Introduction
This article investigates the power-trust relations between actors central to delivering health in Africa: donors and local faith-based organisations (FBOs). Understanding these relations is crucial to global health where weak African health systems face severe resource limitations, the world's greatest health challenges, and there is enduring public distrust.Footnote 1 Many African states rely on development assistance for health (DAH), FBO health providers fill vast gaps in state capacities, and the West's history of scientific exploitation contributes to continued scepticism about donor intentions.Footnote 2 This article is based on several years of fieldwork in Zambia and Malawi, and although we did not start our inquiries intending to focus on trust, trust and the complex ways it intertwines with power emerged from our interviews as fundamental to health diplomacy and health outcomes. And yet, analysis of power-trust relations is neglected in the IR and global health literatures.
This article makes three contributions. First, bringing multifaceted power relations to the study of trust in IR problematises the established relationships between uncertainty, vulnerability, and trust. The trust literature has not engaged fully with the question of power, often conceptualising trust and power as ‘functional equivalents’Footnote 3 and using trust to push back against purely power-based accounts of international politics. Highly asymmetric power relations such as those between donors and aid recipients have fallen outside of trust explorations in IR, and yet these types of relations and actors are part of the conduct of international politics and are central to global health. Rather than deciding that such actors are outside the study of trust because of their dependency, we advance existing research by examining how trust interacts with power in such circumstances. Our analysis of FBO-donor relations in health diplomacy enables us to conceptualise a trust in international politics that extends beyond the interstate and conditions of anarchy to account for actors of objectively unequal power and expose how trust interacts with power. We develop the concept of ‘trust as belonging’, which we define as the exercise of discretion accompanied by the expression of shared identities. Attention to FBOs – institutions that emphasise a spiritual mission and ‘otherworldly calling’ – allows us to highlight the deep foundations for belonging.
Second, we contribute to the literature debating the various forms of power in global healthFootnote 4 through understanding how power interacts with trust. We know that power and trust matter for health diplomacy since they shape collaborative relationships, policy development, and health outcomes. James Pfeiffer highlights that when trust breaks down (or was never established), projects tend to fail. He draws attention to how trust has implications for power, since it may prevent abuses that advantage some over others, generate more equitable access to resources, and give dependent states and actors greater sovereign control over health initiatives.Footnote 5 By examining African non-state actors that are not typically considered to be powerful but are nevertheless crucial in political change and development,Footnote 6 we augment knowledge on health diplomacy, a field that foregrounds a plethora of new actors working at multiple levels from interstate negotiations to multistakeholder, national diplomacy.Footnote 7 We focus on FBOs as one type of non-state actor, because they provide half of health care services in some African countries, and they receive millions of dollars in DAH annually.Footnote 8 Donors also tend to view FBOs as relatively trustworthy actors,Footnote 9 making them a crucial avenue through which to understand the confluence of power and trust. Through our analysis we develop the ‘power-trust cycle’ to account for how various forms of power undergird the vulnerabilities and competencies that matter for trust and how trust can, in turn, augment various forms of power.
Finally, we move beyond analysis of asymmetrical donor-local relations based on donor control of development assistance to recognise how donors and local actors simultaneously possess multiple, interconnected forms of power.Footnote 10 Here we understand power as ‘the production, in and through social relations, of effects that shape the capacities of actors to determine their circumstances and fate’.Footnote 11 This has significance for debates in international development about state capacity and institution buildingFootnote 12 because it enables us to better account for the ways that donors extend their power and how local actors – often perceived as weak or powerless – exert influence.Footnote 13 We find local actors make use of institutional, epistemic, and normative power to leverage trust and, in turn, leverage trust to offset and mediate the structures of dependency.
The article is set out as follows. Section one develops our conceptualisation of trust as belonging to account for trust in relations of dependency. Section two explains the elements of power that are manifest in donor-local relations in health diplomacy. Section three details our methods. Section four analyses trust as belonging in FBO-donor relations and demonstrates how power undergirds trust and trust augments power in a power-trust cycle. The article concludes by challenging global health actors to recognise the consequences of the power-trust cycle, and highlighting the potential for its transformation through donor-local efforts to nurture trust as belonging.
Trust as belonging in relations of dependency
The majority of IR trust literature assumes that the international realm has unique barriers to trust because of the condition of anarchy and the ensuing security imperatives placed on states.Footnote 14 Ken Booth and Nicholas Wheeler pose a question that sums up much of the existing research: ‘How can actors learn to trust each other – should they? – in a condition of anarchy?’Footnote 15 This question binds the study of trust to a set of international actors (notably the state) that, at least in theory, make decisions as more-or-less equal agents in a context of anarchy.Footnote 16 While the literature does not ignore power asymmetries between states, the role of institutions, or the links between trust and interdependence,Footnote 17 it views dependency as the outcome of trust,Footnote 18 as state actors make ‘wilful decisions’ to trust or distrust.Footnote 19 The IR literature thus ignores the potential for trust within relations of dependency. This establishes a set of relations and contexts for trust in international politics that has several impacts. Firstly, it encourages a focus on interstate relations. Even research grounded in social or cognitive psychology, for example, explains the tendency to trust as ‘anarchical social capital’.Footnote 20
