Conclusion and Recommendations

  • Samantha PageEmail author
Open Access


In this conclusion I bring together the various threads of my argument. First, I summarise each chapter in relation to the themes identified and the analytical frame employed in this study. Second, I present my three key arguments. Third, I contextualise my study in terms of where we are today with AIDS at the global level and within Malawi. Fourth, I demonstrate how this study contributes to academic debates. Finally, I present recommendations to improve policies and programmes on HIV and AIDS at the international and national level.

The focus of this research was to examine how policies and programmes on HIV prevention and the sexual cultural practice of fisi have come to be linked. My findings show that policies have been constructed based on inaccurate imaginings of both the sexual behaviour of rural people, who have been primarily blamed for the spread of HIV, and the Malawian elites’ and international donors’ misunderstanding of the bio-medical evidence surrounding HIV transmission during one heterosexual act. I have shown this by using the example of the fisi practice; a practice that involves a man having sex with girls during initiation. Although there are many sexual cultural practices taking place in Malawi, I focused on this practice, as while I was in Malawi working as Programme Manager for a sexual and reproductive health NGO, it was this practice that was recounted to me at length by those working for NGOs and stimulated a desire to learn more.

According to work on sexual cultural practices, they act as a mechanism rendering women inferior to men, and it is this inferiority that renders them vulnerable to violence (Mkamanga 2000; Kamlongera 2007). For example, Anderson (2012) in her study on women’s bodies in Malawi, argues that most women who participate in sexual cultural practices are unable to refuse, as within wider society there is an understanding of a universal ‘masculine sex-right’ where men have the right to make decisions over what can be done with a female body, which makes women vulnerable to violence. Kistner and Nkosi (2003) argue that masculinity has emerged as one of the key factors at the interface between gender-based violence and HIV/AIDS. Thus, we can see that the practice of such sexual acts can lead to women’s susceptibility to violence.

This research draws attention to the fact that the probability of infection from one heterosexual act, such as the fisi practice, is very low: as reflected in the epidemiological evidence provided in this research (Gray et al. 2001; Powers et al. 2008). In light of this, the thrust of the study is the exposure of misconceptions among development practitioners and policymakers in Malawi concerning AIDS: this misconception is grounded in the view that certain cultural practices are fueling the HIV pandemic in Malawi. This research has predominately focused on revealing how very little if any bio-medical evidence is being used to inform current policies and programmes on AIDS in Malawi. Instead a handful of Harmful Cultural Practices have been targeted as the problem, which has led to a focus on eradicating those deemed dangerous. Yet I found that there is no evidence that the sexual practice of fisi has a higher transmission rate than other sexual practices that are common within Malawi. While a fisi may be more likely to be HIV positive than the average male, it is the case that intercourse with a fisi is usually a single act of intercourse and is far from an everyday occurrence: since intercourse within marriage is much more frequent and the use of condoms in marriage is infrequent (Chimbiri 2007), regular marital relations are thus more likely to lead to infection than intercourse with a fisi. For HIV prevention purposes, it would be far more useful to focus on more frequent practices, such as transmission within marriages or stable couples.

In the health sector, the concept of evidence-based policy has gained ground. Yet as I have demonstrated, a lack of capacity to make use of existing data in policy development and programmes imply that inefficiencies in the development process have not been properly identified and addressed. Most HIV prevention programmes in Africa have also arguably had limited impact because the research behind them focused primarily on risk groups, behavioural change models, and flawed understandings of cultural practices and economic conditions (Packard and Epstein 1991; Waterston 1997). In other words, the explanations given by the National AIDS Commission and non-governmental organisations for high rates did not rely enough on biomedical facts but rather on constructed categories of ‘at risk’ groups which once interrogated, can be seen to be inaccurate.

In this conclusion I bring together the various threads of my argument. First, I summarise the findings and discussion of this research in relation to the themes identified and the analytical frame employed in this study. Second, I present my three key arguments. Third, I contextualise my study in terms of where we are today with AIDS at the global level and within Malawi. Fourth, I demonstrate how this study contributes to academic debates. Finally, I present recommendations.

Summary of Key Findings

In Chapter  1, I provide an introduction to the topic including motivation for this research and my methodological approach.

