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African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20

Anthropological perspectives on the challenges to monitoring and evaluating HIV and AIDS programming in Lesotho a

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David Turkon , David Himmelgreen , Nancy Romero-Daza & Charlotte Noble

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Department of Anthropology , Ithaca College , 953 Danby Road, Ithaca, New York, 14850, United States b

Department of Anthropology , University of South Florida , 4202 E. Fowler Avenue, SOC 107, Tampa, Florida, 33620-8100, United States Published online: 08 Apr 2010.

To cite this article: David Turkon , David Himmelgreen , Nancy Romero-Daza & Charlotte Noble (2009) Anthropological perspectives on the challenges to monitoring and evaluating HIV and AIDS programming in Lesotho, African Journal of AIDS Research, 8:4, 473-480, DOI: 10.2989/AJAR.2009.8.4.11.1048 To link to this article: http://dx.doi.org/10.2989/AJAR.2009.8.4.11.1048

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African Journal of AIDS Research 2009, 8(4): 473–480 Printed in South Africa — All rights reserved

AJAR

ISSN 1608–5906 doi: 10.2989/AJAR.2009.8.4.11.1048

Anthropological perspectives on the challenges to monitoring and evaluating HIV and AIDS programming in Lesotho David Turkon1*, David Himmelgreen2, Nancy Romero-Daza2 and Charlotte Noble2 Department of Anthropology, Ithaca College, 953 Danby Road, Ithaca, New York 14850, United States Department of Anthropology, University of South Florida, 4202 E. Fowler Avenue, SOC 107, Tampa, Florida 33620-8100, United States * Corresponding author, e-mail: [email protected] 1

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This article focuses on how numerous international nongovernmental organisations (INGOs) have stepped forward to provide services related to HIV and AIDS prevention and treatment in Lesotho. We highlight some widely recognised challenges associated with the INGO approach and describe how people working in that sector in Lesotho experience similar challenges, focusing especially on weak or inadequate monitoring and evaluation (M&E). Partially in response to such weaknesses, Lesotho is implementing its ‘Partnership Framework to Support Implementation of the Lesotho National HIV and AIDS Response.’ A major goal for this initiative is to strengthen procedures and methods for M&E. Through examination of a partnership that the authors are cultivating with Catholic Relief Services in Lesotho, we discuss some ways that anthropologists can contribute to formulating M&E processes and procedures that can provide sound measures of outcomes and have the potential to inform programme development. Keywords: aid agencies, civil society organisations, development, financing, INGOs, multisectoral collaboration, NGOs, programme evaluation, southern Africa

Introduction This paper discusses a partnership that the authors are forming with Catholic Relief Services (CRS) in Lesotho. Authors Turkon, Himmelgreen and Romero-Daza have carried out field research in Lesotho for nearly two decades and have understandings of aspects of life in Lesotho that predate the severe effects of HIV and AIDS. Our goal is to apply this knowledge toward developing sound monitoring and evaluating procedures and processes for HIV and AIDS programmes that are embedded in CRS’s broader development programming. Prior to developing our partnership with CRS, we gained an awareness of the shortcomings to approaches to health and development programming that is administered through international nongovernmental organisations (INGOs), as has been identified in the literature. We used this awareness to guide our deliberations with representatives from INGOs in Lesotho as we sought out an agency willing to collaborate with us. During these deliberations it became clear to us that many of the shortcomings identified in the literature are pervasive in Lesotho and are a source of frustration for INGO professionals working on development-related issues there. Thus, we sought a partner who either did not display most of the shortcomings or was committed to overcoming them, and who was interested in forming a partnership to work toward monitoring and evaluating their programming in ways that could inform better practices and processes. We draw on lessons we have learned to suggest ways that