Secondly, the anarchy problematic reproduces particular meanings and relationships for core elements of trust: uncertainty and vulnerability.Footnote 21 Anarchy ‘magnifies the impact of uncertainty about the motives of others’ and implicitly limits it to uncertainty about state actions.Footnote 22 For example, rational choice accounts of trust explain uncertainty in terms of distinguishing between status quo and revisionist states.Footnote 23 Others understand uncertainty as discerning the peaceful intentions of states,Footnote 24 or through the dynamics of the security dilemma.Footnote 25 Similarly, the literature emphasises that anarchy compounds the vulnerability that comes with trusting under circumstances of uncertainty. Work on trusting relationships argues that such relationships require either the willing acceptance of vulnerability,Footnote 26 or a lack of felt awareness of vulnerability and thus a lack of hedging behaviour.Footnote 27 This position assumes a level of capacity either to accept vulnerability or hedge against it, as well as a specific understanding of the nature of vulnerability, which is not always appropriate once one moves outside the interstate level. For example, local health providers in Malawi experience multiple acute vulnerabilities and may lack any hedging capacity. Vulnerability is not always something such actors can choose to accept or ignore. We either can decide that these actors are outside the study of trust in IR, or we can supplement current research with work that examines what trust means in these contexts. Existing conceptions of the trust-uncertainty-vulnerability dynamic do not allow for studying trust in highly asymmetric power relations and therefore do not unpack questions of power, instead understanding relations of power/dominance as alternatives to relations of trust in the facilitation of cooperation.Footnote 28
The assumption of anarchy and its effects on vulnerability and uncertainty remain constant across both strategic and moral approaches to trust.Footnote 29 Strategic trust assumes actors decide to trust based on information that one party has about another being potentially trustworthy (that is, cooperative). Potentially trusting actors are rational egoists reacting to varying incentives to cooperate in situations of uncertainty.Footnote 30 Work that has contested the strategic approach argues that trust involves not just the expectation of a potential trustee's cooperative preferences or behaviour but also that any cooperation is based on a conviction of the benevolence of the trustee, not just incentive/assurance structures. Trust requires a ‘human factor’Footnote 31 and a conviction that the other will ‘do what is right’.Footnote 32 This literature roots trust in conditions that include emotions, personal ties, generalised expectations of moral behaviour, common identities, or interpersonal interactions.Footnote 33
We conceptualise trust in two parts. The first is the ‘exercise of [discretion] by some agent (individual or artificial) on behalf of another over matters that the trusting agent cares about’.Footnote 34 The focus on the exercise of discretion places trust in the act of trusting rather than in the belief that the other is trustworthy. This view understands trust as ‘the generic name for habitual practices in which processes of long-term cooperation are embedded in world politics’ in which players do not always consciously decide to trust.Footnote 35 Understanding trust as a practice that can exist alongside other practices does not place trust and power in opposition to each other but allows them to be at work in the same contexts. It also avoids assuming a certain type of formally independent international trusting actor, unlike definitions that rely on accepting/ignoring vulnerability.
Our second element is trust as identification, which builds on Aaron Hoffman's work on ‘fiduciary’ trust that points out how discretion alone is not enough for trust, because exercise of discretion could simply be a calculative act of risk taking.Footnote 36 Trust also needs to include a ‘relational and affective element’Footnote 37 outlined by moral/emotional accounts of trust, so that it ‘involves risk, but cannot be reduced to risk’.Footnote 38 This relational element is evident in trust as identification, or a trust that is founded on an emotional identification with other members of a perceived in-group.Footnote 39 When individuals share values, experiences, and common goals, they view one another as familiar and create ties of reciprocity.Footnote 40 Shared identities lead to the construction of common expectations about obligations and similar views on grievances,Footnote 41 all of which provide the grounding for trust. In our conceptualisation of trust, the granting of discretion is accompanied by ‘shared values, perceived similarities, sympathy and a common vision’.Footnote 42 Such trust is not merely rooted in rational trust linked to calculation, but it also identifies one's needs and self with the other. We term this two-sided view of trust as ‘trust as belonging’.
Our claim is that trust as belonging, understood as the exercise of discretion accompanied by the expression of shared identities, can be understood as a practice that is embedded in the relationships under study alongside complex relations of power. This provides a long-term view of trust developed as the ‘product of particular identity relationships that develop over time’.Footnote 43 Actors identify commonalities, engage at the interpersonal level (such as through face-to-face meetings), and empathetically ‘put oneself into the other fellow's place’.Footnote 44 Donors and local actors may share core values and goals (such as the provision of healthcare services) or identities (such as religious convictions), despite the diversity of power they possess. In addition, they may share common norms and values about the ways the world should work and their role in achieving that vision, with such norms and values promoted by donors and international NGOs. Trust as belonging is part of the ongoing practices and habits embedded into relationships and interacts with the forms of power that are also at play.
Developing an account of trust in IR that engages with dependency and multiple forms of power allows us to examine how actors have different and shifting types of uncertainty and vulnerability and how these are ameliorated or compounded by the power relations in which actors are embedded. It enables us to question how trust as belonging informs, trumps, or is superseded by forms of power. As Nicholas Rengger asserts, ‘the exercise of trust can alter power positions’ so the ‘exercise of trust’ in contexts of large power imbalances and situations of dependency is important in global politics.Footnote 45
Forms of power in donor-local relations in health
The exercise of power is central to health systems and health diplomacy; it shapes resource distribution, policies and practices, issue prioritisation, possibilities for transformation, and ultimately, health outcomes.Footnote 46 Health system performance results from the interplay between ‘hardware’ (finance, technologies, and human resources) and ‘software’ (ideas, interests, values, power, and norms),Footnote 47 and power relations and social processes shape these interactions at the local, national, and global levels.Footnote 48 Using Suerie Moon's 2019 taxonomy of power in global health, this section introduces the forms of power at play in the donor-FBO relationships we examine. These forms of power ‘can mutually reinforce tremendous power disparities in global health’, but power is neither immutable nor divorced from trust.Footnote 49
The most visible form of power in donor-local relations is compulsory power, which enables donors to compel local actors to act.Footnote 50 This power specifically derives from the economic power that donors have through the development assistance for Health (DAH) they provide.Footnote 51 However, this is not straightforward domination. Even where local actors such as the FBOs examined here depend significantly on donors for financial support, dependency is a two-way street whereby donors also rely on local actors to deliver health outcomes.Footnote 52 Locals may enact compliance to gain material resources,Footnote 53 performing identification with economically powerful partners. We recognise that at times, compulsory power (and resulting performances of compliance) may be entangled with trust as identification in an indecipherable knot.Footnote 54
