Rationing Antiretroviral Therapy for HIV/AIDS in Africa: Efficiency, Equity, and Reality

Background: Rationing of access to antiretroviral therapy already exists in sub-Saharan Africa and will intensify as national treatment programs develop. The number of people who are medically eligible for therapy will far exceed the human, infrastructural, and financial resources available, making rationing of public treatment services inevitable. Methods: We identified 15 criteria by which antiretroviral therapy could be rationed in African countries and analyzed the resulting rationing systems across 5 domains: clinical effectiveness, implementation feasibility, cost, economic efficiency, and social equity. Findings: Rationing can be explicit or implicit. Access to treatment can be explicitly targeted to priority subpopulations such as mothers of newborns, skilled workers, students, or poor people. Explicit conditions can also be set that cause differential access, such as residence in a designated geographic area, co-payment, access to testing, or a demonstrated commitment to adhere to therapy. Implicit rationing on the basis of first-come, first-served or queuing will arise when no explicit system is enforced; implicit systems almost always allow a high degree of queue-jumping by the elite. There is a direct tradeoff between economic efficiency and social equity. Interpretation: Rationing is inevitable in most countries for some period of time. Without deliberate social policy decisions, implicit rationing systems that are neither efficient nor equitable will prevail. Governments that make deliberate choices, and then explain and defend those choices to their constituencies, are more likely to achieve a socially desirable outcome from the large investments now being made than are those that allow queuing and queue-jumping to dominate.

Narratives of Holiness Identity: The "Sanctified Person" in the Church of the Nazarene

This dissertation is an exercise in practical theology, which investigates and responds to the problem of changing holiness identity in the Church of the Nazarene. The first part of the study is an empirical investigation into the social context of contemporary Nazarene holiness identity and practices among Nazarenes in three congregations located in the Northeast United States. Previous research relied too heavily on secularization and sect-church theory to understand the dynamics of religious identity change among Nazarenes. The theological result was a pessimistic appraisal of the future possibilities of holiness identity and practice in the Church of the Nazarene. This study employs an alternative theory—Nancy T. Ammerman's theory of narrative religious identity—to understand the dynamics of lived religious life within these congregations and to identify the various holiness narratives at play. Ammerman's theory facilitates an empirical description of the multiple holiness identities emerging out of the social contexts of these Nazarene congregations and offers a way to account for identity change. At the heart of this research is the theoretical notion that a particular religious identity, in the case of the Church of the Nazarene, the "sanctified person," emerges out of a particular ecclesial context characterized by religious narratives and practices that shape this identity. Chapter one reviews the problem of holiness identity in the Church of the Nazarene and offers an analysis of recent sociological attempts to understand the changing identity among Nazarenes. Chapter two draws on sociological research to describe and depict the range of views of holiness held by some contemporary Nazarenes. Chapter three identifies the varieties of holiness identity within the three Nazarene congregations that are part of the study. Chapter four investigates the social sources that shape the various holiness identities discovered in these congregations. Chapter five is a description of the many ways religious narratives are enacted and engaged within these congregations. The second part of the study is a theological critique of contemporary Nazarene holiness identity. Chapter six draws on the theory of narrative identity proposed by Nancy Ammerman and outlines a theoretical model which describes the social conditions necessary to shape holiness identity, "the sanctified person," within the context of the local congregation. Finally, chapter seven draws on the theological resources of Mennonite scholar and historian John Howard Yoder to propose a way of construing and facilitating holiness identity formation that takes the ecclesiality of hoilness more seriously, emphasizes a clearer relationship between Jesus and the "Christlikeness" that is central to holiness, and highlights the importance of religious practices in the formation of a holiness identity.