Between Words and Actions
A local HIV/AIDS organization translating (inter)national and local health discourse into the local context of Denpasar, Indonesia
Michelle Dautzenberg 10535942 michelledautzenberg@gmail.com
Medical Anthropology and Sociology 2014 University of Amsterdam
Supervisor: Sylvia Tidey Second Reader: Julie McBrien Date of Submission: 27-06-2014
Image source: http://dayagainsthomophobia.org/
Between Words and Actions
A local HIV/AIDS organization translating (inter)national and local health discourse into the local context of Denpasar, Indonesia
chelle Dautzenberg 10535942 michelledautzenberg@gmail.com
Sociology 2014
http://dayagainsthomophobia.org/
ACKNOWLEDGEMENTS
There are a lot of people I would like to thank for helping me with my thesis and in the past academic year. First of all, I am grateful to be given the opportunity to study Medical Anthropology and Sociology at the University of Amsterdam. Thanks to all the lecturers and staff members that have made this year very educational. I was very lucky to have Sylvia Tidey as my supervisor, because she is very kind and was always available for help. As a student that needs her criticism constructive and is very stressed sometimes, she was the ideal supervisor. She also knows my research field, so it was fun to exchange stories and ideas with her. Thank you so much, Sylvia! I am also very grateful to the staff of Yayasan Gaya Dewata for letting me into their organization and personal lives. They have helped me from the beginning with my research and were there when I needed a friend. Without them this research would have been impossible. Thanks to all the clients that opened up to me and let me into their houses. Even though the topic was difficult, they were willing to talk to me about personal experiences and thoughts. I want to thank the doctors and nurses that took time to inform me about their hospitals and clinics. Also a special thanks to Dea from KPA Denpasar and Emily from YKP for talking to me about their organizations and the Bali situation. I was lucky to have my parents with me for my last week in Bali, to show them where I had been working and letting them meet my friends at Yayasan Gaya Dewata. Sorry you had to listen to me complaining since we got home. Last but not least I have to thank all the people I have met during my time in Bali that have helped make this a trip of a lifetime: Julia, Alessa, Ragil and Isa. I am so happy I met you and could share this experience with you. Now I thank you, the reader, for listening to my story. Enjoy!
LIST OF ABBREVIATIONS
GWL Gay, waria, LSL (“Laki-laki yang berhubungan dengan laki-laki” or “men who have sex with men”)
HCPI HIV Cooperation Program for Indonesia
IDR Indonesian Rupiah
IMF International Monetary Fund LGTB Lesbian, gay, transgender, bisexual
LSL “Laki-laki yang berhubungan dengan laki-laki” (Men who have sex with men) MDGs Millennium Development Goals
MSM Men who have sex with men
NGO Non-governmental organization
OECD Organisation for Economic Co-operation and Development
PMD Pelangi Muda Dewata
UN United Nations
UNAIDS The Joint United Nations Programme on HIV/AIDS USAID United States Agency for International Development
USD United States Dollar
WHO World Health Organization
YGD Yayasan Gaya Dewata
Table of Contents
Acknowledgements... 3
List of Abbreviations... 4
Chapter 1 Introduction... 6
Chapter 2 Theory... 9
2.1 The History of Development Theory ... 9
2.2 Anthropology and Development... 11
2.3 The Work of Tania Murray Li... 13
Chapter 3 Methodology ... 17
3.1 Choice of Research Location ... 17
3.2 Methodological Tools... 18
3.3 Changes I Have Made... 20
3.4 Personal Reflection and Obstacles... 21
Chapter 4 Programs... 23
4.1 International Level Programs ... 23
4.2 National Level Programs... 28
4.3 Regional Level Programs ... 29
Chapter 5 Practices... 33
5.1 Starting the Youth Branch ... 33
5.2 Discussion Groups ... 35
5.3 Cyber Outreach ... 39
5.4 Condom Distribution ... 42
Chapter 6 Effects ... 45
6.1 Pelangi Muda Dewata ... 45
6.2 Discussion Groups ... 46 6.3 Cyber Outreach ... 49 6.4 Condom Distribution ... 51 6.5 Funding... 53 Chapter 7 Conclusion ... 56 Bibliography... 59
CHAPTER 1 INTRODUCTION
The discussion group takes place at 3pm in Jimmy’s living room. A few other staff members and I are the first to arrive, so we sit down on the floor and wait for more people to show up. After about forty minutes and a lot of phone calls by Jimmy, seven boys and one girl have arrived. I am told that some of them are gogo-dancers like Jimmy and they took some of their friends. Most people seem to know each other, because they are all chatting. All participants are asked to write their name, home area and sexuality on a form, which leads to a discussion and joking between the participants about what to put in the “sexuality”-box: gay, bisexual or LSL1. In the end they all write “LSL”. Jimmy then passes
around bottles of water and soda and bags of crisps and candy, which all the participants start eating and drinking. Jimmy welcomes everyone and introduces Sofia as the facilitator of the discussion. The book from the AIDS commission is used again to guide the story, but Sofia adds some information I have not heard in other discussions before. For instance, she warns the youth for the bad quality condoms with flavors like strawberry and durian2and talks about the risks of the entertainment
industry most participants work in. She also talks about bargaining power: how some people do not use condoms when they get more money to do it without or when their client is extremely handsome. During the discussion, the boys make jokes and ask Sofia questions. One of the boys asks if there is medication, to which Sofia responds shortly that there is, but that they will discuss medication in the next discussion group. Another boy wants to know what an HIV-test looks like and if it hurts. After the basic information about HIV, which lasted about twenty minutes, Sofia takes out a large wooden dildo out of her bag and some condoms. This leads to much laughter. One of the boys, who happens to work at another HIV-focused NGO, volunteers to demonstrate the use of a condom. The discussion is then ended by Sofia. Jimmy distributes packages of nasi campur, which we eat together while chatting. All participants sign a form and receive IDR50,000 for coming and transportation. Another form goes around about the receiving of condoms and lubricants, which are distributed. Around 4.45pm, everyone leaves the house.
The scene above portrays one of the first discussion groups ever organized by Pelangi Muda Dewata (PMD), a new youth branch of the HIV-prevention organization I have done my research with. Starting a youth branch has not been easy for Yayasan Gaya Dewata (YGD). But in March 2014, after three years of meetings and workshops with the National Aids Commission and searching for staff, there are finally three young people that can start working. They will be reaching out to other
1“Laki-laki yang berhubungan dengan laki-laki” (LSL), translated as Men who have sex with Men (MSM). This
usually does not mean that they also have sex with women, but rather that they do not self-identify as gay.
young people from the GWL3- community, asking them to join discussion groups about HIV, taking them for HIV/STI tests and providing them with information and free condoms. Over the years working on HIV-prevention in Denpasar, YGD has found that the young people in their community were particularly hard to reach. Many of them had moved to Bali from other islands, to find work or start a new life. The youth was uneducated and unaware of the risks of HIV and STIs, but also very careless about such topics. At the same time, I found a culture of sex in which it was common for youth to ask money for sexual intercourse. Even when in a relationship, they could still have multiple casual partners. Condoms were not always used, especially with a long-term partner or when more money could be earned without. It became apparent to me that the culture of the youth is to take all the opportunities they can get and “to just have fun”, without thinking about the consequences. Health risks are not something youth in Bali likes to think about in advance. This one-day-at-the-time mentality is inherent to Indonesian culture, making HIV-prevention difficult. However, the reasons why prevention is so difficult are also the reasons why this young group of people need a youth branch like the one YGD has now started.