A more ‘insidious’ form of power that shapes the extent of donor influence in health diplomacy is structural power (the power to ‘structure subjects’ capacities’).Footnote 55 Both structural and productive power (see below) are in no one's hands – instead the global economy works to the advantage of structurally empowered actors (donors) and to the disadvantage of the weaker, local actors. Actors do not necessarily recognise domination and can act in ways that reproduce it.Footnote 56 Donors harness structural power through their positions in institutions (that is, institutional power), whereby they exert indirect control over local actors from a distance through formal or informal rules.Footnote 57 At the global level, for example, donors dominate the World Bank where votes are proportional to a member-state's budgetary contributions.Footnote 58 At the national level, they use health policy processes and structures and embed their external technical advisors within government health ministries.Footnote 59 In these ways, they not only exercise economic power, but also perpetuate a productive power rooted in ideas, beliefs, and discourses.Footnote 60 Yet even within such structural constraints, scholars illustrate how informal networks, common ways of perceiving, and shared identities may enable manoeuvring and discretion, giving those with limited structural or economic power a voice.Footnote 61
Productive power relies on ‘systems of knowledge and discursive practices to provide the meanings, norms, values and identities that not only constrain actors, but also constitute them’.Footnote 62 Thus, productive power may provide opportunities for incorporation and inclusion.Footnote 63 There are three forms of unseen and unrecognised productive power that are particularly suited for entanglement with trust as identification, because they rely on shared meanings, norms, values, and identities to function.Footnote 64 The first is discursive power, which contributes to shared practices and worldviews. Discursive power operates through neoliberalism in the sense that it is a deeply embedded, hegemonic idea – a ‘deep core’ – that conditions debates, shrinks ‘policy space’, and ‘colonize[s]’ global health paradigms.Footnote 65 Neoliberalism refers to the emergence of new ‘arts of government’ developed in the Global North – notably a ‘technical reliance on market mechanisms, valorization of “private enterprise” and a suspicion of the state’.Footnote 66 This neoliberal discursive power limits the realm of activities to those focused on technical efficiency, financial accountability, results, and market-driven solutions. Dominant modes of operation (‘communities of practice’) emerge, become entrenched, and are unquestioningly replicatedFootnote 67 through report writing, development jargon, and ‘best practices’ across multiple contexts.Footnote 68 Although it appears that donors wield discursive power over locals in that they ‘shape the language others use to conceptualize, frame, and thereby define and understand’ in accordance with neoliberalism,Footnote 69 the picture is more complicated. Neoliberalism can take on new life in African contexts:Footnote 70 local actors can perform compliance with these practices (even though it may seem that they just ‘mindlessly enact received scripts’)Footnote 71 and leverage discourses,Footnote 72 all the while laying the foundation for trust as identification.
For FBOs, religious worldview forms an additional layer of discourse alongside neoliberalism. As Erica Bornstein illustrates, religious belief is a powerful undertone, one that ‘inform[s] the ways that development projects are received, interpreted and accepted in specific societal and historical contexts … and the way that development is planned, conceptualized, motivated and instituted’.Footnote 73 FBOs often emphasise service provision as a means to ‘witness their faith, fulfil religious teachings … or “do good” for others in the community’, although the ways that their religious beliefs intersect with secularism vary significantly with the organisation and its staff.Footnote 74 Part of the religious discourse revolves around the ways that ‘spiritual belief offers access to an alternative form of power’.Footnote 75
Second, epistemic power comes from ‘shaping what others consider to be legitimate knowledge’ and claims of expertise,Footnote 76 with a network of experts sharing common values, epistemologies, methodologies, and practices.Footnote 77 However, global health's interdisciplinary and multidisciplinary nature, lack of common epistemology, and colonisation by non-health experts like economists may undermine this power.Footnote 78 Counter-epistemic communities may challenge biomedical ‘expertise’, as occurred in South Africa around AIDS and antiretroviral medications, with a counter epistemic power influencing policies that delayed treatment rollout and ultimately, cost lives.Footnote 79 Additionally, because the boundaries of relevant knowledge in global health are porous, actors may have epistemic power because of localised, contextual knowledge.
Third, normative power is ‘when an actor shapes the principles that others believe to be right or wrong, and the actions that may then follow’.Footnote 80 It emerges from standing for ethical principles, claiming to serve as a community ‘conscience’, and at times, challenging other powers that distort justice, equity, and access. As the power of what ‘ought to be’, normative power may be rooted in religious or ethical beliefs or in the participation of those it affects.Footnote 81 In Africa, where many people claim high levels of religiosity, FBOs may embody this power.Footnote 82 Unlike discursive power (which is systemic), normative power involves direct claims making based on principles (‘naming and shaming’), with such claims-making being a tool to achieve policy outcomes.Footnote 83 Christian FBOs, for example, may point to Christ's admonition to ‘do for the least of these’ when asserting the ‘rightness’ of their position. Because Christ's words are foundational to the faith, they evoke shared understandings that can promote trust as identification.
Finally, existing work on global health governance recognises trust as a foundation for one aspect of power – network power – which ‘is wielded when individuals use their personal relationships with others to shape their thinking and/or action. Such relationships may be built on trust, reciprocity, repeated interactions over many years, shared experiences, shared identities, or other factors’.Footnote 84 Network power can translate into other forms of power (economic, institutional, epistemic, or discursive).Footnote 85
Methodology
We employ a two-level definition of trust. At its most basic, trust focuses on discretionary actions, meaning that donors’ trust of locals could include giving funds to those partners and putting them in control of their projects, ultimately placing both their material interests and their reputation into the partners’ hands. In turn, locals’ trust of donors is apparent when locals play by donors’ rules, giving donors discretion over outcomes. Yet, because we view trust to include identification, we also operationalise trust as evidenced in shared expressions of meanings, worldviews, values, and empathy expressed for the other.
