Decentralisation of Brazil’s HIV/AIDS programme: intended and unintended consequences

ABSTRACT

Brazil’s response to the HIV/AIDS epidemic was characterised by an innovative alliance of governmental and non-governmental actors inspired by a strong progressive tradition in public health. Brazil eventually moved to decentralise HIV/AIDS programmes to its states and cities, a policy endorsed and supported financially by the World Bank as consistent with the mix of public and private elements central to the country’s HIV/AIDS strategy. However, decentralisation has not provided the results anticipated. Through interviews with key informants, government officials and patient advocates as well as observation of treatment sites, we outline how the shift of administration and resources to state and municipal bodies operated in practice. The Bank promoted decentralisation as an uncontroversial technical matter, and its programmatic guidelines implied that the nonprofit sector would be strengthened by it. However, instead of bringing HIV/AIDS policy closer to the grassroots, decentralisation has undermined the country’s early work and opened the door to a rejuvenated epidemic by empowering unsympathetic local elites, marginalising the human rights focus, and removing federal oversight. Its experience holds crucial lessons for developing countries facing similar conditions.

KEYWORDS:

• HIV/AIDS
• Brazil
• decentralisation
• health systems
• World Bank

Acknowledgements

This work was supported by the French National Agency for Research on HIV/AIDS and Hepatitis.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Timothy Frasca http://orcid.org/0000-0002-0859-0071

Additional information

Funding

This work was supported by French Agency for Research on AIDS and Viral Hepatitis (ARNS) [grant number 12223].