Stuckler et al. Respond

Abstract

We welcome the effort by Larson et al. to extend our analysis of inequalities in health care provision in South Africa1 to an external disease-specific agency, the US President's Emergency Plan for AIDS Relief (PEPFAR). Although the analysis is interesting, the authors misleadingly suggest that their findings may be more robust because they used district level data. In fact, they are looking at something quite different. There is no a priori reason to expect that the distribution of funds by an international aid agency should be the same as that in the national government's healthcare budget. A larger question that the authors do not address is whether external agencies and private donors substitute for domestic spending on health care.2 PEPFAR has gone to great lengths to avoid such a possibility, for example, by setting up matching initiatives with government finance. Yet one unresolved concern is that when external groups provide health care services to vulnerable groups, they may unintentionally relieve the pressure on those making domestic budgetary decisions to reverse historical inequalities in health care. Independent analysis and scrutiny is needed to understand how external bodies such as PEPFAR have perpetuated or helped alleviate historical infrastructure-inequality traps that we observed. While considerable effort is expended in public health research to assess the determinants of health outcomes and inequalities,3 an equal need exists for rigorous studies to understand how to address deeply embedded causes of institutional inequalities and their influence on the evolution of public health systems.