We utilise a comparative case study of the Christian Health Association of Malawi (CHAM) and the Churches Health Association of Zambia (CHAZ), two FBOs that provide health care services in Malawi and Zambia, respectively. Formed in 1964, CHAM is a network of 175 health institutions (for example, clinics and hospitals) that the Catholic Church and 11 Protestant denominations operate. CHAZ, established in 1970, includes 157 health institutions run by the Catholic Church and 15 Protestant denominations. Both FBOs have professional secretariats to manage relations with member churches and donors and mobilise donor funding, and both employ nationals as public health experts in their secretariats and member health institutions.Footnote 86
CHAZ and CHAM cannot be divorced from their country contexts. As southern African countries, Zambia and Malawi share many historical, cultural, and political experiences (for example, high poverty rates; British colonial history; Christian majority populations). In both countries, donors operate within a neoliberal transnational aid context and rely on biomedical expertise.Footnote 87 Holding these factors constant, we can point to variations that may affect the power and trust that donors and FBOs exercise. First, the countries have different levels of DAH dependency, potentially giving donors more economic power in health in Malawi than Zambia. In 2016, DAH accounted for 72 per cent of all health expenditures in Malawi (US $443 million),Footnote 88 but 34 per cent in Zambia.Footnote 89 Second, each country presents different possibilities for the FBOs’ institutional power. Both FBOs are not autonomous from government, which is responsible for most of their operational costs (90 per cent for CHAM and 75 per cent for CHAZ).Footnote 90 Both FBOs have representation on multiple government institutions (see below), but unlike CHAM, CHAZ has been a principal recipient of multi-million dollar Global Fund grants since the programme began in 2002.
Our ground-up approach with respondents in Lilongwe in July 2014 and Lusaka in 2007, 2011, and 2014 allowed respondents to shape the research agenda around questions of power and trust.Footnote 91 We conducted semi-structured interviews with key actors: (1) country-level programme officers working with the major international donors in the health sector (for example, UK Department for International Development-DfID and US Agency for International Development-USAID); (2) technical advisors working with the Ministries of Health who have discretion over health resources; (3) officials in the Ministries of Health; (4) representatives of FBOs that provide significant health services (CHAM and CHAZ representatives, as well as officials at ecumenical church organisations like the Christian Council of Zambia); (5) major international NGOs that operate health programmes; and (6) international consultants who work with donors. We conducted 24 interviews in Malawi and 42 in Zambia. In addition, we rely on informal discussions with key actors, and informal observations at trainings or meetings we attended. Finally, we conducted documentary analysis of agreements, reports, presentations, and media stories.
We sought to establish trust between the researcher and participants in various ways. We relied on snowball sampling based on personal recommendations to gain access to officials. Because the research spanned over multiple years, authors had previously met and even interviewed several informants. In addition, one author's knowledge of the Chichewa language, and another's deep ties to Anglican, Presbyterian, and Reformed Church institutions facilitated access to and rapport with local actors. A shared status as an outsider helped to establish rapport with donor and NGO officials. We recognise how at times we too relied on trust as identification.Footnote 92 We structured interviews around broad themes, such as the actors’ roles, perceptions of key health challenges, efforts to address these challenges, expectations of other actors, and expectations they face. This sequencing allowed the interviewees to determine the conversation's direction, as questions moved from issues that respondents were more comfortable discussing to those that were more sensitive.Footnote 93 We recorded most interviews (with permission) and assured respondents of the confidentiality of responses and their anonymity in publications.Footnote 94
Trust as belonging in FBO-donor relations
This section examines the nuances of how trust as belonging – or the complex duality of trust as discretion and identification – interacts with various forms of power in the relations between FBOs and donors in Malawi and Zambia. We begin by examining how trust is exercised where donors give the FBOs discretion over two things they fundamentally care about: their resources and projects. We find that power and trust interact in a dynamic cycle that can be virtuous or vicious. We then explore the role of trust as common identification through shared neoliberal and faith-based values, examining how FBOs identify with communities and donors as knowledge brokers, and the crucial role of networks. We expose how identification underpins the power-trust cycle. Finally, we draw conclusions about the potential for the power-trust cycle to be transformed.
Discretion over resources
Resources are key to trust as the exercise of discretion in contexts where donors have considerable economic power and FBOs, significant dependency. Donors provide DAH to Malawi and Zambia and have power over whether to give or withhold (conditional) aid. The resulting volatility undermines local capacity and may mean local actors agree to what donors want, fearing that if they do not, donors will cut recipients’ funding when aid budgets shrink. And yet, despite these asymmetrical power relations, trust is often present in donor-local relations.
In Zambia, donors exhibit trust by giving CHAZ discretion over significant (and increasing) amounts of funding.Footnote 95 CHAZ received its first grant from Danish Church Aid in 1992, and by 2004, it was a Global Fund principal recipient.Footnote 96 In 2012, the US government authorised CHAZ to receive funds directly as the lead agency for the PEPFAR-funded AIDSRelief project.Footnote 97 Between 2011 and 2018, donor income grew from US $25.79 million to US $33.3 million, and the organisation had maintained other income sources and annual surpluses. Its list of donors has expanded,Footnote 98 and there has been some flexibility in donor aid.Footnote 99 Most notably, as of 2019, CHAZ had received US $365 million from the Global Fund, just behind UNDP (US $385 million) and the Ministry of Health-Zambia (MoH-Z) (US $420 million).Footnote 100 CHAZ's relations with multiple donor partners limited the economic power of a single donor, though its secretariat did recognise overall dependency as a problem.Footnote 101
In Malawi, local actors are acutely dependent and lack economic power.Footnote 102 Discretion in this case may be partial, superficial, and precarious, such that for donors a calculation of the risks of defection is still prominent. CHAM has faced major resource challenges because reports of financial mismanagement in 2010 eroded donor confidence. One key secretariat official with responsibility for the budget reflected on how this had become a ‘vicious circle’: ‘Where we had no funding we could not attract competent people. When the donors came to the secretariat they did not find anyone who was competent and they think CHAM is not worth it [funding].’Footnote 103 Where CHAM had limited economic power, it had to be more responsive to donor requirements to improve its reputation and attract funding.Footnote 104
CHAM's lack of economic power leads it to use extraversion: the process of strategically turning one's poverty and powerlessness into assets to gain resources and status.Footnote 105 Extraversion is a strategy that both requires a level of trust and is a request for trust. The CHAM secretariat has stressed the hopelessness of CHAM's situation, particularly in light of past financial mismanagement and poor donor relations: ‘There are so many issues that are legacies of that mismanagement that are coming in the way of our partnership. I do not know if I can see through them.’Footnote 106 Like the dependency found in patron-client relations, CHAM expresses its vulnerability with the ‘leap of faith’Footnote 107 that economically powerful donors would benevolently provide resources, exemplifying how the ‘exercise of trust’Footnote 108 can change power relations.Footnote 109
Economic power and discretion can interact as part of a virtuous power-trust cycle, as CHAZ demonstrates. As CHAZ is entrusted with greater funding, its economic power increases, which empowers it to lobby for both increases in future funding and greater discretion over how such resources can be used. On the other hand, as CHAM shows, a lack of trust can limit economic power and diminish capacity, which further erodes trust as discretion in a vicious power-trust cycle. While power-trust cycles can be mutually reinforcing, they are neither static nor immutable, but are subject to continuous contestation and renegotiation.