HIV in Indonesia is a concentrated epidemic, which we can see in the skyrocketing prevalence numbers for key populations, such as transgender people (43%), female sex workers (7%), and MSM (8%)4. In order to fight this epidemic, a MDGs5Acceleration Action Plan 2011-2015 has been
developed by international funders and national government: keeping HIV/AIDS high on the national agenda and promoting stronger responses from a subnational level. International actors are mainly interested in the funding of technical solutions, such as free antiretroviral therapy and condoms. They also fund Indonesia’s national government, which is asked to take up responsibility and coordinate all the projects that are implemented on national and regional level. Funding ends up at the local organizations such as YGD through national level actors. Because of international funding and national coordination, YGD is heavily influenced by international discourses on gender, HIV, and human rights. At the same time, they know the local context and their community better than anyone. I believe it is interesting to see what YGD is able to do in reality and therefore in this thesis I ask the question: How does the youth branch of Gaya Dewata translate (inter)national and local HIV/AIDS and LGBT discourses into the local Balinese context?
3Gay, waria and LSL. GWL is the Indonesian version of LGBT. In the case of Yayasan Gaya Dewata, lesbians are
not a focus.
4Indonesian National AIDS Commission 2012: Republic of Indonesia Country Report on the Follow up to the
Declaration of Commitment On HIV/AIDS (UNGASS). Reporting period 2010-2011.
My research explores the position of a local NGO within the field of global health. This has been done by more scholars within the field of anthropology of development6, to which I want to add a study from the perspective of the local NGO. I believe current literature too often portrays
grassroots organizations as puppets at the bottom of a hierarchy7or shifts its focus to the need for anthropological methods within development programs8. Luckily there are also many scholars who try to show the agency and flexibility grassroots organizations might show and the practical differences they do make. Many organizations, like Gaya Dewata, have given us new and better understandings of local contexts, laying bare the social inequalities underlying the disease, as well as the agency of the local population. In order to analyze if and how Gaya Dewata’s (inter)national discourse gets translated into local actions, I draw upon three key concepts in the work of Tania Li Murray: programs, practices and effects. Through her theory I can show the discourses that underlie HIV-prevention in Denpasar, but most of all discuss the actual local practices and their effects in detail. This is also the goal of my research, to show how global health discourse influences local NGOs and vice versa, but without taking away the agency and flexibility the NGO might show.
After this introduction, I elaborate in a theory chapter on the history of development, the role of anthropology in development and Tania Li Murray’s theory on governmentality. Chapter 3 then discusses the methods I used during my fieldwork, as well as changes I have made in the process and obstacles that I encountered. Chapter 4 discusses the programs that are being implemented from the international, national and regional level by the different actors I have encountered in YGD’s aid chain. Chapter 5 portrays three of the main activities YGD’s youth branch occupies itself with, while giving their background and telling what I have learned about these practices. Chapter 6 discusses the positive and negative, intended and unintended effects of the three practices, as well as the possible effect of the cancelation of further funding. I end with a conclusion in which I answer my research question and raise some new questions for further research.
6See for example: Fyvie and Ager 1999; Barr et al. 2005; Aveling 2010; Kelly and Birdsall 2010; Vaughan 2010;
Watkins et al. 2012.
7See for example: Aveling 2010; Kelly and Birdsall 2010.
8For examples of anthropological methods in development research see: Campbell and Jovchelovitch 2000;
Vaughan 2010; Aveling 2012. For an overview of anthropologists in the field of development, see for example: Paiement 2007.
CHAPTER 2 THEORY
2.1 THE HISTORY OF DEVELOPMENT THEORY
The history of development theory can be roughly divided into five timeframes, each with different underlying theories, ideologies and perspectives. It remains hard to pinpoint the exact beginning of what we now see as “development”, for it may refer to: “improvements in well-being, living standards, and opportunities. It may also refer to historical processes of commodification,
industrialization, modernization, or globalization. It can be a legitimizing strategy for states, and its ambiguity lends itself to discourses of citizen entitlement as well as state control” (Edelman & Haugerud 2005:1). Here I follow the outline that is also used by Greig, Hulme and Turner (2007) and that traces back the origin of contemporary development theory to the ‘evolutionary development’ in the eighteenth and nineteenth century. Based on the ideology of the Enlightenment and fuelled by the French and Industrial Revolutions, the idea evolved of the need for “underdeveloped” countries to catch up to the Western world. Since the West had already followed this linear path to modernity, they could provide an example and guidance for other countries. This idea also justified colonization, since the West was just: “providing native populations with the benefits of improvement and orderly rule” (Li 2007a:13). Colonies would become more developed, while the West remained their “right to rule”.
The post-war era has also been named “The Development Project” or after its underlying “modernization theory”. Under pressure by economic and military blows suffered in the World Wars and growing independence movements many countries had to let go of their colonies. But not further helping them on their road to development, or “replicating the form of development achieved in the West”, would be a threat to the West’s security and leave them open to the “seductive promises of communism” (Greig et al. 2007:67,70). Big international institutions such as GATT, IMF and World Bank were founded for this purpose and were heavily influenced by the United States and the popular ideologies of capitalism and Marxism. During this period decolonization, national economic planning, agricultural modernization, industrialization and managing the Cold War were more important than poverty. Modernization was what was needed and as a side-effect “economic growth would sweep away poverty as income rose” (Greig et al. 2007:20). Modernization theory did take into account that social, cultural, political and economic life is connected and that all need to be addressed in order to reach a state of modernity. The theory however, underwent heavy critiques for being ethnocentric, portraying post-war capitalism too glorious, believing in a linear and straightforward path to modernity and for not paying attention to existing power struggles.
