Does epidemic control inadvertently reinforce inequality?

An HIV clinic in Maputo in Mozambique. Photo by: Talea Miller / PBS NewsHour / CC BY-NC

Over the last two years, ministries of health in sub-Saharan Africa and other countries with a high burden of HIV/AIDS have implemented strategies that concentrate resources on high prevalence areas and key populations.

Encouraged by their donor partners, such as PEPFAR, UNAIDS and The Global Fund, these strategies employ a biomedical approach that focuses on suppressing the viral load in the population in line with UNAIDS’ 90-90-90 objectives to reduce new infections and bring the HIV epidemic under control. If successful, this approach holds out the tantalizing prospect of ending the AIDS epidemic by 2030.

Often referred to in U.S. government circles as “the pivot,” this shift in strategy reflects constrained foreign assistance budgets as well as a number of successes in fighting AIDS over the last decade. We now have more robust surveillance methods that allow us to better target disease hotspots and key populations; countries have improved diagnostic and laboratory capacity that enable more rapid and sophisticated analyses; and new therapies allow people who are HIV positive to treat HIV/AIDS as a chronic condition instead of a death sentence. Call it the triumph of the medical epidemiologists.

There is an irrefutable logic to concentrating resources on the areas where a problem is worst. And this is especially the case when the problem is preventing the spread of an infectious disease. But does this logical approach inadvertently reinforce social and economic inequality by allocating scarce health resources to areas and communities that are already economically better off?

There are two reasons why this may be the case. First, allocating funds to target the highest prevalence areas shifts funding away from rural areas to more densely populated urban and peri-urban centers. Due to resource constraints, even rural areas with relatively high prevalence rates may lose external assistance. For example, in Zambia rural districts with prevalence rates as high as 5 percent were deprioritized and their PEPFAR funding was reallocated to other areas in the last year.

Second, funding to combat HIV/AIDS through PEPFAR and the Global Fund makes up a disproportionate share of external support for health programs in many poor countries. Over the last decade, ministries of health have taken advantage of these resources to improve health information systems and build delivery platforms to provide a comprehensive package of services that integrates maternal, infant and child health, malaria and vaccination programs, family planning, and a range of other services with HIV prevention, treatment, and care.

This has enabled national governments to expand and improve health services in rural areas that were once seen as potential reservoirs of untreated HIV infection.  

Reallocating resources to focus on epidemic control comes at a time of growing disparity in income and living standards between rural areas where a majority of the poor live and urban areas where there is greater access to basic social services and economic opportunities. Since HIV/AIDS funding makes up the lion’s share of external resources available to the health sector, there seems little doubt that the move away from integrated service delivery towards vertical interventions that concentrate resources in urban areas has reduced funding available to meet the health care needs of rural communities.

If this is indeed occurring it poses a dilemma for both U.S. and developing country policymakers. In 2014, USAID made ending extreme poverty the mission statement for U.S. foreign assistance.

While refocusing HIV/AIDS funding on epidemic control has the advantage of being a straightforward proposition with a clear exit strategy, in the absence of a clear strategy to make up for the loss of HIV/AIDS funding, it is likely to undermine the success health ministries have had leveraging HIV/AIDS resources to strengthen health systems to meet a broad range of health needs in rural areas, and thereby weaken efforts to end extreme poverty.

For their part, developing country finance and health officials are left to figure out how to reallocate domestic resources to sustain the health care delivery platforms HIV/AIDS funding has enabled. However, this comes at the very moment that optimistic projections of domestic resource mobilization have been punctured by a severe economic downturn. Combined with structural biases that favor urban spending, it may well be that epidemic control will inadvertently contribute to growing inequality and work against the objective of ending extreme poverty.

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About the author

  • Patrick Fine

    Patrick Fine is the chief executive officer of FHI 360. Prior to joining the organization, he served as the vice president for compact operations at the Millennium Challenge Corp. He was also the senior vice president of the Global Learning Group at the Academy for Educational Development from 2006 to 2010.

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