anthropologists can contribute to overcoming some of the shortfalls that we identify, by highlighting areas of progress in our work with CRS. Where we speak of health services and programming in this article, we are referring broadly to any development initiative that is aimed at improving the health of citizens. In many instances, however, we speak directly to nutritional health, which has been recognised as a highly important factor in HIV and AIDS prevention and treatment. Contextualising HIV and AIDS in Lesotho Since the first case of AIDS was recorded in Lesotho in 1986, the HIV epidemic has spread rapidly. UNAIDS (2008) reports adult HIV prevalence at 23.2%, placing Lesotho among the top-five countries in the world in terms of prevalence. However, depending on the surveillance data used, the HIV prevalence estimate may be higher, with significant differences between rural and urban areas (Kates & Leggoe, 2005). Before the onset of the HIV epidemic in Lesotho, life expectancy was projected to increase to 60 years by 2003. As a result of AIDS, however, life expectancy declined to 37 years, although it has since rebounded to 42 years (UNICEF, 2009). The rapid spread of HIV in Lesotho should be understood in multifaceted terms. Lesotho’s labour history has been dominated by males’ migration to mining jobs in South Africa (Murray, 1980 and 1981). In more recent years, internal job migration has become pronounced with the onset of the

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Lesotho Highlands Water Project. As well, approximately 50 000 jobs were created in the textile industry, since May 2000, when Lesotho signed the African Growth and Opportunity Act allowing Lesotho-produced textiles tariff-free access to markets in the United States. Approximately 80% of the resulting jobs have been held by females (Turkon, 2008). Changes to that agreement in 2005 led to massive job reductions, but the textile industry has rebounded and remains a major employer in Lesotho. Multiple layers of social and livelihood insecurities stem from labour migration while others stem from Lesotho’s environmental and economic marginality (Turkon, 2003). These layers include early average age of sexual debut, multiple and concurrent partnerships, trans-generational sex, gender inequalities, lack of education, recurrent drought, poor soil quality, food insecurity and hunger, high unemployment as well as other economic insecurities. These factors combine to form highly unstable social and cultural foundations that are conducive to the initiation and maintenance of behaviours that pose a high risk of exposure to HIV (Romero-Daza, 1994; Romero-Daza & Himmelgreen, 1998; Modo, 2001) and which weaken community support structures that would otherwise support food redistribution and the sharing of hardships through institutionalised reciprocity (Turkon, 2003 and 2009). Underlying the multiple factors that facilitate the spread of HIV in Lesotho is the fact that most Basotho do not have control over their productive livelihoods. Decades of modest development gains in the country have been lost due to HIV/AIDS and other health conditions. Efforts to reduce poverty and improve living standards have been severely undermined as HIV and AIDS has made significant social and economic impacts, resulting in a decline in Lesotho’s Human Development Index (HDI = 0.514; UNDP, 2009), particularly in the areas of education, health and life expectancy. The country was ranked 127 among 174 countries in 2000 on the HDI, but subsequently dropped to 156 among 182 countries (UNDP, 2009). More than 50% of Lesotho’s primarily rural population lives in poverty (Rural Poverty Portal, 2007) and poverty rates are increasing (Kingdom of Lesotho, no date). Most Basotho clearly struggle to subsist in physical and economic environments that are stressed and ill suited to either the agricultural or pastoral pursuits on which they traditionally relied (Turkon, 2003). Not surprisingly, Lesotho is a net importer of food and in most years is dependent on food aid. Insecurity in livelihoods constrains peoples’ abilities to make use of many of the HIV programmes otherwise available to them. To be sure, poverty is associated with access to poorer HIV-prevention knowledge, lower levels of HIV testing, less access to condoms, higher rates of ‘cofactor STIs that increase susceptibility to HIV infection,’ and poorer nutrition and health status which compromise the immune system (Stillwagon, 2002; Glick, 2007). As we show in this article, especially with regard to CRS’s Household Urban Gardens (HUG) project, the social and livelihood insecurities that stem out of these unstable social conditions raise acute challenges for effective HIV/ AIDS programming, selection and monitoring and evaluation (M&E) processes and procedures.

