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Distributional equity in demand-driven HIV programmes: lessons from Malawi

Date: Poster sessions
Source: Forum 11
Authors: Arild Schou, Associate Professor, Department of Economics and Social Sciences, Buskerud University College, Norway


Over the last decade, development agencies and governments in low- and middle- income countries have turned their eyes towards the local level in implementing national HIV programmes, focusing on local level institutions and processes. The underlying idea is that by `going local', development efforts will promote popular involvement and that programme activities will be attuned to local development priorities. Such programmes are supposed to be superior to traditional public service delivery, with its `supply-driven' problems ­ centralization, rigid and top-down bureaucracies and insensitivity to service users. However, recent research on such programmes has shown that demand-driven programmes are particularly vulnerable to elite capture and unequal sharing of programme funds.

The aim of this paper is to analyse intra-district distribution of programme benefits to community-based organizations in the Malawi national HIV programme. The evidence is based on a comparative case study of the implementation in two rural district councils. The paper argues that in an early phase of programme implementation there is a tendency of relatively unequal sharing of benefits among the target groups. In both councils it was the most advantaged areas (Traditional Authority Areas) in terms of access to education and closeness to the councils' headquarters that benefited the most from the programme. Some of these areas were also the most advantaged ones in terms of access to health services, which shows that the programme does not necessarily reach those who are most in need of improved HIV prevention and care. Finally, in both councils it was found that it was the areas that already had a vibrant organizational life in the field of HIV that benefited the most. In all this, elite capture by `local strongmen' serves as an explanation. However, elite capture is systematically correlated with other area characteristics such as educational level and vibrancy of civil society. Thus, in this context the elite capture perspective seems to be too narrow.