Discretion over projects
Trust is also present where donors give local actors discretion over the projects rolled out in their name. FBOs have considerable institutional and epistemic power that donors rely on in the realm of health. The institutional power of both FBOs is rooted in the hundreds of local churches that support them across both countries, giving them extensive reach into remote areas hard to resource and staff. A CHAM secretariat official with responsibilities for managing relations with members reflected that ‘at the local level we are appreciated, particularly in remote areas’ because CHAM is ‘all they have known all their lives’.Footnote 110 Similarly, local partners say they trust CHAZ to look out for their interests, repeating statements like: ‘They help us. They assure our voice is heard. They are our friends.’Footnote 111
The FBOs’ institutional power intertwines with epistemic power derived from expertise in health care delivery. They are organisations led by medical doctors and individuals with lengthy public health experience and both have particular expertise in delivering health care in hard-to-reach rural communities.Footnote 112 CHAM institutions provide 37 per cent of Malawi's health services and 75 per cent of services in rural areas. CHAZ affiliates provide 40 per cent of Zambia's health care and 50 per cent in rural areas. In addition, their presence in underserved areas has been long-standing, with many health centres existing from before independence and some for over one hundred years. FBO health workers live in the local communities in areas where it is hard to entice health workers to stay, with CHAM's workers, for example, being bonded to four to five years of service after their training. Thus, they are uniquely positioned to understand local needs. A CHAM representative described them as ‘partners with the people’.Footnote 113 They have informal relations with local power brokers such as traditional leaders. Reflecting a common theme in all the Zambian interviews, one CHAZ official explained that long-standing community relations enabled CHAZ to understand the types of health interventions that local populations would, or would not, accept.Footnote 114
Both FBOs extend their epistemic power by sharing their expertise. At the national level, they run health-training programmes that contribute significantly to much-needed capacity development.Footnote 115 CHAM's 12 training colleges provided the ‘backbone’ of training for up to 80 per cent of mid-level health professionals in Malawi in 2014. With student intake doubling in ten years, CHAM's epistemic influence is growing.Footnote 116 This track record brings some economic power because it attracts donor support, including for scholarships.Footnote 117 CHAZ operates 11 similar training schools and conducts trainings in auditing and management for church-health institutions.Footnote 118 The donors IMA World Health and USAID have showcased the efforts of both FBOs through the Africa Christian Health Associations Platform (ACHAP).Footnote 119 CHAZ also has shared its management expertise with other African FBOs. CHAZ's ability to teach ‘best practices’ through ‘south-south learning’ deepens its epistemic power,Footnote 120 which in turn advances its institutional power.
This institutional and epistemic power provides the foundations for trust in terms of the discretion for both CHAM and CHAZ over delivering health care, which then strengthens their institutional power through their partnerships in national institutions in a virtuous cycle. Both FBOs are the major partners to the government and this facilitates resource pooling, service delivery, and specialisation along task or geographic lines.Footnote 121 Both are represented on national AIDS councils, Global Fund required Country Coordinating Mechanisms, and Ministry of Health technical working groups, yet the two differ somewhat in the depth of institutional power and the levels of trust.
In Zambia, informants say that even when CHAZ has had differences with the government (for example, about government reimbursements), they work to preserve a ‘cooperative’, ‘positive’, ‘collaborative’, and ‘trusted partnership’.Footnote 122 CHAZ often plays along when government claims credit for its accomplishments. As one donor official said, reflecting a widespread donor sentiment in Zambia, ‘Sometimes government is really proud of CHAZ and says it [CHAZ] is actually government.’Footnote 123 The relationship has enabled CHAZ to convince the MoH-Z to act on issues such as hospice care, the creation of health databases in new districts, and autonomy for church-run facilities.Footnote 124 The relationship may be aided by the larger political context, in which the national ecumenical church bodies that support CHAZ have played only a limited role in politics in the last decade.Footnote 125 The positive CHAZ-government relationship also makes it easier for donors to work with CHAZ, because they can claim to respect state sovereignty and eschew political entanglements. Hence, CHAZ has been involved with the World Bank's Performance-Based Financing group, the Country Coordinating Mechanism grant formulation and disbursement meetings, and stakeholder sessions to write the National Health Strategic Framework, and the National AIDS Strategic Framework.Footnote 126 CHAZ's institutional power enables it to benefit from discursive power as it reifies the neoliberal idea that service delivery is a technical, apolitical exercise.Footnote 127
CHAM also has institutional power through its relationship with the government, with a key representative of the CHAM secretariat who worked closely with the government explaining that ‘government points the direction and we come in to support the government to steer the ship in that direction’.Footnote 128 However, disputes between CHAM and government due to mismanagement of donor funding and the breakdown in local service level agreements have had the potential to limit CHAM's institutional power and make it harder for the donors to work with CHAM. Both the government and CHAM claimed the other had reneged on obligations in the service level agreement whereby CHAM provides services and the government reimburses those services by paying CHAM salaries.Footnote 129 This affected the operation of facilities, led to diminishing worker morale, and exacerbated ‘brain drain’ of workers from CHAM facilities to government facilities. In response, some CHAM facilities refused to provide services and others reintroduced user fees – both actions diminished community trust for those facilities and eroded CHAM's institutional ties to member churches.Footnote 130 A key independent negotiator in the dispute reported that ‘meaningful dialogue’ had broken down, primarily because of the ‘trust gap’ between the Ministry of Health-Malawi (MoH-M) and CHAM.Footnote 131 These tensions are set within a context in which Malawian churches have become more engaged in civil society mobilisation on good governance issues.Footnote 132 In the wake of this dispute, a CHAM secretariat official highlighted the importance of strengthening trust, working with donors and government so that they understand CHAM's role, interests, and needs, particularly its fundamental need ‘to be valued and seen as relevant’. The secretariat's strategy included face-to-face interactions through participating in technical working groups where ‘[we should] express [our]selves without being self-serving’.Footnote 133
Long-term relationships, institutional partnerships, and practices of knowledge transfer are foundations of trust as discretion, as donors depend on the FBOs to deliver project outcomes, something possible because of their experience and knowledge of local contexts. This dependence also deepens the FBOs’ epistemic power and can position them as brokers between donors and local communities (explored below) in a virtuous cycle. However, the power-trust cycle can become vicious and we highlight the importance of understanding these complex dynamics. We now move on to consider the important role of common identification that operates alongside trust as discretion.