The 1960s and 1970s herald a new time period for development theory: that of dependency theory and the “basic needs” approach. The focus in development shifted from economic growth to actual poverty reduction. Structuralists perspectives flourished: “rather than looking at the
symptoms of inequality (individual opportunities and outcomes), the focus should be the
underpinning processes and causes (social structures that foster unequal power relations). [..] From a structuralist perspective, poverty and deprivation are not the result of a lack of resources but the maldistribution of resources” (Greig et al. 2007:13). The market was considered imperfect and in need of help: The supranational finance and governance institutions (World Bank, IMF, UN) were to assist nation-states in the development quest (Edelman & Haugerud 2005:6). Service delivery strategies, direct action by government and civil societies and redistribution of resources and power were the new actions being taken by national governments and international institutions. The poverty line was introduced as an instrument of measurement. Structuralist perspectives and the rising critique on modernization theory gave rise to dependency theory and World system analysis. According to these theories, the world can be divided in core and periphery and the possibility of development is determined by the relationship of exploitation between the two. While the core and periphery were seen as mutually beneficial in modernization theory, in dependency theory the core gained its power and wealth at the expense of the periphery. Instead of underdevelopment just being there, the West was actively creating it. Dependency theory was criticized for portraying a zero-sum game. If this were the case it could be expected that the periphery withdrew from the system or abandoned capitalism, which did not happen. It contributed too little agency to the periphery and was once more considered to be ethnocentric.
The 1980s mark the start of neoliberalism and rational choice theory in development. A radical shift came about from structuralist perspectives to individualist perspectives: “neoliberal (or rational choice) frameworks focus on individual human agency and conceptualize social processes as the aggregation of the choices and outcomes that all the individuals in a society take and achieve. [..] People experiencing poverty (those on low incomes) will rapidly make a set of choices (working longer hours, reducing expenditure, developing new skills, and taking new jobs) that will lift them out of poverty.” (Greig et al. 2007: 24). Poverty was the result of bad choices and bad luck, but since the world is a level playing field, poor people would be able to lift themselves out of poverty. Policies should only create an “enabling environment so the poor people can work themselves out” (Greig et al. 2007:29). And since the problem lies with the people, the people and the free market will have to work things out without the state: “Governments were part of the problem, not part of the solution; they were inefficient and often corrupt and hence parasitic, not stimulators of growth” (Leys 2005:113). Completely opposite to the programs that provided basic needs in collaboration with
national governments in the 1970s, The World Bank and IMF now promoted structural adjustment: to reduce the state role in the economy, and called for reductions in state expenditures on social services such as education and health care, introduction of user fees for such services, trade liberalization, currency devaluation, selling off of state-owned enterprises, and financial and labor market deregulation (Edelman & Haugerud 2005:7). Growth, liberation of economies, expending of free markets and the minimization of the dead hand of the state would lead to growing economic wealth that would eventually trickle down to the poorest people.
The development theory of the twenty-first century is still dominated by neoliberalism and its focus on free markets. Meanwhile globalization discourse is increasingly becoming intertwined with development discourse. Now that a world economy becomes more visible, so is the fact that some parts of the periphery become irrelevant to it, while it provides more opportunities to others. The power of the state is being questioned further, as the global market gains momentum (Edelman & Haugerud 2005:3). Globalization discourse with its questions of inclusion and exclusion
complicates individualistic perspectives on development that see human agency, social processes and the market as naturally leading to improvement. It seems that inequalities are not only getting bigger between nations, but also within nations. Neoliberalism is therefore being critiqued for letting economic growth overshadow the growing inequalities. The role of the state must be reconsidered.
2.2 ANTHROPOLOGY AND DEVELOPMENT
Anthropology has always been closely connected to the field of development, either critiquing it or contributing to it. The initial evolutionary schemes of the nineteenth century were heavily critiqued for being empirically flawed and ethnocentric. Anthropologists took it upon themselves to show how each society was unique in its own way and deserved to be valued (Ferguson 2005:142), what we would later name salvage anthropology. This vision changed drastically with the end of the war and proceeding decolonization: “Where anthropological liberalism had once been most comfortable arguing that non-modern ‘others’ had functioning, well-adapted social and cultural orders of their own, the times more and more called for a different argument: that ‘‘natives’’ could just as well, given a little time (and perhaps a little help), participate in the modern world on equal terms (Ferguson 2005:144). Modernization theory gave anthropology the task to figure out how to do this in the best way. Not only modernization theory, but also traditional anthropology then became heavily critiqued in the late 1960s for not paying enough attention to processes of social change and power struggles. This led to two new insights: dependency theory and the rejection of capitalist development (Ferguson 2005:146). Instead of describing static traditional societies in the Third
World, anthropology started to focus itself on the dynamic processes of the world and underlying structures.
Up until this point anthropology had academically written about development problems, but kept its distance from applied issues of development. According to Paiement (2007:206) this worked the other way as well: their colleagues in development preferred to ignore or remained skeptical about the contribution of anthropology and its general or abstract knowledge. It was not until the 1970s that the social sciences became actively involved with program planning and policy. It dawned on the field of development that economists alone were not able to account for human behavior, not in the least due to the failures of previous development programs. In the 1970s anthropology finally got the chance to show its relevance and prove that it could also say something about change and the modern world (Ferguson 2005:147): the subfield of development anthropology was born. However, development anthropology still had to adapt itself to the bureaucratic demands of government agencies, for which they were especially critiqued by academic anthropologists. Also, within development agencies, anthropology was still questioned for bringing more complexity than solutions (Ferguson 2005:147). Still, with a newfound focus on the social context of development, the basic needs approach came to define development programs at that time.
In the 1980s and 1990s anthropologists, greatly influenced by the work of Michel Foucault and poststructuralists, kept criticizing prevalent development approaches that they considered too technical, too economy focused and too top-down. Instead, it was key to “analyze the dynamic interpretations, strategies, and practices of local actors and not just their reactions to outside interventions” (Paiement 2007:203), techniques the anthropologist was trained in. With the creation of Rapid Rural Appraisal, “a multidisciplinary set of techniques adapted from social science interview and survey methods” (Paiement 2007:208), qualitative methods were introduced to the field.
In contemporary development, anthropology seems to have finally been able to show its relevance, which is reflected in the number of social scientists working within the development industry and their power. These people have been able to shift “definitions of development” and grow “awareness of the importance of social and cultural phenomena to effective development policies and planning” (Paiement 2007:205). However, it can often be seen that even now the global health apparatus keeps searching for “one-size-fits-all”, technical solutions from a biomedical expertise, while anthropologists have long proven that the social inequalities underlying medical problems need a more horizontal and sustainable approach (Cueto 2013). In practice, “quick and clean” methods are often still preferred, especially with the bigger organizations that need clear and fast results (Paiement 2007:210-211). This has led to a broader subdiscipline, anthropology of
development, which critically looks at the role of anthropology within development. Here critical questions are asked about the failing of planned development and the rise of poverty, as well as the global health approach and anthropological contribution to development.
