The development and implementation of health policies in developing countries have become increasingly driven by the practices of research communities, inter- and non-governmental organisations, and donor agencies operating at the global level. Critics of this shifting landscape argue that the concurrent rise in demand for experimental evidence of cost-effectiveness reflects not only the ‘superior’ epistemic truth-value often attributed to experimentation, but also the permeation of neo-liberal market-principles into global health that took force in the 1990s with the rise of “philanthrocapitalism” and public-private partnerships. Simply put, cost-effectiveness measures facilitate the calculation of returns on investments, thereby enabling donors to hold recipients to account in highly detailed technocratic ways. Concern with growing neo-liberalism in global health has given rise to a series of counter-narratives relating specifically to the reductionistic and universalizing tendencies of cost-effectiveness frameworks. Epidemiologists and social scientists now routinely point to the disjuncture that arises when evidence-based guidelines, which are assumed to be broadly universally applicable, are transposed onto a variety of local “contexts” that are rife with “culture.” Many now actively engage in producing alternative epistemologies that they argue are better suited to understanding “context” and “complexity.” Drawing on an ethnographic study of the safe motherhood initiative, this paper explores the social and political life of these alternative epistemologies. Focusing on the recent proliferation of two specific concepts — “context” and “complexity” — we compare key differences in the ways these concepts are used by various stakeholders, depending on their type of expertise, and their role, rank and geopolitical placement. We demonstrate that underpinning debates regarding the epistemic importance of complexity and context are long-standing concerns with the workings of neocolonial power. Our analysis explores how debates relating to contingency are entrenched in geo-political negotiations and the emergence of new “community”-oriented politics of self-governance among experts who identify as representing the Global North and Global South. Focusing less on the polarised fringes of normative epistemologies (e.g. epistemic “resistance”) and more on how epistemic genres divide, multiply and inter-relate, we explore how assertions of the importance of “context” and “complexity” are trapped in a finely-tuned dualistic and dialectical relationship, thereby rendering these concepts unlikely vehicles of change.
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