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Coordinating a national response to HIV and AIDS programming in Lesotho The HIV epidemic in Lesotho accentuates poverty and represents a development crisis that threatens the nation’s ability to resist worsening poverty and work towards livelihood security and sustainable human development (Matlosa, 2006). Stressing the need for programming strategies that address HIV/AIDS and food security simultaneously, Lesotho’s government reviewed the National HIV and AIDS Strategic Plan and created the National AIDS Commission with the goal of coordinating and supporting the scaling up of efforts to resist HIV and AIDS (Kimaryo, Okpaku, Githuku-Shongwe & Feeney, 2003). In response, Lesotho has developed a well-defined national response to the HIV epidemic. The Lesotho National HIV and AIDS Strategic Plan lays out an overarching plan for scaling up universal access to HIV/AIDS information and services, with the goal of enabling individuals to protect themselves from HIV infection and to access treatment and care networks (Lesotho National AIDS Commission, 2006). The plan adopts the ‘Three Ones’ principles to provide a coordinated response through “One agreed HIV/AIDS action framework that forms the basis for coordinating the work of all partners; one National AIDS Coordinating Authority with a broad-based multisector mandate; and one agreed M&E framework for overall national monitoring and evaluation” (UNAIDS, 2004, pp. 2–4). Thus, the plan strives to: reduce new HIV infections (HIV incidence) from 2.9% in 2005, to less than 2% by 2010; increase the percentage of children orphaned by AIDS who are identified, and increase access to services for orphans and vulnerable children (OVC) to 90% by 2011; achieve universal access to treatment by 2010; and mitigate the effects of HIV and AIDS on individuals and communities. Lesotho’s strategic plan responds to an emerging awareness that HIV and AIDS programmes have been based on limited strategic analysis and directed mainly by the perceived goals and objectives of the individual implementing organisations. As a result, most programming has failed to contribute to achieving national strategic goals. Equally problematic was the fact that most civil society organisations (CSOs) in Lesotho did not track outcomes, thus compromising any ability to measure impact and evaluate programming and use those evaluations to develop sustainable projects that are portable to other locations. With regard to the latter, Lesotho’s government has also developed a national monitoring and evaluation (M&E) framework (Lesotho National AIDS Commission, 2006). There will likely be considerable progress in implementing both the strategic plan and the M&E framework in the near future. In August 2009 Lesotho signed a partnership agreement with the United States to fund and move forward with the national strategic plan. A principle goal for this plan is to engage all partners in development programming, including civil society, people living with HIV or AIDS (PLHIV), development partners and the business community, in order to implement and monitor the national plan (PEPFAR, 2009). With regard to Lesotho’s strategic planning, INGOs fall within the partnership area defined as civil society. CSOs

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include community-based organisations (CBOs) and faithbased organisations (FBOs) as well as INGOs. As the national plan has yet to unfold, numerous CSOs continue to formulate and implement most of the HIV-intervention strategies in Lesotho. Indeed, in Lesotho there has been a proliferation of CSOs in recent years, described as ‘unfolding without a roadmap’ (Birdsall & Kelly, 2007). And because Lesotho lacks nationally administrated sub-granting mechanisms to support both national and sub-national programmes, CSO funding tends to be concentrated among a small number of larger INGOs that are positioned “to access support directly from donors or through sub-recipient agreements with the government” (Birdsall & Kelly, 2007, p. 189).

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Deciding on international nongovernmental organisations (INGOs) as potential research partners While many of the issues discussed below may apply to CBOs and FBOs, our primary focus here is on the international nongovernmental organisations (INGOs) in Lesotho. Where we use the term CSO we refer broadly to include all of these organisations, while we use INGO to refer specifically to the group of international agencies with which we discussed a potential partnership for contributing to HIV and AIDS programming, especially to M&E. We sought out larger INGOs because these tend to have the infrastructural capacity to carry out large-scale programming and the administrative and staffing capacity to support intensive M&E activities. Indeed, recent assessments of the capacity of civil society in Lesotho have identified significant gaps between INGOs and CBOs in terms of organisational capacity to design, develop, manage and implement effective HIV and AIDS programmes (Armstrong, 2008; Akoku, 2009). In consideration of the multiple factors that facilitate the spread of HIV and exacerbate the impact of the epidemic in Lesotho, the authors sought to establish a partnership with an INGO to develop strategies that would improve peoples’ control over their livelihoods, particularly in ways that can provide reliable and nutritious food supplies and strengthen a community’s economic support networks. Indeed, because the spread of HIV and the impact of the epidemic are intimately linked to poverty and associated economic and food insecurities, we felt that a sound strategy should include advancing control over food production in ways that improve individuals’ nutritional health, alleviate the burdens associated with having to pay for food, and encourage development or empowerment of cooperative frameworks, and so strengthen social support networks. Problems associated with HIV and AIDS programming among INGOs in the developing world Literature that we had read prompted us to be cautious in seeking an INGO partner. Indeed, there is a growing body of literature that focuses on how the emphasis on INGOs as the primary institutional framework for HIV and AIDS intervention programming has contributed to fragmented health services provisioning, which can undermine local control of health programmes, compromise programming standards, contribute to social inequality, and which are not