Part of this critical literature by anthropologists on development centers around the global HIV/AIDS epidemic (Campbell & Cornish 2010; Hanefeld 2010). For example in the studies of Campbell (2003) and Campbell and Cornish (2010) in which they critique current HIV-interventions for having a top down approach from a western perspective, without any input by the local
community. Other studies for example by Vaughan (2010) and Aveling (2012) strengthen this critique on the lack of engagement with local target communities as well as the lack of input of
non-biomedical knowledge. Such causes are said to hinder the finding of diverse, tailor-made, locally successful and sustainable solutions to the HIV/AIDS epidemic. It is to this body of literature I hope to make a contribution.
2.3 THE WORK OF TANIA MURRAY LI
Anthropology has often been criticized for adding complexity to the understanding of development, while not coming up with alternative solutions or methods. The work of Michel Foucault was especially helpful in complicating the discussion and has been the foundation for the work on development of many contemporary anthropologists. Tania Li is one of the many anthropologists interested in the problematics of "improvement of the human condition" who has been inspired by Foucault. In her work she has mastered the art of using detailed ethnography to make us think about more overarching and abstract Foucauldian processes such as governmentality, development and the practice of politics. She lays bare the underlying processes and power struggles that shape a particular development situation (mostly Indonesia in her work) on local, national and international level. Li is able to show both top-down and bottom-up perspectives, where they might complement each other and where they clash. This not only provides a better understanding of the problem, but also about the effects of the development program implemented. According to Li, complex and multileveled situations can be studied on multiple levels by the anthropologist, which I will elaborate on below. Li has given development anthropology the analytical instruments to bring academic discussion to the field. With her detailed understandings of local culture and sociocultural processes, while not losing sight over the bigger processes, she really has something relevant to add to
development discourse. I will now discuss how she draws upon the work of Foucault and has put his words into practice.
Foucault defines modern government as the conduct of conduct: “arranging things so that people, following only their own self-interest, will do as they ought (Scott 1995 in Li 2007b:275). Basically, government decides what is best for the population and then tries to make the population believe it is their own idea. This is not a simple process with a singular dogmatic goal, but does entail an utopian element, a future vision for the nation. Actually “multiple tactics” are being used to a “whole series of specific finalities” (Foucault 1991a:95). Then what are these specific finalities and tactics? According to Foucault, government has the purpose to secure the “welfare of the
population, the improvement of its condition, the increase of its wealth, longevity, health, et cetera” (Foucault 1991a:100). It starts with thoughts which then attach themselves to technologies in order to set the change to improvement in motion. It is thought and technique that “together comprise the ensemble of institutions, procedures, analyses and reflections, the calculations and tactics, through which governmental interventions are devised, and conduct conducted” (Li 2007b:276). Not just one monolithic state, but multiple actors like scientists, NGOs, activists and missionaries with competing visions, mandates and techniques are involved in these processes (Li 2007b:276). Power is not something implemented from above, but a dynamic process or as Foucault (1982:222) names it “permanent provocation”. It is limited, earned, given and enforced through an ever-changing system of actors that keep shifting position. Every governmental intervention has an effect: intended or unintended, they change things.
Concerning development, NGOs and other governments are filling the gaps that national governments leave when they cannot provide the welfare of the population. Scientists and experts are in a powerful position now that people rely on them to come up with solutions. People and things become numbers and passive objects that render it possible to use technology on them. Political economy and technology become the principal form of knowledge (Li 2007b:277). All actors together are working towards improvement: an utopian future. But who decides what constitutes improvement? So-called experts? Dreyfus and Rabinow (1982:196) argue that expert knowledge takes “what is essentially a political problem, removing it from the realm of political discourse, and recasting it in the neutral language of science”. Ferguson (1994) even named development an “anti-politics machine”, since it has so little effect and just depoliticized the real issues. But then what would be a solution? It is easy to criticize development for being depoliticizing and too focused on technological and economical solutions. Luckily, scholars such as Nikolas Rose and Tania Li Murray have taken Foucault’s work and gone beyond simple critique of development. To bring discourse forward, they ask questions about what the real effects of development programs are and describe the agency and flexibility that is being shown from and ethnographic perspective.
The governmental interventions pursued might not always be as beneficial as hoped, but that does not make them any less important for they have set something in motion. When studying government, one can both look at “what authorities of various sorts wanted to happen, in relation to problems defined how, in pursuit of what objectives, through what strategies and techniques” (Rose 1999:20) and “the rationale of programs as ‘fragments of the real,’ and the real nature of their effects-the fact that things happen because of them that would not happen without” (Li 2007b:278). Ethnographic study on these real effects would be an addition to the theoretical approach by
Foucault. This is why Tania Murray Li (2007b:279) proposes three key terms to “help orient an ethnographic enquiry into government that combines analysis of governmental interventions (their genealogy, their diagnoses and prescriptions, their boundaries and exclusions) with analysis of what happens when attempts to achieve the "right disposition of things" encounter -and produce- a "witches' brew" of processes and practices that exceed their scope”. Or just a simpler way to make sense of the complex processes of power and possibilities within the field of development. She identifies programs, practices and effects.
“A program is the goal to be accomplished, together with the rationale that makes it thinkable, and the associated strategies and techniques” (Li 2007b:279). This asks for a technical approach and is often thought up by the so-called experts. The problem must be defined, as well as a key population and mechanisms to address the problem. In order to evaluate results, statistics or another design for measurement must be created. Programs are also based on former experiences and are constantly changed in the process. They are based on a vision for the future, not yet aware of their actual effects. In the creation of programs the importance of funding for development comes forward, which always comes with expectations and power struggle.
“The practices that constitute an arena of intervention and render it technical are crucial to the formulation and implementation of a governmental program” (Li 2007b:279). What is it that is actually being done? Programs are just words on paper, but through practices they come alive. Sometimes the practices are quite similar to the desires described in the program, but often they turn out differently or were not described in the program at all. Plans might be compromised, resisted or just refused. “Since there is always a gap between a plan and its realization, an
ethnographic study of government would be attentive to the practices that form in, around, through or against the plan” (O'Malley 1996:311). This might for instance happen when the pressure to succeed is so high that people start looking the other way or contradictory data is removed from the successful data. Such situations would not be noticed if the actual practices were not studied closely.
“The effects of governmental interventions are both proximate and indirect, planned and unplanned, and they can be examined at a range of spatial scales” (Li 2007b:280). All practices have their effects that can be studied by the ethnographer. These effects will eventually mean whether the program can be considered successful, sustainable and worth the input. We live in such a complicated world that things never have just one effect. By doing something good, something else might be negatively affected. Effects might also look good at first sight, but turn out to be
unsustainable or even have a reverse effect in the future. The effects of practices will probably not turn out exactly as they were predicted in the program. Studying them can help with the creation of new (and better) programs.
The terms programs, practices and effects are used in this thesis to shape my analysis. They help me to make an analysis on international, national and regional level, show what the original plan was and how things actually turned out. This way I can show that knowledge of the local situation and the commitment of the local community is crucial to sustainable development. But also that the local level needs the national and international level for coordination, funding and their power. By studying the effects of the practices improvement for further development can be made. As an anthropologist doing ethnographical fieldwork I can study programs, practices and effects from up-close.
