Therapeutic citizens and clients: diverging healthcare practices in Malawi's prenatal clinics

Abstract

This article examines how HIV policies and the funding priorities of global institutions affect practices in prenatal clinics and the quality of healthcare women receive. Data consist of observations at health centres in Lilongwe, Malawi and interviews with providers (N = 37). I argue that neoliberal ideology, which structures the global health field, produces a fragmented healthcare system on the ground. Findings show two kinds of healthcare practices within the same clinic: donor‐funded NGOs took on HIV services while government providers focused on prenatal care. NGO practices were defined by surveillance, where providers targeted pregnant HIV‐positive women and intensively monitored their adherence to drug treatment. In contrast, state‐led practices were defined by rationing. Government providers worked with all pregnant women, but with staff and resource shortages, they limited time and services for each patient in order to serve everyone. This paper builds on concepts of therapeutic citizenship and clientship by exploring how global health priorities produce different conditions, practices and outcomes of NGO and state‐led care.

Disability policy and practice in Malawian employment and education

“…This article has highlighted the damaging legacy of colonialism, through universalising definitions of disability and the short‐termism of both UK research funding and certain NGOs for workers with disabilities and long‐term health conditions in Malawi. Our data echoes the findings of Zhou (2019), who argues that within Malawi, formal health care is usually impairment or disease‐focussed, for example, focussing on pregnant women with HIV. This individualised, condition‐specific biomedical approach, while benefitting some people, is often informed by neoliberal ideologies that fund the work of NGOs delivering such care, and risks ignoring community health care and familial structures of society (Kalinga, 2018).…”

The necropolitical spectrum

“…In sum, in these two instances of surplus death, the normalised cycle of life, death and burial has been unsettled by active or passive necropower creating a 'bad death' Human Remains and Violence 8/1 (2022), [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Nicole Iturriaga and Derek S. Denman for thousands of expendable citizens. As bodies are unable to receive full death rites, families are unable to complete and the process of mourning.…”

The tyranny of empty shelves: Scarcity and the political manufacture of antiretroviral stock‐outs in South Kivu, the Democratic Republic of the Congo

“…Whyte et al (2013), for example, document stock-outs in Uganda arising at the interstices of a patchwork landscape of "projectified" donor-funded interventions where lack of coordination and heterogeneity are notable. Umlauf and Park (2018) connect perennial pharmaceutical stock-outs in the same country to supply-chain interruptions arising in an under-funded health system reliant upon improvisation and bricolage (see Livingston, 2012;Zhou, 2019). Others suggest that stock-outs are instantiations of more mundane problems, such as limited accessibility, corruption, or staff incompetence (Schouten et al, 2011;Bateman, 2013).…”

“…The spectre of scarcity, however, still haunts these "new political geographies of scaleup" (Kenworthy 2017, p. 72) as donors impose -or 'fast-track' -market rationalities onto recipient states who, in turn, take these interventions as "premises for the rationalization of welfare, reciprocity, and citizenship" (Ingram 2013, p. 13). A highly selective treatment apparatus emerges here -built upon the roll-out of neoliberal governmental practices (Sparke, 2019) -that denies ART to those deemed undeserving, irresponsible, or incompetent, and allocates it instead to clients deemed worthy, adherent, and supplicant (Whyte et al, 2013;Reed, 2018;Zhou, 2019).…”

“…The Baraka hospital director reported FARDC leaders told him that this policy was "necessary to flush out [CNPSC] by making them weak, so that we can punish them." The denial of ART to the hospital meant that pharmacists had to initially ration stocks (see Livingston, 2012;Zhou, 2019). To make every pill count, pharmacists dispensed first-line antiretrovirals sufficient for two weeks use instead of the usual full month.…”