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subjected to uniform M&E standards nor consistent codes of conduct (e.g. De Waal, 1997; Pfeiffer, 2003; Bebbington, 2004). Some authors suggests that there are CSOs that rely on funding from ideologically motivated donors and are under pressure to produce results that portray their activities in ways that appeal to these constituencies (Barnett & Whiteside, 2002). Other authors have alleged that some funding sources impose ‘gag rules’ on recipient CSOs, forbidding them to engage in specific practices or discourses with clients (Whelehan, 2009). There are likely degrees of truth to these assessments that will vary significantly on a case-by-case basis. Nonetheless, a recent report by the World Bank admits that, despite a US$10-billion increase in spending on health programming, there has been little progress in improving the health of poor people. The report highlights how health programming is hampered by weak government capacity and overly complicated project designs, and that monitoring is weak and evaluation nearly ‘non-existent’ (Elliott, 2009). Most research remains focused on specific case studies of projects or organisations. Consequently, little is known about the social and institutional networks through which priorities are set, how funding decisions are made and CSO practices take place, and how CSO programmes interact with locally embedded social and institutional processes (Bebbington, 2004). Indeed, CSO efforts seldom employ standardised instruments for selection or M&E which are comparable with instruments used by other agencies. Similarly, the selection criteria and processes used by CSOs are commonly executed with little or no empirical evidence to justify them (Glick, 2007; Armstrong, 2008). Consequently there is a lack of data that can be used to gauge and compare the effectiveness of different strategies, understand their effects on community dynamics, and set priorities for future programming. Recent emphases on privatisation have resulted in significant international aid for primary healthcare in the developing world, most of which is channelled through INGOs (Sullivan, 2003; Guest & Jones, 2005). Most INGOs that operate in Lesotho are based in the capital, Maseru, and are not well linked to community-situated CBOs (International Records Management Trust, 2006). As primary administrators for a great deal of HIV and AIDS programming, INGOs have received much scrutiny in recent years and as a result have agreed on common development goals at the Millennium Summit in 2000, the 2002 Summit on Sustainable Development, and the 2002 Summit of the Americas. Goals that emerged from these summits focus on areas such as poverty eradication, environmental protection, and the promotion of democracy and human rights. However, there is much disagreement on how to achieve these goals and there is a lack of enforceable guidelines. Lesotho has taken a positive step in working towards addressing many of these guidelines, however, in signing the partnership agreement with the United States (described above). Seeking an INGO partner in Lesotho During May and June of 2008, authors Turkon and Himmelgreen met in Maseru with representatives from