In Chapter  2 I reviewed the literature within the field of anthropology of development, with particular emphasis on the work of Mosse (2011) and Crewe and Harrison (1998). Both demonstrate that many actors are involved in the policy process, which is not linear or straight forward: this makes it hard to unravel by whom these policies are constructed. These scholars demonstrate the usefulness of ethnography as a way of understanding the threads that interlock in the formation of policies and thereby have helped me identify how misconceptions seeped into the policy process in relation to HIV prevention in Malawi; although I do not analyse the policy process elsewhere in sub-Saharan Africa, it is likely to be similar to that of Malawi. They critically analyse the complex relationships of power between global multilateral organisations, donors, governments of resource-poor countries and local communities, and their impact on development projects. They also demonstrate how to critically engage with development practice by combining academic development work with academic writing and reflection therefore they have insights due to their positioning. Their approaches have been instrumental in developing my own analytical framework, as my research looks at how different elites working within the field of AIDS are able to construct policies based on vested agendas and interests.

In Chapter  2 the work of Chin (2007) is also particularly relevant to the central argument of my research, that elites working on HIV and AIDS perpetuate the myth that the fisi practice contributes significantly to the spread of HIV in Malawi. I argue that Malawian elites perpetuate this myth to maintain their professional status and to secure external funding from donors for projects on HIV prevention. Chin (2007) argues that UNAIDS and AIDS activists accept certain myths about HIV epidemiology to keep the disease on the political agenda and, by implication, ensure funding and jobs.

In Chapter  2, due to the inter-disciplinary nature of this research, I show how a number of theories influenced by argument. First, using the approaches used within the anthropology of development I provide a critique of HIV policymaking. Second, and in order to understand how policy was constructed based on misconceptions, I draw on elite and policymaking theories to demonstrate how the policy process is being mediated by the agendas of elites as opposed to bio-medical facts. Third, I use postcolonial theory to highlight how the elites are interpreting for themselves the colonial narrative that is founded on a binary opposition; civilised (the elites) and the uncivilised (the rural uneducated population) (Galtung 1971). This then enables the elites to distance themselves from those living in rural areas, allowing them to maintain a position of power and access to the resources flowing in from the aid community.

In this chapter I also review literature on HIV epidemiology. Epidemiological studies have estimated the risk of HIV-1 transmission. Although Malawians believe that HIV transmission is inevitable in a single act of unprotected intercourse (Anglewicz and Kohler 2009), epidemiologists found that the average rate of HIV transmission is 1 in 1000. These findings demonstrate that HIV is not easily transmitted. This is relevant to my study because the fisi practice occurs as a one-off heterosexual act and therefore it is statistically unlikely that this practice contributes significantly to the spread of HIV.

Moreover, the practice of fisi occurs in only a very small number of rural communities. In this chapter I also argue that the traditional practice of fisi is being utilised as a scapegoat for the spread of AIDS in Malawi to deliberately detract attention away from everyday sexual practices in urban areas of Malawi, such as extramarital relations and multiple sexual partners. As reflected in the evidence below, HIV prevalence is in fact higher in urban areas where the fisi practice does not take place.

In Chapter  3 I demonstrate the powerful and influential role that international donors (bilateral and multilateral agencies and INGOS) play in constructing AIDS policies and programmes. Additionally, this chapter emphasises that aid conditionality can fail to respond effectively to the AIDS epidemic by demonstrating how funding is often donor led. For example, if donors disagree with policies being implemented in the country to which they are supplying aid, whether it is the way money is being spent or the type of policies the government implements, then they will withdraw funds. I provide an example of the British Government suspending aid because it was unhappy with the President of Malawi’s autocratic management style. The paradox of such policies in practice is that they reduce the ability of nation states to be self-sufficient and instead put them in a dependency relationship with international donors.

Data from the Malawi Demographic and Health Survey (2004) shows that urban residents have a significantly higher risk of HIV infection than rural residents. While 18% of urban women are HIV positive, the corresponding proportion for rural women is 13%. For men, the urban–rural difference in HIV prevalence is even greater; urban men are nearly twice as likely to be infected as rural men (16 and 9%, respectively) (MDHS 2004, p. 231). This is significant because harmful cultural practices are reported to be largely rural practices, yet infection rates are significantly higher in the urban areas where the majority of the elites—Malawians with at least a university education—live. This highlights the inaccuracy in the elites’ narrative, one that blames rural Malawians for high prevalence rates. The problem is conversely higher in urban areas where the elites live. Further, HIV prevalence rates are higher among women aged 30–34 compared to women aged 15–19 (there is no data for women under 15). The fact that data was not collected and yet this is the demographic that is partaking in initiation ceremonies supports my argument that those blaming the sexual cultural practice of fisi for the spread of HIV lack evidence to support their case. In terms of education and wealth, the HIV prevalence rate is highest among women with a secondary education and above (15.1%) compared to those women with no education (13.6%). In terms of income those women with the highest rates of HIV were in the top wealth quintile. The emphasis of AIDS policies should therefore in fact be attributed more to contemporary patriarchal constructions of gender and power than a one-off highly un-evidenced traditional sexual practice.