CHAPTER 3 METHODOLOGY
3.1 CHOICE OF RESEARCH LOCATION
UNAIDS estimates that there are 610,000 [390,000 - 940,000] people living with HIV/AIDS in Indonesia at the moment9. Indonesia is also one of the thirty countries stated in the UNAIDS Global Report 2013 where 90% of the people with an unmet need for antiretroviral treatment live and which therefore calls for “enhanced focus to accelerate scale-up” (UNAIDS 2013:57). International actors are working together with the national government and regional organizations to improve the health system and access. However, HIV in Indonesia remains an epidemic. The extra attention by the international development community to HIV-prevention in Indonesia and the commitment by the national government to improvement makes Indonesia an interesting country for a case study like mine. I believe the island of Bali is a good region to focus on due to its struggle with rising numbers of HIV/AIDS cases, its unique character and its function as a role model for HIV-programs to other regions.
Bali is one of the islands with the highest numbers of HIV-cases, which are still growing at an exponential rate. According to data by HIV-organization Yayasan Kerti Praja there are currently 7,317 people living with HIV/AIDS on the island10. Even though the majority of these people are female sex workers and their male clients, Yayasan Kerti Praja’s data indicates that “the epidemic is shifting from a concentrated one (that is, restricted to ‘high risk’ communities such as intravenous drug users and female sex workers) to a generalized epidemic with increasing numbers of housewives and their children being affected”11. While these numbers raise concern, there are also many positive changes being made according to UNAIDS: “Bali is a province heralded as having a growing number of strategies and initiatives that are showing positive results. For example, Bali’s programme to prevent sexual transmission of HIV has been strengthened through updating of regulations on sex work that enable sex workers to have easier and confidential access to HIV and sexual health services. Bali has also been in the forefront of implementing the national programme on the strategic use of
antiretroviral therapy, providing treatment to all key populations without reference to CD4 levels. Community-centred and community-led services are showing significant results in terms of increasing interest in and uptake of services”.12The growing number of organizations with an HIV/AIDS-focus is already reducing the stigma on the theme and stimulating discussion. I thought it
9http://www.unaids.org/en/regionscountries/countries/indonesia/ 10http://www.kertiprajafoundation.com/about-us.html
11Ibid.
was very interesting to see that the growing HIV-epidemic has motivated new initiatives and that Bali can have a exemplary function for HIV-prevention in Indonesia.
Two characteristics of the island have a major influence on the success of HIV-prevention in Bali. Both came to my attention during my research every day: Balinese religion and Bali as a
tourism/migration island. Religion is a major factor when it comes to HIV-prevention, especially since some religions have a strong opinion about sex and contraception. The majority of the Indonesian citizens self-identify as Muslims (87.18%), but the majority of Balinese citizens identifies themselves as Hindu (1,69% of all Indonesians, 83,47% of all Balinese)13. I was told that because of this unique difference, the population was more open to discussion about sexual health and it was easier to distribute condoms. The other unique character of Bali is its popularity as an island for tourism and migration. Especially in the more touristic areas, Western culture has obviously mixed with
traditional Balinese culture and keeps influencing it every day. Also, many of my informants had moved to Bali from other islands in order to find more work opportunities or to have a chance for a better life. They told me that it was more difficult to discuss HIV/AIDS and their sexuality in their traditional hometowns than it was in Bali. Being homosexual or transgender was thought to be more accepted here. They could come out of the closets and did not necessarily have to tell their parents back home. Due to its unique character amongst the Indonesian islands and its hard-fought commitment to improvement, Bali struck me as a great location to study HIV-prevention.
3.2 METHODOLOGICAL TOOLS
During my nine weeks of fieldwork in Denpasar, I spent most of my time with the management and outreach staff of Yayasan Gaya Dewata and their clients. I was able to do participant observation at different activities they organized, such as discussion groups, clinic visits, condom distribution and meetings. Together with some of the outreach staff I visited clients at home, the clinic or in the hospital. I also went on a weekend trip with two of my informants, was included in a fun staff day and sometimes went to the gay bars at night with staff. During or after these activities I wrote as many observations as I could in my field notes. I was often included in activities and conversations, but these were not always in English. Most of the time people spoke Indonesian, which I only understand partially. When I thought something was important for me to understand, I asked one of the English-speaking staff members to translate or explain to me. But since there was not always time or a person for translation during activities, participant observation has been an important method in my research.
I also had informal conversation with all staff members, clients and other people from the LGBT community. This was mostly in English, and sometimes in Indonesian. Their comments were jotted down in my field notes. If there was no outside activity or it was too early to visit clients, I would spend time at the office chatting with the management staff and the outreach staff that came and went from clients to the office and back. This way I could follow what everyone was doing all day, and also had enough time to ask all the questions that were on my mind. Clients would occasionally walk into the office or I would go to meet them outside the office with a staff member. After the first two weeks of exploratory research I made a list of relevant topics that I used as a reminder during informal conversations. I wanted to have a general idea of the situation and with this list of topics I could fill up the gaps in my data. In the office I was able to write a little bit more elaborate in my field notes and look back on the rest of the day. When I felt that something personal might have affected my research, I also wrote it in my field notes. At times I would also reflect on the whole Indonesian experience and my personal thoughts on the subject in my diary. After three weeks in the field, I wrote a report to my supervisor with my first thoughts about the topic and how I wanted to proceed with my research.
The second half of my fieldwork I wanted to do more formal interviews. Based on what I had learned in my first weeks in Bali, I made a list with interview questions. I then conducted twelve semi-structured interviews with: three YGD management staff, one KPAN staff, one YKP staff, three youth branch staff, two youth branch clients and two condom man staff. Translation during interviews with non-English speaking informants was provided by two of YGD’s management staff. All interviews were recorded on a digital voice recorder and afterwards the English translation was transcribed. I selected these specific people for in-depth interviews because I already had multiple informal conversations with them, so I knew a little what to expect and how to prepare. And because they were around a lot, I could compare their actions to their words. I also mainly chose staff
members, because I could ask them personal questions as well as questions about their organizations and the more general situation in Denpasar. Namely, the times I spoke informally to clients they could tell me a little bit about their own lives, but conversation about this sensitive topic remained minimal. Staff members were more suited for formal interviews, because they were very open about their personal lives and had a lot more knowledge about the situation. Most staff members were also able to draw from their many experiences with different clients and could provide many examples to their statements. However, I also understand that my informants are probably biased in favor to their own organization. They would always applaud their own work and hide its flaws. I do think this only adds depth to the data when I compare what they said to me during interviews to what I have been witnessing in my nine weeks of fieldwork.