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several INGOs engaged in HIV prevention, AIDS mitigation, and related development programming to alleviate poverty and improve people’s livelihood security. Their goal was to find a partner who administers programming that is aimed at: livelihood improvement; building cooperative economic security and improving nutritional health in target communities; transferring ownership of the project to the recipient population; sustainability; and employing reliable tools for M&E over the duration of a project. The researchers were aware of shortcomings attributed to INGOs, as identified in the literature, and therefore approached potential partnerships with caution. During those meetings Turkon and Himmelgreen came to better understand the degree to which INGO efforts are sometimes hindered by uneven national coordination, by underdeveloped or underutilised methods for M&E, and by priorities that are established by granting agencies rather than by on-the-ground realities that could dictate best practices. These overall shortcomings are quite pronounced in Lesotho, and people working within these organisations expressed high levels of frustration with the culture within which their organisations must function. Such frustrations were commonly accompanied by feelings of helplessness to change an often ineffectual system. Because their deliberations were in confidence, we cannot mention specific individuals or organisations, and must speak in generalities. In this regard we do not present this material as an evaluation of any specific projects or institutions, but as representative of frustrations that people working within the INGO sector in Lesotho commonly experience. The sentiments that follow were pervasive enough to give us confidence that INGO operations in Lesotho share many of the shortcomings that we had become familiar with through the literature. Furthermore, they validate for us the value that such observations hold for informing selection choices in research partnerships and the cautious approach we took in seeking one. Most of the INGO representatives who Turkon and Himmelgreen met with said they saw the system they were working in as being fragmented and not responding to the country’s healthcare demands. It was commonly expressed that those setting the funding priorities do not grasp the scale of the HIV epidemic nor the underlying causes, such as poverty and inadequate livelihood options. These same professionals felt that the failure to grasp the scope of the problem may help to explain why little has been done on a national scale and why many INGOs perform work that can be described as crisis management. Another common sentiment in these conversations was that millions of dollars are spent each year on projects and programmes that fall far short of their intended goals, and yet the same kinds of projects keep getting funded. Another common assessment was that research is weak and there are few standard instruments employed which facilitate measuring impacts, understanding failures, or comparing results against similar or different strategies. These are assessments with which the researchers were already familiar because they had encountered discussions of similar ones in some of the literature (e.g. UNAIDS, 2008; Disease Control Priorities Project, 2009; Elliott, 2009).

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Similarly, another concern was that some INGOs use sets of ‘good instruments’ but switched between them even though they were not comparable, thus producing data from across the programme that were not comparable. Regarding more specific programming, many INGO representatives commented that agricultural programmes tend to be large-scale and not centred on sustainable practices at the level of household livelihoods. Some went on to comment that food-security programmes often have to do mostly with food and aid distribution and modest homestead garden activities, instead of promoting food production. Additionally, there was little emphasis on nutrition education in these programmes. Programmes were also described as being poorly targeted and not always reaching people with the greatest need. For example, some participants in these programmes were described as being likely to sell produce from ‘nutritional gardens’ because they preferred earning money over consuming the types of foods they were producing. More important is that even when those with the greatest need are identified, they do not always recognise the importance that diet, for instance, plays in maintaining health in the face of HIV and AIDS. More positively, however, many INGOs in Lesotho are recognising a need for organisational development, strategic planning and capacity-building, and are in fact initiating efforts to work toward more strategic programming in collaboration with other CSOs and government ministries. Many development projects, such as the Lesotho Irrigation Project (LIP) (discussed below), are executed through partnerships between communities and multiple CSOs, although oversight and M&E commonly resides primarily with one INGO partner. Nonetheless, the red flags raised in the literature motivated us to carefully scrutinise potential partners in hope of finding one in which the personnel were likewise sensitive to these shortcomings. What we found was that most INGO personnel do indeed want to work towards addressing many of these issues, and some are further along than others. In the end we established an intent to work towards a partnership with Catholic Relief Services, which has a history of partnering with researchers as a means for enhancing programming and M&E. Defining the parameters for a partnership with Catholic Relief Services (CRS) As already noted, a primary interest for us was to partner with an INGO that was willing to collaborate on developing M&E that is sensitive to the socio-cultural and physical environments of the targeted population. Through such an approach, the efficacy of HIV and AIDS programming can be more easily ascertained, which in turn will result in improved efforts to address the epidemic in Lesotho and carry the potential to inform programming elsewhere. There has been growing appreciation of the value of evidence-based and informed social science research in HIV and AIDS programming at all levels, yet the potential for this sort of research has not been adequately explored (Auerbach, Parkhurst, Cáceres & Keller, 2009). Anthropology has much to offer towards developing evidence-based research that contributes to M&E in programming aimed at improving areas such as food