I also examined how the advent of AIDS has provoked a reinterpretation of the impact of certain sexual cultural practices, which have now been labeled ‘risky’ or harmful. Some studies carried out have used culture as an explanation for high-risk behaviour, which can lead to HIV infection (Rushton and Bogaert 1989; Rushing 1995; Caldwell et al. 1989). However, this research shows that targeting specific population groups as opposed to addressing gender inequalities and issues of sexual power to a general population can be ineffective and misleading. This book does not argue that the cultural practices such as the fisi practice are not harmful and violent towards women but that these are not adversely contributing to the spread of HIV. Incorrect messages regarding HIV transmission rates are relayed which inhibit effective programme implementation.

Chapter  4 began by reviewing national and international policies on gender-based violence, harmful cultural practices and HIV/AIDS to highlight how these policies have been constructed around harmful cultural practices. I then reviewed literature on elites and used this to inform my own argument that policy processes are driven by elites as opposed to the argument made by Lasswell (1936) that policy implementation is a linear, rational process. These policies are being constructed around narratives of blame, which portray rural communities as backwards and the parties responsible for spreading HIV. This chapter concludes that the elites use these narratives as an ‘imagined fact’ in terms of how they contribute to high prevalence rates.

In Chapter  5 I argue that elite Christian religious morality has played an active role in portraying indigenous cultural practices as negative and blaming them for the spread of HIV/AIDS. In this chapter I also demonstrate how Christian elites portray themselves and their theology as enlightened in comparison to the minority Muslim population. Thus, casting indigenous cultural practices as responsible for the spread of AIDS with the agenda to undermine forms of traditional culture and validate a Christian lifestyle as unproblematic in terms of AIDS.

In Chapter  6 I examine theories of policy implementation, arguing against scholars such as Lasswell’s (1936) presentation, that policy implementation is a linear, rational process. Instead, I agree with Lipsky (1980), Lindblom (1980), Shore and Wright (1997), and Sabatier (2007) who postulate that policy processes are less of a linear sequence but rather a political process underpinned by a complex mesh of interactions and ramifications between a wide range of stakeholders who are driven and constrained by competing interests and the context in which they operate.

I have argued that there are a wide range of stakeholders involved in policy construction and implementation. These stakeholders include large, and powerful bilateral and multilateral agencies, such as DFID, USAID and the World Bank, as well as international Non-governmental organisations, national NGOs, international and national faith-based organisations, and the organs of the Malawi government, both at the national and the district levels, each with its own vested interests and each with its own policies. Therefore I argue the evidence produced to apply policies is not objective evidence but narratives shaped by various policy agendas and interests of the elites. As a result policies are pushed in a direction that does not benefit the vast majority of Malawi’s population in terms of HIV prevention, but instead perpetuate these groups’ standings and beliefs.

The Three Main Arguments

In this book I argue that a complex interplay of interests has led to the construction of the narrative that the sexual cultural practice of fisi is contributing significantly to the spread of HIV and AIDS. I argue this interplay can be best understood through three sets of arguments. Although these three sets of arguments are presented separately here, in practice these are interlocking.

The first and main argument is that the ‘narrative of blame’ is maintained by the national elites in Malawi to ensure that HIV is kept on the development policy, thus attracting donor funding and retaining elites’ professional status. I place emphasis on understanding policy construction as a process mediated by stakeholders involved in the policy process and argue that one reason why national elites are able to influence the policy agenda on HIV is due to the narrative they have constructed that has been sold to the donors. Thus they have a vested interest creating and maintaining the narrative of harmful cultural practices as responsible for the AIDS epidemic. This agenda permits them to maintain their own status and positions. Therefore, by maintaining the narrative that the sexual cultural practice of fisi, as well as other cultural practices that the elites consider harmful, drive the AIDS epidemic, they try to ensure that the policies and programmes directed to reduce HIV transmission continue.

