Beyond the Matrix: Thinking Three-dimensionally About Social Determinants of Health

Increased availability of antiretroviral therapy (ART) for HIV infection is a global health success story. According to UNAIDS, in just the three years from 2003 to 2006, the estimated number of people receiving ART in low- and middle-income countries quintupled (from 400,000 to just over two million); in sub-Saharan Africa, where the need is greatest, the number of recipients of ART increased thirteenfold. However, the figure of two million is still far short of the estimated seven million people in need of ART (UNAIDS 2007), and despite this shortfall in treatment access the concentration of health system effort and donor funding on AIDS treatment has been criticized as examples of a ‘vertical’ orientation that neglects the need to strengthen health systems as a whole. Among the criticisms, one with special force is that scaling up AIDS treatment and similar vertical programs actually weakens health systems, creating an internal brain drain of health personnel from public health systems to which they are indispensable to relatively better funded, disease-specific programs. Another is that the lack of personnel available for follow up in weakened health systems leads people not to maintain their ART regime, increasing the risk of that new drug-resistant HIV strains will develop (Wakabi 2008; Anonymous 2008).