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and nutrition security, which are intertwined with HIV and AIDS (Okello-Uma, 2003). Our colleagues at CRS shared this value for evidence-based research to enhance their programming. We deliberated with them to find areas where we could begin to develop strategies aimed at enhancing their M&E, in ways that determine if aspects of their programming are working in accordance with the models they use to justify funding for them. We found a common interest especially in the area of food and nutrition security. Food and nutrition security are achieved only when households have secure access to food, sanitary environments, adequate health services, and the care needed to ensure healthy lives for all members (Gillespie & Kadiyala, 2005). HIV and AIDS precipitate and exacerbate food and nutrition insecurity, and accelerate the spread of HIV when people, due to worsening poverty, adopt high-risk food provisioning strategies, such as exchanging sex for food (Gillespie & Kadiyala, 2005). The livelihoods of families with an AIDS sufferer are further compromised as they lose wages and the ability to produce food for household consumption, leading to household under-nutrition and, in some cases, chronic hunger (Gillespie & Kadiyala, 2005). The HIV epidemic negatively effects crop production and food processing, also undermining food and income security. Clearly, support for agricultural production is a crucial element to be considered in HIV and AIDS programming (White & Morton, 2005). CRS addresses food and nutrition security in three of its programming areas: Mountain Orphan and Vulnerable Children Empowerment (MOVE); Household Urban Gardens (HUG); and Lesotho Irrigation Project (LIP). Programmes such as these are challenging in terms of selection, monitoring and evaluation. Problems with participation and selection in HUG programming As noted above, representatives from several INGOs indicated concern that participants in nutritional gardening programmes sold the produce from their gardens, rather than consume it, thus compromising benefits to their health. Charlotte Noble evaluated Household Urban Gardens (HUG) project that targeted textile workers in Lesotho’s urban lowlands for CRS. Textile workers in the country are primarily internal migrant labourers; most live in rental properties near the mills they work at. Noble found that while the HUG project recognises and even encourages the sale of surplus produce as a means to augment meagre incomes, households that sell vegetables in order to purchase foods of less nutritional value may be missing the full benefits of the project. For HUG, CRS gauges success based on the number of gardens planted, the number of vegetable varieties grown in the gardens, and the proportion of project participants who sell from their gardens. However, for participants to gain the full benefits of household gardens (that is, both increased access to vegetable variety and supplemental income), projects like HUG need to incorporate nutritional education that emphasizes the importance of consumption, while at the same time selecting M&E indicators that reflect this emphasis. Because of Noble’s work, CRS is considering using ethnographic methods to gain a better understanding of people’s decisions to sell

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or consume their home-garden outputs, thereby informing nutrition education and enhancing M&E criteria to include nutritional assessments. Problems with selection emerged when Noble investigated uneven participation in the HUG project. Observations and interviews conducted with participants and non-participants revealed that selection was based on individuals who agreed to participate after demonstrations hosted by the village chief. In some villages, the non-participants indicated that when the chief calls a gathering, it is often assumed that he is calling only ‘his’ people — that is, those who hold rights over land-use through him. People spoke of ‘their’ villages as places where they or their family possessed land, and hence the villages in which they rented did not figure as part of their identity. As a result, those who rented tended not to respond to these calls to gather, because they did not see themselves as linked to the village’s community. In other villages, however, notification of scheduled presentations was uneven and many households geographically near the chief had not heard of HUG, while other more distant households were contacted, attended demonstrations, and joined the project. Some participants indicated that they had already been consuming vegetables after a mere one to two months after planting, and some households had even sold produce to neighbours and co-workers. Interestingly, almost all the non-project households encountered indicated a desire to join. Problems with selection in LIP programming During a site visit to a Lesotho Irrigation Project (LIP) programme in a rural area, Turkon and Himmelgreen learned that in two targeted villages only about 30 households were participating. Selection had been based primarily on individuals who agreed to participate after an initial presentation hosted by the chief. In output terms, the project was quite successful, producing highly nutritious produce and surpluses that the participants sold for profit. There were numerous people from the target population who were not participating but who wanted to be involved. Current participants in LIP were reluctant to take on any more because they did not want to dilute the amount of food and profit they were experiencing. However, they were considering expanding the project to enable others to participate but no plans had been formulated yet. We did not have the time or the resources to ethnographically explore the situation to determine if, for example, the project was unevenly spread among different factions within the target population. However, it seems likely that it was. Such an evaluation should have been done at the outset to establish selection criteria. Notably, such problems are likely to arise in many settings when project administrators fail to recognise the complexities of community structures and how these can undermine the abilities of people to work towards common causes. Professionals engaged in development and health programming commonly operate under the assumption that shared geographical space within a village constitutes membership in a community. Within populations that are targeted for specific projects one can commonly find different ideas about what a community is and how