There are a few other types of data that I have been gathering throughout my fieldwork. All my informants loved to take pictures with me and of themselves. I also received some written documents such as flyers, information booklets and activity programs. On the Internet I can find websites of all the organizations involved that state their vision and mission and other information. A few articles about the HIV/AIDS situation in Bali can be found online as well. And then there are the many social media that keep providing me with data, such as Facebook and gay dating websites.
I have anonymized some of my informants by changing their names in this thesis. The families of these informants do not know about them being homosexual, waria or LSL and I do not want to “out” anyone. A reader with knowledge of the Denpasar GWL situation would maybe be able to understand who I am talking about, but within the GWL-community these are all well-known people already. None of my informants asked me to keep them anonymous and none of them said something that I see as potentially harmful to anyone. Changing their names is mere an additional caution. Informants that did not hide their homosexuality or change of gender and that allowed me to use their name have not been anonymized. I looked critically at the data and I do not think this will cause them any harm now or in the future.
3.3 CHANGES I HAVE MADE
During my first month with the organization I became more and more critical about the way HIV-prevention came into practice. The work of YGD seemed at first sight something that was just too little too late and non-sustainable in the future. Compared to the big changes that international funders were talking about and the enormous challenges the Millennium Development Goals provide us with, this just did not seem to have much impact. International discourse was not able to translate to local practices, since these grassroots organization did not have the power and means to make changes that large in my initial vision. It felt like the government refused to take real action on a national scale and just put of the problem to local organizations like YGD. After my first report with my pessimistic thoughts about the situation my supervisor Sylvia reminded me that it was not my place to judge the situation. I realized I was thinking more like a development worker than an anthropologist.
After that I started focusing more on the things that YGD was able to do. Where at first I felt like nothing was being done, I now saw the many things that were happening that actually very valuable to the LGBT community. And when things were not happening as they were supposed to, I tried to see what was happening instead. I was also surprised by the great communication between all levels of organization: international and national actors were actually asking YGD what they
thought the problem was. Some of my former concerns about the national government putting of their responsibilities I discussed with the director of YGD and he flat out told me I was wrong. He explained for example the changes that were being made by the government in the public health care system and how antiretroviral (ARV) therapy had become more accessible over the past years. Also, one of the National AIDS Committee’s employees told me about the program to educate children in high school about HIV/AIDS. These were practices that only came later to my attention when I really started focusing on the work that was being done, instead of all the work that was not being done. After this, concentrating on the youth branch helped me focus on a specific part of the situation instead of feeling “all over the place”. After I changed my focus and became more understanding (without judging) I really felt I was onto something that was worth writing a thesis about.
3.4 PERSONAL REFLECTION AND OBSTACLES
There were a few obstacles and personal experiences that affected my research. Since this is something that comes with doing anthropological research, how you handle it is probably more important. As anthropologists we are asked to reflect on these obstacles, experiences and the use of ourselves as an instrument, which is what I also did during my fieldwork. My diary has proven to be a useful tool for reflection.
The most obvious obstacle during my fieldwork has been the language barrier. Especially in the beginning that has frustrated me. Often I wanted to participate in an activity, but they only spoke Indonesian. I tried to understand as much as I could, but I knew I was missing more. And I got
frustrated when it felt like it could have been valuable data. The people that did speak English were always happy to translate for me, but I could not ask them to do so all day. For these reasons, I tried to pay extra attention to my observations and describe situations from my perspective. I also know some Indonesian, not enough to conduct interviews in, but was able to have some small talk with informants during the activities. When I felt like I might have missed something really important, I asked someone to explain to me what had just happened. For my formal interviews I used two of the management staff as a translator. He or she knew the informant, which might have had both
beneficial and negative effects. I think it was mostly beneficial, since the translator already knew the situation and was able to comfort the informant a little. The use of a translator affects my research in more ways. The words in my transcripts and the answers I reacted to in the interview are from the translator, so that adds an extra level of interpretation that might alter the original content, meaning or direction of the interview, and adds alterations due to translation as well. For this reason I asked questions multiple times to different informants. At times I would also discuss some of my
understandings and thoughts with English-speaking staff members to make sure I understood correctly.
Another obstacle was the sensitivity of my topic. You cannot ask people what their HIV-status is. If you do ask them, do not expect an honest answer. My subject was sometimes difficult to talk about, since HIV/AIDS, sex and sexual health are still a taboo in Indonesia. I was often warned by staff members not to bring up someone’s HIV-status or to ask about HIV right away. They also sometimes told me if they thought someone was lying to me, for example about their status, the use of ARV drugs and condom use. This also showed me how important it was not to blindly trust everyone’s first answer or the numbers I read in articles. But staying with the same people for nine weeks and using different methods to obtain data certainly helped to get an idea of the situation closer to the truth. During my research two clients died of AIDS, which made the situation even more sensitive at times.
Being homosexual or transgender in Indonesia still leads to discrimination and painful situations. Most of my informants did not tell their families they were homosexual. And even the families that do know pressure my informants to get married to a woman. Some of the transgenders dressed like men during the day in order to keep up their social performance. To me most of them talked openly about their sexuality, boyfriends and sexlife, but to some it was still a bit sensitive. It was interesting to see how different they all acted when their family was around, from their normal ways around their LGBT friends.
During my fieldwork I had multiple bad experiences. In my first week in Yogyakarta, where I took two weeks of Indonesian language course, the volcano Kelud erupted and I had to stay inside for three days because thick ashes kept raining down, making it hard to breath, see and move. Luckily, my lessons had not started yet, but it definitely made me question if I made the right decision coming to Indonesia. During my weeks in Bali I came into contact with corrupt police multiple times, which I got very angry about the first few times. I then got sexually harassed in broad daylight, which made me feel a little uncomfortable. But the worst thing that happened was when I got robbed. I was driving home from the gay bar on my scooter, when a man brutally ripped my bag and almost pulled me of my scooter. I looked him straight in the eye when it happened. I was shaken up about it for a few days and have been scared at night until I went home. In the first month I used to go to the gay bars a lot at night, but after the robbery I was too scared to go there at night. Although my bad experiences have had their effect on my research, I think the experience was overall very positive and that will reflect in my writing more.
CHAPTER 4 PROGRAMS
“A program is the goal to be accomplished, together with the rationale that makes it thinkable, and the associated strategies and techniques” (Li 2007:279). For a program to be created, someone has to decide what the problem is, whom it concerns and how to solve it: a situation must be “rendered technical”. In my theory chapter I have discussed how development theory has evolved over the years and why anthropologists have critiqued it. The top-down and technical character from development has been the main concern, which is also what current HIV-programs can be accused of. Li (2007) however encourages us to see programs as “fragments of the real” (Foucault 1991b:81-82): change would not be made without them. She also proposes to study programs on different scales, which is why I here distinguish the international, national and regional programs that concern HV-prevention in Denpasar.
