Background: HIV and AIDS are significant and growing public health concerns in southern Africa. The majority of countries in the region have national adult HIV prevalence estimates exceeding 10 percent. The increasing availability of highly active antiretroviral therapy (HAART) has potential to mitigate the situation. There is however concern that women may experience more barriers in accessing treatment programs than men.

Living conditions and poverty are two common quantifiers or parameters of socioeconomic status and both have evolved from rather narrow economic and material concepts to encompass broader and more complex understandings.According to Heiberg and Øvensen (1993), studies on living conditions have evolved to include individuals' capabilities and how they utilise their capabilities. Likewise, the concept of poverty has expanded beyond a derived level of income or accumulation of material goods whereby 'poverty is now seen as the inability to achieve certain standards', poor people 'often lack adequate food, shelter, education, and health care', and 'they are poorly served by institutions of the state and society' (Wolfensohn and Bourguignon, 2004, p 4). The two concepts are not interchangeable, however; they stem from different research traditions and differ in use both for research and for practical purposes. While poverty research has focused on defining poverty and establishing poverty profiles, identifying poor populations and strategies for reducing poverty, studies on living conditions are based on more loosely bound sets of indicators that are applied to measure, for example, level of income, education, access to information, access to healthcare and social participation in a population, and to establish differences between population sub-groups for descriptive, comparative and monitoring purposes. Poverty is both a more general and complex phenomenon than living conditions, and the field of poverty research has recently been characterised as 'polyscopic', indicating that we are dealing with a multifaceted umbrella term and a conglomerate of perspectives and methods (Øyen, 2005). Surveys of living conditions in a population can, however, provide indicators on poverty and disability, and, if properly designed, they can be applied to study poverty mechanisms, poverty development and trends in a population, as well as contributing to decisions that may be applied to poverty alleviation. In this chapter data collected on the living conditions among people with and without disabilities in the southern African region will be utilised to assess the disability-poverty relationship.

We describe a number of pitfalls that may occur with the push to rapidly expand access to antiretroviral therapy in sub-Saharan Africa. These include undesirable opportunity costs, the fragmentation of health systems, worsening health care inequities, and poor and unsustained treatment outcomes. On the other hand, AIDS "treatment activism" provides an opportunity to catalyze comprehensive health systems development and reduce health care inequities.However, these positive benefits will only happen if we explicitly set out to achieve them. We call for a greater commitment toward health activism that tackles the broader political and economic constraints to human and health systems development in Africa, as well as toward the resuscitation of inclusive and equitable public health systems.

Despite multiple efforts to strengthen health systems in low and middle income countries, intended sustainable improvements in health outcomes have not been shown. To date most priority setting initiatives in health systems have mainly focused on technical approaches involving information derived from burden of disease statistics, cost effectiveness analysis, and published clinical trials. However, priority setting involves value-laden choices and these technical approaches do not equip decision-makers to address a broader range of relevant values -such as trust, equity, accountability and fairness -that are of concern to other partners and, not least, the populations concerned. A new focus for priority setting is needed. Accountability for Reasonableness (AFR) is an explicit ethical framework for legitimate and fair priority setting that provides guidance for decision-makers who must identify and consider the full range of relevant values. AFR consists of four conditions: i) relevance to the local setting, decided by agreed criteria; ii) publicizing priority-setting decisions and the reasons behind them; iii) the establishment of revisions/appeal mechanisms for challenging and revising decisions; iv) the provision of leadership to ensure that the first three conditions are met.REACT -"REsponse to ACcountable priority setting for Trust in health systems" is an EU-funded five-year intervention study started in 2006, which is testing the application and effects of the AFR approach in one district each in Kenya, Tanzania and Zambia. The objectives of REACT are to describe and evaluate district-level priority setting, to develop and implement improvement strategies guided by AFR and to measure their effect on quality, equity and trust indicators. Effects are monitored within selected disease and programme interventions and services and within human resources and health systems management. Qualitative and quantitative methods are being applied in an action research framework to examine the potential of AFR to support sustainable improvements to health systems performance. This paper reports on the project design and progress and argues that there is a high need for research into legitimate and fair priority setting to improve the knowledge base for achieving sustainable improvements in health outcomes.

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