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it functions (Wayland & Crowder, 2002). Residents of a village may indeed refer to that village as a community, but the village may also be factionalised around issues about identity and group interests (Campbell, 2003). Indeed, ‘communities’ are venues for both inclusion and exclusion, and they can develop or divide around multiple issues (Barnett & Whiteside, 2002). Thus, it is important to comprehend social divisions prior to establishing selection criteria for a project. To be sure, involving community members in a project’s design and implementation enhances cultural appropriateness and improves the prospects for sustainability (Cornwall & Jewkes, 1995), while inequitable selection can compromise such prospects by fomenting or exacerbating existing social divisions. Using social network analysis to select and monitor project participation A standardised means that can be used to locate social divisions within a population is social network analysis. This is an especially important consideration in settings such as Lesotho, where social factionalism is pronounced in many rural areas (Turkon, 2003 and 2008). Networks represent ‘webs’ of human relationships through which social norms are played out during social exchanges (Auerbach et al., 2009). Social network analysis can be used to index the sources and distribution of power as well as the degrees of inequality within populations (Hanneman & Riddle, 2005). If inequalities are pronounced, ethnographic investigation can illuminate the types of social structures or relations they cluster around, such as political or religious affiliation, cooperative endeavours, class structures, lineage or clan membership and so on. This sort of analysis can identify groups of people who normally do not cooperate, as well as ones who do, and thus open for consideration ways to administer a project’s benefits across segments of the population in ways that better ensure broad inclusion. In order to actualise a geographic population’s potential it may be prudent to work with interest groups until common foci around which community solidarity can be promoted are ethnographically identified or verified (Wayland & Crowder, 2002). Once such areas are identified, strategies can be developed to enhance opportunities for bridging divides within the given population as well as the prospects for building capacity by creating or strengthening community networks. Defining complimentary strategies: the utility of panel data Sound M&E procedures and processes are important for ensuring that HIV and AIDS programming — and development programming in general — are transparent, accountable and comparable. Standardised methods should be employed at each step in order to: validate selection criteria; establish baseline data for monitoring progress; adjust strategies along the way or identify best practices that may have been overlooked at conception; and yield results that are comparable with programmes that administer projects with similar goals. There is excellent potential to achieve

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more holistic programming if M&E is employed in ways that generate data that facilitate combining strategies that are potentially complimentary. Panel data has this potential. Panel data relies on data from a cross-section of individuals, or a panel, to measure some aspects of peoples’ lives through a series of points in time. Causal factors affecting people’s behaviour can be attributed to areas such as their beliefs, attitudes and other subjective criteria, and these factors are commonly not independent of each other (Auerbach et al., 2009). Thus, M&E data are enhanced when panel data that reflect cultural responses to programming longitudinally, and in ways that correlate with other areas of programming, are employed. Panel data can reveal shifting attitudes, health conditions or patterns of behaviour, and so on. For example, our current work with CRS aims to improve M&E to achieve programming focused on livelihood enhancement through agricultural development. For this programming CRS is concerned with enhancing and expanding people’s livelihood options, improving individuals’ nutritional health, and building community capacity across target populations. As discussed above, social network analysis can help to identify social divisions that might hinder goals for capacity-building. By mapping data on degrees and the nature of social connectedness among participants at the outset, social divisions could be identified and then ethnographically explored to find common grounds around which cooperative work arrangements might be established. By executing the same instrument at follow-ups, researchers can determine whether or not the project is facilitating the development of cooperative relationships, creating or exacerbating factions, or maintaining the status quo. By considering both the space and time dimensions, panel data enhances the quality of information in ways that are impossible when employing only one of the two dimensions (Yaffee, 2003). Expanding the types of data gathered can enhance the understanding of a project’s effectiveness. For example, if some participants are experiencing improved nutritional health, livelihood security, and social connectedness, while others are not, correlating the data sets (i.e. on nutritional health and social connectedness) may indicate that people who are socially connected in some ways are experiencing most of the benefits. The same analysis might identify a cluster of people (a node) within the social networks who interact with people who are experiencing benefits as well as those who are not. That particular node might be able to be cooperatively engaged within the project’s framework in ways that help to bridge the differences or satisfy the interests of each faction, and thus achieve fuller inclusion and participation. Conclusions There is need for HIV and AIDS intervention strategies that consider broad social and structural change (Parker, Easton & Klein, 2000). Indeed, in recent evaluations of Lesotho’s national response to HIV and AIDS, the government noted shortcomings that included low coverage of HIV-prevention programmes, a lack of programming for sustainable and appropriate programming to mitigate the economic and