4.1 INTERNATIONAL LEVEL PROGRAMS
The aid chain that ends with the practices discussed in chapter 5 starts on the international level. Global Fund and Australian Aid are two of the biggest funders of HIV prevention in Indonesia. Both have quite similar ideas about health development and how to work towards the Millennium Development Goals for 2015. These MDGs seem to have a very top-down character, since they are just general goals written by the main funders of the United Nations: it is not written out how exactly these goals can be accomplished. National governments, with the help of Western experts, are expected to play an important role in deciding what the nation needs and how to get there. I will elaborate on these MDGs below. Global Fund and Australian Aid are working with national governments on multiple approaches. Economic development remains important, but also
community-based programs, working with risk populations, governments providing basic needs and the big dependency on ARV therapy as a technical solution. After discussing the MDGs as the main framework for international HIV-programs, I will go into the programs both organizations implement and the discourse they use for their work.
THE MILLENIUM DEVELOPMENT GOALS
In 2000 the joined project of the Millennium Development Goals started. The combat against HIV and other diseases is one of these goals, which are then further divided into sub goals. Target 6.A. states to: “Have halted by 2015 and begun to reverse the spread of HIV/AIDS”14. The United
Nations claims that in most regions new HIV infections and AIDS-related deaths continue to decline, but that comprehensive knowledge of HIV transmission and condom use remain low among young people and a large number of people remain to be living with HIV15. Target 6.B states to: “Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it”16. According to the United Nations website eight million people were receiving antiretroviral therapy for HIV by 2012 and the number keeps increasing17.
The MDGs provide a very technocratic approach to development, with organizations strongly relying on the effects of ARV therapy. But that is not the only solution that can be read in the many MDG reports and program outlines: remains of all of the development theories from the past come back. When reading about the project, metaphors that were also used in modernization theory can be found, such as a “ladder” that the poorest countries need to climb, and that exogenous actors can diffuse modernity to help them “take-off” (see for instance UN Millennium Project 2005 and UN Development Programme 2003). The project is also partially conform to dependency theory, since the discussion is not just about poverty and targets, but also about the structural constraints that block improvement or lead to inequality. It is admitted that rich countries are getting richer while the poor countries stay poor, and that the rich are in part to blame for this. The MDGs ask for the liberalization of markets, but do not think such a neoliberal approach alone will suffice. Economic growth and human development are equally important. In the UN Millennium Declaration (2000) it states that eradicating poverty alone is not enough, but that we have to support “human dignity, equality, and achieve peace, democracy and environmental stability”. A focus on human
development has to make sure that the whole population is reached from the start. Marginalized populations such as youth and LGBT should receive extra attention. Basic needs have to be available to all people, which often asks for the improvement of national healthcare systems. And unlike development theory claimed in the past twenty years, the state has to take responsibility again for its own nation, fighting for all its citizens and providing sustainable solutions to the nation’s problems. The MDGs try to reach their goals from different angles, while working with national governments and international experts to decide what is needed in a specific country.
15http://www.un.org/millenniumgoals/aids.shtml 16Ibid.
GLOBAL FUND
According to the Global Fund: “At the end of 2011, an estimated 34 million people were living with HIV worldwide”18. As the main multilateral funder in global health, the Global Fund channels 21 percent of the international financing against AIDS, as well as financing for the general improvement of health systems. They estimate at least eight million people in low- and middle-income countries are receiving HIV-treatment at the moment, resulting in dropping statistics of HIV-related deaths over the last years. Besides funding ARV-medication, Global Fund is concerned with the prevention of mother-to-child transmission, HIV testing and counselling, free condoms and basic care and services. However, more and more people are still getting infected by the virus. This leads the Global Fund to search for other ways to gain control over the situation, but ARV treatment seems to be most successful so far. This fuels the dependency on technical solutions over sociocultural solutions, for which development is so critiqued by anthropologists. The Global Fund does see the importance of input from the lower level, since “existing prevention efforts, although improving, are often insufficiently comprehensive or inadequately tailored to local epidemics”, but then mainly speaks about national government and political apparatus as main actors.
The Global Fund claims to specifically focus on “the needs of the poorest, at-risk and marginalized groups”. They use the language and discourse of ‘human rights’ to underpin their actions. One of these marginalized groups that deserve to use their human rights is the LGBT community. Discrimination, marginalization and stigma are obstacles in the fight against HIV/AIDS that must be overcome. The Global Fund states on its website: “The Global Fund renews its call on all governments and states to protect the dignity and the human rights of LGBT people. We know that the battle against hatred and stigma will not be won only in courtrooms or parliaments. We need to celebrate diversity as well in our homes, our classrooms, at work and in our neighborhoods and villages. Community-based organizations are an essential component of the HIV response. They need to provide services without facing harassment and intolerance. The Global Fund is committed to implementing policies and strategies to address these challenges. In line with the Global Fund’s mandate to better integrate human rights into health interventions, the Global Fund’s new funding model is intended to allow partners to expand country dialogue and to work in closer partnership with vulnerable communities and community-based organizations to affirm their role in the response to the diseases”. So it seems that the input of local knowledge and organizations will become more in the future. In Indonesia, Global Fund still prefers to work through the national AIDS commission at the moment.
18UNAIDS, 2012 Global Report, p8
The Global Fund developed a new plan for 2012-2016, with eyes on the Millennium
Development Goals for 2015, based on five strategic objectives: 1) Invest more strategically in areas with high potential for impact and strong value for money, and fund based on countries’ national strategies; 2) Evolve the funding model to provide funding in a more proactive, flexible, predictable and effective way; 3) Actively support grant implementation success through more active grant management and better engagement with partners; 4) Promote and protect human rights in the context of the three diseases; and 5) Sustains the gains, mobilize resources – by increasing the sustainability of supported programs and attracting additional funding from current and new sources. To date, Global Fund has signed USD 236,686,334 to Indonesia for HIV/AIDS grants and USD 16,526,360 for health system strengthening grants.
AUSTRALIAN AID (FORMER AUSAID)
Australia has its own programs for development in multiple fields. Their program for health
improvement is directed towards the Asia Pacific region and East Africa, where they provide bilateral support directly to countries. Australian Aid tries to work with national governments as well as local organizations in order to reach the most vulnerable people. Working with local NGOs enables the organization to advocate for good quality health care, deliver much-needed services and help people gain access to health care. Just like the Global Fund’s approach, providing basic needs is high on their agenda. Besides their own funds, Australia Aid contributes through multilateral actors like the World Health Organization and the World Bank in order to have global influence and reach.