Neoliberal and faith-based identification
The sharing of ethical values and practices between donors and FBOs is key to trust as identification. Both FBOs relied on sharing common identities and commitments with donor audiences to promote trust, harnessing the discursive power of neoliberalism and drawing on shared faith-based identities. They differ in these efforts because of their organisations’ histories: CHAM engaged in performances to build trust while CHAZ reaffirmed trust.
CHAM has emphasised its commitment to transparency by publicly acknowledging a legacy of mismanagement and contrasting past and current organisational practices. Reflecting the position set out in the ‘Strategic Plan 2015–2019’, one secretariat member explained how ‘five years ago the secretariat had huge management issues, so we lost a lot of partnerships with financial mismanagement. International Christian and government donors were pulling out. That legacy led to a weakened position.’Footnote 134 To address this weakness, CHAM had to be responsive to donor requirements to improve its reputation and relied on DfID (through the consultancy organisation Options) for technical support in financial management and governance.Footnote 135 CHAM instituted reforms, repaid debts, ‘initiated a thorough organisational overhaul’, and terminated responsible parties.Footnote 136 Its strategic plan emphasised a commitment to reposition itself as a ‘modern, sustainable and efficient association’ with a focus on ‘management’.Footnote 137 In short, it adopted the practices and language that undergird donors’ discursive power in order to be attractive to a variety of donors.Footnote 138
CHAZ has engaged in activities that remind partners that it already is a trusted partner. It has heralded its history of transparency, made its external audits public, disclosed tenders for procurement of medical supplies, and held annual meetings with CHAZ members to gain their input on policy proposals. CHAZ had internalised the activities and jargon of neoliberalism, including a focus on ‘remaining competitive’, even framing its new office location as an efficient way to avoid the ‘unbearable’ downtown Lusaka traffic.Footnote 139 CHAZ's normative power rooted in a history of ethical behaviours deepens donors’ trust. CHAZ emphasises this history:
CHAZ has had 15 years [of] unbroken record of accomplishment as a PR [principal recipient] of the Global Fund mostly attributed to its strong governance structures and adherence to its principles of transparency and accountability … During the 2009 Global Fund OIG [Office of Inspector General] audits, CHAZ was the only PR to have passed a clean bill of health.Footnote 140
Both CHAM and CHAZ contrasted themselves with government ministries and other NGOs that were perceived to be corrupt, incompetent, and unable to do their jobs (such as paying health workers’ salaries).Footnote 141 In the wake of ‘Cashgate’ in Malawi in 2013, when news broke that government officials absconded with an estimated US $150 million, CHAM had the opportunity to make such contrasts. There was a ‘crisis of confidence’ among donors who then withheld US $150 millionFootnote 142 and embedded technical advisors into the MoH-M in order to have ‘eyes on the ground’ to help audit DAH expenditures and to bolster technical capacity.Footnote 143 Even if donors did not fully trust CHAM, it became the least distrusted partner, as donors bypassed government and funded NGOs.Footnote 144 Similarly, ‘CHAZ looked good’ in 2010 when another Global Fund principal recipient – the Zambia National AIDS Network (ZNAN) – was reported to have stolen significant Global Fund monies. Donors then trusted CHAZ to take over management of ZNAN's grants.Footnote 145 Because the scandal related to channelling ZNAN funds to government officials,Footnote 146 CHAZ appeared to be a technical organisation above the dirtiness of politics, one aligned with neoliberal discourses on service delivery and religious discourses on honesty and integrity.
While the two organisations differed in how they portrayed themselves in light of their past experiences, both drew on religious discourses to promote shared values and identity with donors and local populations. For CHAZ, this meant emphasising its family-centred approach to health care, as the executive director wrote: ‘I have no doubt that the CHAZ model of delivering healthcare services that places the family at the centre … contributed to CHAZ's outstanding performance over the years.’Footnote 147 The Catholic concept of subsidiarity that focuses on tackling underdevelopment at the lowest level undergirds CHAZ's activities, as well as the cultural focus on the individual as part of a family unit.Footnote 148 This faith-based perspective aligned CHAZ with several international FBOs, such as World Vision, Ecumenical Pharmaceutical Network, Catholic Relief Services, and Christian Aid. Together, locals and donors shared a biblical language and spiritual motivation for engagement on health, believing that people are created in God's image and that God calls Christians to build ‘heaven on earth’ by meeting people's basic needs.Footnote 149 Not only does the family-based approach show CHAZ's identification with faith-based donors, but it also helps CHAZ identify with neoliberal organisations that stress civil society's creativity and the private realm.Footnote 150 For CHAM, confirming a shared identity revolved around the use of biblical imagery. In its 2015 report, CHAM compared itself to the Old Testament character of Daniel, a leader whom God rewarded for his integrity: ‘As we commit this report to the CHAM family and partners, we are drawn to the image of Daniel … his enemies sought to find fault in him, but could not find any “because he was trustworthy and neither corrupt nor negligent” (Dan. 6:4).’ The reference to God's reward for the honest person reminds readers of a shared foundation among local and international FBOs.Footnote 151
Both CHAM and CHAZ emphasise that their unique spiritual calling makes them accountable to God, in contrast to the secular state. For example, at the conference of ACHAP in 2015 the CHAM Secretariat spoke of CHAM's ‘Biblical mandate’ in contrast to the government's ‘Constitutional obligation’.Footnote 152 Donors spoke about how this commitment made them trust CHAZ's work – they were an organisation that ‘walked the walk’.Footnote 153 Their executives had chosen to work for these organisations because of their Christian commitment to ‘serving the poor and underprivileged’.Footnote 154 Donors illustrated a certain amount of willingness to see things through CHAZ's perspective and to search for common ground, possibly because even among secular organisations, many Zambian staff were Christian.Footnote 155
Trust as the expression of shared identities plays a vital role in the power-trust cycle. Where local actors – such as CHAZ – are effective in harnessing the discursive power of neoliberal practices they become trusted partners to donors and this brings more discretion over resources and projects. However, crucial in the relations examined here is how FBOs draw on the normative power of shared religious and ethical beliefs, to build deeper faith-based identification, which is in turn fundamental to extending various powers.