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social impacts of HIV and AIDS, inadequate data collection and dissemination, uncoordinated stakeholders among whom there is an absence of collaboration at the community and district levels, and “lack of clarity of roles and responsibilities at all levels” (UNAIDS, 2008, p. 7; World Bank, 2009). Conceptualising and implementing strategies that move in these directions will be challenging. Most CSOs do not have the technical expertise needed to formulate, much less implement, such broadly defined programming strategies. Aid-provisioning is most effective when equitable and trusting partnerships are formed among foreign workers, their national counterparts, and local communities (Hearst, Mandel & Coates, 1995; Pfeiffer, 2003). Such partnerships can go a long way towards building national capacity to take control over communal problems. The system that privileges INGOs to provide the bulk of HIV and AIDS intervention programming has thus far not facilitated the development of this sort of holistic approach. Recent trends, however, see cooperation emerging as an ideal, or even coming into practice in some instances. A challenge to formulating meaningful venues for cooperation is to identify strategies around which partnerships can be formed. A sound means for identifying and validating such strategies is through the implementation of M&E procedures that generate culturally informed panel data. This is an area with excellent potential, because there is a great need to address the social, cultural and structural factors, or ‘drivers,’ that do not operate universally in uniform ways. Such drivers influence the spread of HIV and exacerbate the effects of AIDS, but are difficult to understand and measure (Auerbach et al., 2009). Anthropologists have much to contribute to HIV and AIDS intervention programming. Ethnographic methodologies, when brought into a complimentary relationship with standardised methods for selection and M&E, can provide cultural perspectives that cover variables that are often neglected by professionals who may be unfamiliar with social science methodologies, especially those who have clinical objectives. Many, if not most, anthropological contributions to HIV and AIDS are strongly informed by strategies developed by professionals outside of anthropology. We can clearly strengthen our understandings of HIV and AIDS through partnerships with CSOs. Such cross-disciplinary collaboration, if undertaken using sound M&E procedures, can yield data that is highly valuable to formulating intervention strategies. Approaches that generate panel data are especially promising because they bring together longitudinal and cross-sectional approaches in a comparative framework that has strong potential to inform selection criteria, programming and the monitoring of results, and to suggest strategies for broader implementation or scale-up. Acknowledgements — We thank the faculty and staff of the National University of Lesotho who worked so diligently and sincerely with us on early phases of this project. We also thank the many dedicated employees of NGOs and consultancies who took time from their busy schedules to discuss HIV/AIDS-intervention programming in Lesotho with us. Our sincere appreciation goes to the professionals at Catholic Relief Services, Lesotho, for their collegial and professional collaboration. We especially thank Dr Megh Raj of Catholic Relief Services for comments on many aspects of this

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paper. Finally, we thank the anonymous reviews for AJAR, and especially the managing editor Kevin Kelly, for valuable comments that improved this paper exponentially. The authors — David Turkon (associate professor, Ithaca College) is a socio-cultural anthropologist who studies community dynamics, community capacity-building in Lesotho and among Sudanese refugees in the United States, and is Chair of the AIDS and Anthropology Research Group. David Himmelgreen (associate professor, University of South Florida) is a biological anthropologist with interests in nutrition, food security, globalisation, and HIV/AIDS. He has conducted research in Lesotho, Costa Rica, India, and the United States. Nancy Romero-Daza (associate professor, University of South Florida) is a medical anthropologist interested in HIV/AIDS and other sexually transmitted infections, reproductive health, and cultural competence in the provision of services. She has research experience in Lesotho, Costa Rica, and the United States. Charlotte Noble is a dual master’s student in applied anthropology and global health at the University of South Florida; she has conducted research in Haiti, Costa Rica, and Lesotho.

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