On Australia’s Department of Foreign Affairs and trade website it is stated that “Australia had been appointed Vice Chair of the Programme Coordinating Board of the Joint United Nations
Programme on HIV/AIDS (UNAIDS) in 2013”19. Having to live up to their leadership role in the United Nations body and the world’s fight against HIV/AIDS, the virus is now one of their main focusses in the health program. One of their ideas to bring attention to the situation is the organization of AIDS 2014, the 20th International AIDS Conference with around 18,000 delegates from nearly 200 countries that will be held in July 2014. Besides the improvement of health systems, HIV-prevention and access to treatment, Australia also strongly focusses on economic development, since they believe this will benefit the health situation: “Australia is demonstrating a recognition that healthy economies begin with healthy communities”20. HIV and the economy have a direct impact on each other, since “poor health often leads to being excluded from opportunities to improve living
19http://aid.dfat.gov.au/HotTopics/Pages/Display.aspx?QID=1101
standards by participating in the economy” and vice versa: “access to HIV prevention and treatment is lowest among poor and marginalized populations”21. Australian Aid tries to approach development from all angles: their focus on structural inequalities and the provision of basic health care services seems to reflect development theory of the 1970s, while at the same time they advocate the importance of economic growth that has been pushed since the post-war era.
On the government website Australia’s domestic HIV response is applauded, which seems to be their argument for helping the surrounding regions struggling with HIV/AIDS. Indonesia has a special interest for Australia as their neighbor country. Many Australians go on cheap vacations there and Indonesia has a growing regional and economic status that has “changed the nature of
development cooperation between Australia and Indonesia”22. As the largest bilateral grant donor to Indonesia, Australian Aid tries to work on all levels: international with multilateral institutions such as the World Bank, national with the Indonesian government and regional with local NGOs. As an anthropologist I think that with good communication between these levels, Australian Aid has the funds, knowledge and apparatus to make positive changes.
Australian Aid’s partnership with Indonesia is strongly shaped by the Paris Declaration, which calls for greater national ownership and control over development assistance and better alignment of donor activities at the national level. General budget support has been the most direct implication of the declaration. The international community agrees that development partners need to align with the priorities, systems and processes of national governments, also that they need to coordinate country missions and donor collaboration in the direction of national governments, so they can take control over their development processes and to reduce transaction costs and the duplication of efforts (OECD 2005). For Indonesia this means a bigger accountability for aid loans and grants for the government and a coordinated national response to the HIV epidemic. This way help is not being implemented from outside, but through local processes and systems, that will improve in the process and can provide a more sustainable solution for Indonesia. Using the government systems and coordinating multiple approaches is considered to be a difficult change in approach, but a more effective one in the end. With this renewed importance of the state as an active actor in development, the neoliberal approach that was favored since the 1980s seems to be on its detour. Besides providing funds, Australia Aid will also keep assisting Indonesia with their own development program, to “spend its own funds more effectively to increase growth and reduce poverty”23. Anthropologists can argue whether such help is really needed, or that this is once again an ethnocentric assumption.
21Ibid.
22http://aid.dfat.gov.au/countries/eastasia/indonesia/Pages/how-aid.aspx 23http://aid.dfat.gov.au/countries/eastasia/indonesia/Pages/home.aspx
4.2 NATIONAL LEVEL PROGRAMS
The neoliberal approach to development that has dominated since the 1980s suggest a minimization of input by the state and the liberation of markets. I believe the growing understanding of processes of globalization as enhancing global inequality is now leading us away from such an approach. The development theory of the 1970s that started focusing less on economic development and more on inequality reduction seems to gain ground again, but is heavily influenced by processes of
globalization. The state has been assigned an active role in development again, especially in the creation of good health care systems that can provide basic needs to everyone. Also, they are the coordinator between international funding and the local organizations and communities that actually put development in practice. Both Global Fund and Australian Aid think that funds should go through the national government in order to create a more sustainable solution. Global Fund therefore provides their funds to KPAN (national AIDS commission), and Australian Aid provides their funds to HCPI24, a national HIV cooperation program between Australia and Indonesia.
KPAN (NATIONAL AIDS COMMISSION)
In order to coordinate international, national and regional actors in the battle against HIV in Indonesia, a National AIDS Commission was established in 1994. Multiple national AIDS strategies have been developed over the last years, but HIV numbers keep rising25. This asked for a multileveled approach that can be implemented by Indonesia’s decentralized governmental system. This
approach should include preventing and reducing the risk of HIV transmission, improving the quality of life of people living with HIV, and mitigating the social and economic impact of HIV and AIDS on individuals, families and communities. The KPAN states on their website26that the strategies that are to be implemented at the moment are:
• Improve and expand the coverage of the whole prevention • Improve and expand the scope of care, support and treatment
• Reducing the negative impact of the epidemic by improving access to social combat programs • Strengthen partnerships and public health systems
• The co-ordination between stakeholders and the use of resources at all levels • Develop structural measures
24HCPI stands for “The HIV Cooperation Program for Indonesia” and is a five-year support project funded by
Australia’s Department of Foreign Affairs and Trade and Australian Aid and that works in partnership with the Government of Indonesia. I do not elaborate on the project here, since its vision and mission are conform to that of the already discussed Australia Aid.
25UNAIDS estimated 76 000 new HIV infections in 2012.
• Implement planning, prioritization and execution of data-driven program
The goals are a little vague, but some of the adjustments made have been very visible to me. In 2013 a national strategy was adopted to increase access to ARV therapy. Instead of having to wait to be eligible for therapy until your CD4 count drops below 350, anyone can now get therapy in any stage of the disease. Antiretroviral therapy had already become subsidized by the government in order to make it more accessible to the poorest patients. This encourages people to get tested as soon as possible. To make it easier to get tested, more clinics for testing and counselling are being set up. KPAN also works closely with local NGOs that employ outreach staff who try to get as much people as possible to the clinics. Since recent years, Indonesia started to focus more on HIV
prevention among key population such as pregnant women, drug users, LGBT and sex workers. These populations are often hard to reach. During my research I met a representative from the KPAN that came to meet staff and clients of YGD. He was very interested in the local situation for GWL in Denpasar and the work YGD does to help them. Just before he left, he told me: “It’s so hard to take care of the GWL people in Indonesia. There is still so much discrimination. And they just don’t care about themselves, about their own health. Like using condoms”. In order to change their minds, KPAN needs help from many NGOs that each have their different key population. Free condoms have been made available to the organizations to distribute. In order to execute all these plans properly in the next years, Indonesia’s health system has to be renewed. The Indonesian government is currently working on universal health care for all its citizens by the year 2019.
That provincial and district institutions play a key role in a decentralized country like Indonesia, is understood by the national AIDS commission27. That is why they remain good communication with and support the local NGOs, while also making sure the international
community keeps supporting them as a country. I believe the national government will increasingly become more of a coordinator to all national and regional activities that is supported and advised by international institutions until it does not need that help anymore.
4.3 REGIONAL LEVEL PROGRAMS
Part of the funding from international and national actors makes it to regional scale organizations, both organized by the state or civil society. As I have said earlier, interventions are often critiqued for having a top down approach from a western perspective and lack of engagement with local target