Dual identification as knowledge brokers
Trust as identification also emerged as the two organisations translated knowledge between epistemic and counter-epistemic communities. As ‘knowledge brokers’Footnote 156 navigating between biomedical (secular) approaches and holistic (spiritual) approaches to health, these FBOs cultivated trust with donors through a shared identity as practitioners of modern medicine and with locals through a shared cultural and religious identity. They reflected the epistemic power of biomedical expertise in their physicians and nurses, their evidence-based approaches, and their lengthy health care experience, all of which donors respected.Footnote 157 But the two organisations also recognise that many of the people they serve view health holistically to include spiritual elements. Thus, they translate biomedical knowledge into arenas that locals understand and they support prayer and reading scripture as part of care.Footnote 158 One CHAZ physician explained what she told clients when they wanted to rely solely on prayer, not AIDS medications, for healing, ‘God gives us the medicine and His power is within it. Pray hard but also drink the medicine.’Footnote 159 When the FBOs emphasise these spiritual messages, they deepen trust as identification with clients, many of whom seem to respect their emphasis on compassionate care and God's power.Footnote 160 Their spiritual messages also deepen trust as identification with faith-based donors.
Being a knowledge broker necessitates negotiating and mediating between communities. At times, donors and locals may distrust brokers, particularly if these intermediaries seem to prioritise their own needs.Footnote 161 In our cases, sometimes the FBOs had divided loyalties, requiring deft manoeuvring to please all.Footnote 162 For example, early in its days as a Global Fund recipient, CHAZ felt pressure from its church members to provide them with grants. Yet, it had to be financially accountable, and some of its church affiliates ‘just did not have the capacity to write a report or keep a spending ledger’.Footnote 163 CHAZ could not give grants to low-capacity partners, but, as one church official who worked closely with churches on AIDS programmes said, some of these local partners questioned why, since they were compassionately meeting a community need.Footnote 164 These grassroots organisations’ lack of capacity for financial accounting (a form of epistemic power) undermined CHAZ's ability to exercise discretion. Yet, as indicated above, CHAZ over time translated knowledge to local partners through providing them with training on financial management, indicating how brokers continuously jockey for opportunities as they build trust as identification.Footnote 165
A focus on FBOs exposes how trust as belonging is complicated where actors are embedded in bidirectional relations of trust and identification: in this case with both donors and local communities. This bidirectional identification can be leveraged by the FBOs and other local actors to underpin their epistemic, institutional, and network power in a positive power-trust cycle.
Trust as identification and network power
Trust as identification is linked to network power, or the ways that personal, informal connections affect government, donor, and FBO dynamics. Many donor, FBO and government personnel have attended the same schools and worked for other organisations in the health sector.Footnote 166 For example, prior to 2014 the Director of CHAM worked for the MoH-M and the National AIDS Council, which gave him strong informal ties to government despite the aforementioned breakdown in formal relations.Footnote 167 In addition, some donors are nationals or married to local people and part of their networks.Footnote 168 Building trust as identification through networks may be more difficult between international donors and locals; because some donor personnel shift from post to post across countries, they cannot easily forge deep relationships with local actors.Footnote 169 However, these challenges seemed less apparent with CHAZ and CHAM and their international FBO partners, and there was a striking sense of ‘in group’ among these actors that respondents conveyed and we observed. FBO officials referred to mutual friends that work at other FBOs throughout the world; they mentioned the faith-based health conferences they attend and their membership in groups like Christian Connections in International Health. Some discussed their education (or their children's education) at Christian universities abroad (for example, Wheaton College-Illinois). Even for individuals with no prior direct experiences with each other, they seemed willing to give each other the benefit of the doubt because of their connections to this faith community.Footnote 170
These informal relations can enable manoeuvering within formal relations and can undergird institutional power in a virtuous cycle. However, they also may create an in-group identity that leads some to distrust those outside of the group, and vice versa. Although space prevents analysis of the issue, this lack of trust as identification has been apparent in HIV prevention programs, in which faith-based actors (both donors and locals) have felt under attack for their emphasis of abstinence and monogamy approaches,Footnote 171 while secular (and some religious) groups have felt similarly for their attention to condom distribution.Footnote 172 The limited identification between these in-groups can inhibit trust.
Transformation of the power-trust cycle
For CHAZ, economic, institutional, epistemic, and normative power deepened trust as discretion, giving CHAZ the competence to achieve an ‘unbroken record of accomplishment’, empowering it to meet its commitments and enabling further discretion and influence.Footnote 173 For example, CHAZ successfully lobbied the government for a fee waiver for foreign medical volunteers in Zambia if they affiliate with CHAZ.Footnote 174 This action benefited hundreds of Christians from high-income countries who travel annually with FBOs to Zambia on medical missions. The policy change increased the organisation's epistemic power (it could bring more experts); its economic power (it could get more faith-based donor support); and its normative power (it could provide more health services). It also reinforced trust as identification between CHAZ and FBO donors such as World Vision that sponsor medical missions. By successfully integrating the dual faces of trust as belonging, CHAZ can shape Zambia's discourse on health as a partner with donors. One official, reflecting a broad sentiment within CHAZ, explained that some donors ‘have taken our goals, looked at the strategic plan for the nation and our own plan and based priorities on those’.Footnote 175 By shaping the debate and defining the possibilities for health in Zambia, CHAZ exhibits the power to affect what others think and do. CHAZ problematises the notion that power and dependency only operate in one direction, from the donor to the local actor.