The second argument identified in this study is that AIDS is presented by national, urban elites as a rural disease because the sexual cultural practice of fisi is reported to take place in rural areas. Therefore the narrative told by the elites is that the disease is being spread by people living in rural areas who are mainly illiterate and uncivilised. This narrative distances the urban elite from the disease, thus detracting attention from the higher level of AIDS in urban than in rural areas. As I highlight in this study, this ‘othering’ is a result of those elites working in HIV prevention providing explanations to ‘problems’ that satisfy donors and therefore ensure continued funding. Therefore, educated, urban elites who perceive themselves as civilised distance themselves from rural people who they position as uncivilised. I argue that elites in Malawi maintain their positions through adopting concepts of modernity held by the donors that rely upon a binary that divides the modern from the un-modern. Thus, the Malawian elites present themselves to donors, and potential donors, as suitable partners.

The third argument is that the Malawian elites have constructed a category of ‘uncivilised’, populated by those with little education (the majority of Malawians). They contrast these with themselves: educated Christians who are modern and progressive. This leads them to assert their superiority by placing the blame for the AIDS epidemic on those who practice what they call ‘harmful cultural practices’ that they associate with Malawian traditional religions. Within this context, Christian leaders play a role in projecting the narrative of blame as an ideological tool to promote a Christian lifestyle.

Contribution to AIDS Policy in Malawi

I have argued that although findings from epidemiological studies have shown that the probability of infection by one heterosexual act is 1 in 1000, I demonstrate that epidemiological evidence is ignored by policymakers. The gap between research and policy therefore needs to be bridged by disseminating research findings to policymakers so that when development programmes are designed they are based on evidence. Therefore for policy to be effective it needs to be informed by objective, empirical research on the population as a whole. For example, epidemiological evidence is particularly useful when preventing and controlling disease in populations and guiding health and health care policy and planning. Therefore such evidence can enrich health policies and plans to improve the health of a population.

The second contribution I make is a methodological one, enabling an understanding of how policy translates into practice across levels from the global arena down to the community level. The analytical framework and approach I proposed intended to facilitate analysis in evaluative and formative studies of—and policies and programmes on—AIDS, to generate meaningful evidence to inform policy. Therefore this study is not just applicable to Malawi but may be used in any country in the Global South. It is an original contribution to research as it focuses on narratives told by actors working in organisations, which focus on AIDS, while also tracing the impact of these narratives on the production of policies and programmes, rather than on geographically bounded local communities. My analytical framework has built on theoretical propositions and empirical research in development studies, particularly the work of Mosse (2011) and Crewe and Harrison (1998). I show that narratives on AIDS and sexual cultural practices are an obstacle to the development process. I argue these narratives become the dominant themes in the construction of policies. As a result, other key themes such as gendered power relationships are ignored or overlooked.

Thirdly, this study demonstrates a contribution to ethnographic research as it has shown how ethnography can be used to help construct policy and practice, which responds to the complexity of peoples’ lives. Using this ethnographic approach has enabled me to highlight why progress is slow in terms of improving gender relations and has emphasised how these narratives of blame are used as a smokescreen to pursue government and donor interests.

The newspaper article by Nyasa Times ‘Gender Minister wants women to hurt “hyenas”’ tells the story of the Minister of Gender who, speaking at an event to commemorate 16 days of activism against gender-based violence, advised women to hurt the hyena. She is reported to have said ‘Hit them (those hyenas) hard in their private parts and I can assure you it hurts’ (Nyasa Times 2011). Of course, advising women to carry out violent acts towards men is not particularly helpful and will not help improve women’s lives: to the contrary, it could leave them more vulnerable to abuse. But it is examples such as this one featured in the Malawi media that can be read by international donors and thereby influence international policy and programmes.


The following recommendations are based on the research I conducted for this study. What this research enabled me to do is develop my critical thinking on this issue.
  • Policies and programmes developed on HIV/AIDS at the international and national level need to be informed by rigorous evidence, collected through critical, reflexive methodologies.

  • To advance HIV/AIDS policies and programmes, stakeholders will need to embed policies in epidemiological evidence and pay greater attention to how the wider political contexts at national and international levels impact on the policy and implementation processes.

  • Stakeholders need to better articulate the link between sexual cultural practices, gender-based violence and women’s health.

  • Donors need to ensure they visit rural areas so that they understand the culture of the country and respond to local concerns and priorities.

  • Quantification of the risk of HIV infection after sexual intercourse is difficult to measure therefore more quantitative studies are also needed regarding the risk of HIV infection after sexual intercourse to inform policy.

  • Research needs to be accessible to non-academics. Researchers need to educate policymakers, by carrying out research that focuses on the ordinary cultural practices, such as extramarital relationships instead of the taken-for-granted understandings of rural people.


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Authors and Affiliations

  1. 1.Department of Global Development and PlanningUniversity of AdgerKristiansandNorway

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