thematic Approaches to Institutional Analysis………………………….64 2.4.5.1 The Normative Approach………………………………………………..64 2.4.5.2 The Rational Choice Approach………………………………………….65 2.4.5.3 The Historical Institutional Approach…………………………………...66 2.4.5.4 The Empirical Institutionalism…………………………………………..66 2.4.5.5 Measuring the Extent of Institutionalization…………………………….67 2.5 Summary and Conclusions………………………………………………………...69 Chapter Three………………………………………………………………………….71 Institutional Linkages and Stakeholder Analysis of the HIV/AIDS Sub-Sector…...71 3.1 Introduction………………………………………………………………………71 3.2 An overview of the situation……………………………………………………..72 3.3 Relevant indicators specific to Malawi…………………………………………..74 3.4 Global policy and the role of IDAs in health…………………………………….77 3.5 The funding mechanisms by IDAs………………………………………………81 3.6 National and Sectoral Policy Frameworks………………………………………90 3.7 Decentralization and the structural stakeholder linkages in HIV/AIDS…………93 3.8 Analysis of systemic outcomes of the organizational arrangements…………….95 3.8.1 Outcomes associated with the IDAs in HIV/AIDS context……………..97 3.8.2 Outcomes associated with government and NAC partnership…………102 3.8.3 Outcomes associated with the NGOs in the HIV/AIDS context……….107 3.8.4 Outcomes associated with the CBOs in the HIV/AIDS context……..…109 3.9 Summary and Conclusions……………………………………………………..115 Chapter Four……………………………………………………………………….…118 Outline of the Research Methodology……………………………………………….118 4.1 Introduction…………………………………………………………………….118 4.1.1 The study objectives……………………………………………………119 4.2 Sample and Data Collection Methods…………………………………………….119 4.2.1 Overview……………………………………………………………….119 4.2.2 Sampling Technique.…………………………………………………...120 4.2.3 Sample Size ……………..……………………………………………..121 4.2.4 Specific Sampling Stages ……………………………………………...122 4.2.5 Study locations …………………………………………………………123 4.2.6 Limitations of the Study Sample ……………………………………….124 4.2.7 Ethical Considerations …………………………………………………125 iii 4.2.8 Secondary Data Collection …………………………………………….125 4.3 The Analytical Approach………………………………………………………….125 4.3.1 Application of the Institutional and Development Framework (IAD)….126 4.3.2 Broad Outline of Variables……………………………………………..128 4.3.3 Specific Analytical Techniques………………………………………...129 4.3.4 Quantitative Techniques………………………………………………..129 4.3.5 Qualitative Techniques…………………………………………………130 4.3.5.1 Construction of Categories for Analysis………………………………. 130 4.3.5.2 Relevance of the Categorical Summaries in NIE ……………………...130 4.3.5.3 Isolating and Coding for Variable Formation………………………..…133 4.3.5.4 Turning Qualitative Observations into Numbers…………………..…...133 4.4 Summary and Conclusion………………………………………………………134 Chapter Five…………………………………………………………………………..135 The Role of Community Attributes in CHBC Service Delivery…………………...135 5.1 Introduction…………………………………………………………………….135 5.2 Conceptualizing Attributes of the Communities for CHBC ….…………………137 5.2.1 Characteristics of Communities ……………………………….…..…...137 5.2.1.1 Sources of Assistance at Community level……………………………..146 5.2.2 Household Consumption Spending Patterns …………………………...150 5.2.3 Indicators of Group and Individual Resources Used for CHBCs ……...153 5.2.3.1 Provision of the CHBC Kits……………………………………………154 5.2.4 Perceptions of Internal Conditions…………………….……………….156 5.3 Distinct Patterns of Physical and Material Conditions found in the Two Districts...159 5.4 Summary and Conclusions………………………………………………...…...163 Chapter Six…………………………………………………………………………....166 Institutional Scope for Community and Home Based Care and Support………...166 6.1 Introduction…………………………………………………………………….166 6.2 National and Sectoral Policy Frameworks …………………………………….167 6.2.1 The Malawi Health Sector Policy ………………..…………………….168 6.3 Who are the Care givers at International and National Levels? ……………….170 6.4 Care and Support at Local Government Level ………………………………...171 6.4.1 Care Giving in the wake of Public Sector Decentralization Process …..172 6.5 The Community and Home Based Care and Support…………………………..177 6.5.1 External Factors in Care and Support for HIV/AIDS at Community Level…..178 6.5.1.2 Origins and Evolution of CHBC Groups……………………………….178 6.5.1.3 Indicators of Group Formation and Evolution………………………….179 6.5.1.4 Perceptions of Partners External to CHBC Groups…………………….183 6.6 How CHBCs Interact with the rest of their Community……………………...188 6.7 What Motivates the CHBC Actors?..................................................................192 6.8 What do the Actors bring to Service Delivery? ………………………...…….195 6.9 Distinct Patterns of Interaction Emerging from the Two Districts…………...199 6.10 Summary and Conclusions…………………………………………………...200 iv Chapter