In contrast, CHAM illustrates that power and trust may intertwine in a vicious cycle. At the time of fieldwork, donors showed limited trust in CHAM, and the organisation acknowledged that donors viewed it to have a damaged reputation (weak normative power).Footnote 176 Donors provided relatively few resources directly to CHAM, as shown in Global Fund disbursements. Of Malawi's 13 grants (a total of US $711 million), none went to CHAM as a principal recipient.Footnote 177 Low levels of trust undermined CHAM's economic power by limiting access to resources. The resulting low capacity and the perception of limited competence for meeting obligations eroded epistemic power, and CHAM's reliance on DfID to help with financial management partly illustrates this gap. Normative and institutional powers also could not support trust as discretion because CHAM lacked a positive reputation with state officials and could not fully meet the community's demand for care. Unmet obligations undermined any accumulation of the powers that undergird trust as discretion.
Despite these challenges, CHAM shows how trust as identification may create new opportunities to gain various forms of power. Through highlighting shared beliefs and commitments, as well as personal connections, trust as identification enabled CHAM to begin to repair some donor relations after 2014. CHAM's faith-based orientation helped it to point to shared values and forge ties with Norwegian Church Aid and Danish Church Aid, while its embrace of neoliberal practices facilitated ties to USAID in a positive trust cycle. It also secured new project funding from the European Commission and a second award from the US Centers for Disease Control and Prevention for 2015–19. One CHAM secretariat official highlighted that some donors were prepared to ‘give CHAM the benefit of the doubt so CHAM can rebuild its reputation by giving small amounts of money’.Footnote 178 That is, they were willing to take a first trusting step based on intangible elements such as common values and emerging friendships. In the process, they illustrated an empathy for the other that undergirds trust as identification.Footnote 179 This was partly possible because DfID invested in CHAM's capacity building through trainings, and its consultants who worked closely with CHAM staff over several years developed a shared interest in helping the organisation to succeed. Trust as identification helped to begin rebuilding trust as discretion.
CHAM's improved situation illustrates that the power-trust cycle in donor-local relations need not be static. It can be transformed when donors exercise trust as discretion and when they strive to align their objectives with local interests.Footnote 180 Trust as identification can make it possible for donors and locals to adopt strategies needed to build long-term equitable professional relationships.
Conclusion
The interaction between trust and power has been neglected in both the IR and global health literatures and yet our research has shown that this interaction is fundamental for global health systems, impacting the possibilities for cooperation between multiple health actors, with implications for health outcomes. While previous work has often placed trust and power as functional equivalents, treating them as different means to elicit cooperation, we examine how trust and power can interact in asymmetric power relations. In doing so, we recognise that dependency is not simply the outcome of trust but can be a context in which trust is both possible and necessary. Although donors have compulsory power in their relations with local actors through control over funding – placing these relationships outside of the purview of trust by standard IR accounts – trust is still important in circumstances of dependency. We argue this literature must recognise the role of ‘trust as belonging’ to account for how common identification (shared identities) complements trust as an exercise of discretion (over resources and decisions) in complex relations of dependency.
We extend the IR literature on trust and the global health literature on power by developing the concept of the ‘power-trust cycle’ to account for the complexity of how various forms of power compound and ameliorate actors’ different, shifting vulnerabilities and undergird the competencies that matter for trust; and how trust, in turn, can augment various forms of power. Leveraging this trust as belonging successfully, we contend, can enable local actors to harness different types of power in an effort to offset and mediate the hegemonic power of neoliberalism. This, in turn, extends trust in a virtuous power-trust cycle. Conversely, actors who lack trust find it more difficult to harness alternative means of managing global imbalances of power, a pattern that then deepens distrust in a vicious power-trust cycle.
The power-trust cycle in donor-local relations is not static or immutable. It can be transformed through conscious donor-local efforts to nurture trust as belonging: when actors make requests for trust; when donors take a leap of faith and give local actors discretion over resources and projects; and where donors strive to align their objectives with local interests. Common identification can provide important foundations for donors and locals to build long-term equitable professional relationships. Strategies include coordinating donor action around locally determined plans, building long-term professional relationships that transfer skills (instead of one-off training sessions), and adopting longer project cycles that foster opportunities to recognise shared values.Footnote 181 Such strategies also can build trust, for they give actors the space, time, and equal footing on which to recognise commonalities and nurture personal relations.
The power-trust cycle, and the recognition that trust includes both discretion and identification, must be taken seriously in debates about local capacity and institution building, issues that permeate all Sustainable Development Goals.Footnote 182 In particular, we challenge donors firstly to embrace a multifaceted view of trust that moves beyond a trust-building agenda that focuses narrowly on transparency and accountability.Footnote 183 There are multiple risks when donors and locals embark on a new project, and minimising these risks often requires the other element of trust – trust as identification. That is, donors must be willing to act on those intangible, relational elements that move beyond adopting neoliberal communities of practice but often make achieving outcomes possible. Secondly, donors must recognise the complexity of the power-trust cycle so as to acknowledge that a lack of various forms of power – not a lack of desire – may undermine trust. For example, even if an organisation wants to keep transparent financial records, without sufficient economic power to hire well-trained accountants, it cannot do so. Recognising the complexity of power and trust would open possibilities for greater engagement with the very low-capacity organisations that local communities rely on and trust. Finally, more nuanced views of power-trust linkages would encourage donors to adopt strategies to invest in relationships, nurture shared values, and foster common objectives – all actions needed to foster the trust essential for achieving development objectives and more immediately, improving health outcomes in the COVID-19 pandemic and beyond.
Acknowledgements
We thank Alexander Beresford, Anna Mdee, and the anonymous reviewers for their feedback and direction on this article. We are also grateful to Claire Brolan, Joseph Harris, and the audience at the ISA Annual Conference in 2019 for their comments and suggestions on an earlier draft of the article.
