Tackling HIV/AIDS - More sense is needed, not money

[Guest guest]

Tackling HIV/AIDS - More sense is needed, not money

by Rami Chhabra

HIV/AIDS is a high-visibility media issue. So is trafficking. Yet surprisingly,

major developments in both are quietly underway with no media focus, much less

debate. The media flurry will perhaps follow after events are fait accompli.

This month (October) the World Bank board will meet and undoubtedly approve

(alongside its development partners, notably the UK’s DFID) the Third National

AIDS Control Programme (NACP III ) for India for which the National AIDS Control

Organisation (NACO) has developed a strategy/implementation plan with an outlay

of Rs11,585 crore ($ 2 1/2 billion) for five years. This figure does not reflect

Rs1500 crore to be catalysed from other programmes, nor thousands of crores

worth of states’ resources that will inevitably divert as state AIDS societies

expand the HIV/AIDS empire to the district/subdistrict level with “horizontal

linkages” to district health societies in concession to the National Rural

Health Mission direction for integrated health programmes.

The direct outlay represents a five-fold resource jump for under one- third

time-frame as against the NACP I & II corpus for over 14 years. The basis for

this extravagant scaling-up mystifies, particularly as NACO’s past record is

badly wanting.

The Public Accounts Committee (2005-6) totted up Rs 2344.65 crore as the

financial corpus with NACP Phase I & II and categorically blasted NACO for its

“limited success” and “under-utilisation of funds”. Besides, it raised several

accountability issues, such as “non-reconciliation of accounts”, “absence of

adequate infrastructural facilities”, failures on almost every front — from

inadequate provision of condoms, drugs, trained manpower, numbers of STD

clinics, modernised blood banks and voluntary counselling and testing centres to

“ineffective Targeted Interventions Programme” and non-assessment of the impact

of various components of the programme. It particularly indicted the “failure of

the National AIDS Committee to meet after 2001” to steward. Earlier, the

Comptroller- General of Audits’ programme review (2003) had picked innumerable

holes in implementation and financial matters. This has been reported earlier.

The World Bank had in March suspended funding to the health sector in a show of

severity on corruption allegations, since proven. But it is now

business-as-usual. In the past NACP phases it had happily upped the carrot each

time without bothering about performance implementation/evaluation obligations.

This round is no different. Besides huge amounts cavalierly earmarked for a

programme lacking procedurally stipulated mid-and-end-evaluations (and

self-evidently in disarray), disturbing is what is proposed through much of this

colossal outlay. The expenditures impact the very contours of Indian society.

NACP III’s lofty goal is “halting and reversing the HIV/AIDS epidemic in India

in the next five years through an integrated programme for prevention, care,

support and treatment”. Ironically, the “integrated” approach allocates under-17

per cent to care/ support/treatment of 5.2 -5.7 million HIV/AIDS-affected per

official estimates. Of these, at least 10 per cent (520,000-570,000) are already

seriously immuno-compromised.

The humanitarian aspect is curiously limited. Support/ treatment/care targets

are cautiously sketched: free ART medicines for only 100,000 persons living with

HIV/AIDS (PLWHA) by 2007; a target of 300,000 for 2011-end. (What happens to

near-half?) Targets for HIV-positive mothers (babies get infected during

birth/breastfeeding) are as economical. Fifty per cent of deliveries in India

are picked as the reachable universe, then 80 per cent coverage of this

truncated 50 per cent target to be reached by project-end. Interestingly, total

funds for care/ support/treatment are less than three-fourths of the Rs 2000

crore available for just one “prevention” commodity — condoms!

Mistake not. NACP III opens the flood-valves for a deluge of the

condoms-and-STD-drugs-treatment-formula euphemistically termed Targeted

Interventions (TIs) for high-risk-sexual-behaviour-groups, i.e.

“prostituted-women, homosexuals, injecting-drug-addicts, truck drivers and

migrant labour”. For NACP II, the World Bank insistence on “decentralised”

outside-government-administration-systems and TI component-introduction as a key

“paradigm shift” tied its $ 191 million plus $100 million partners’ grant

package.

Pivotal position to TI-grounding was further ensured by making the assessment of

India’s capacity to respond to HIV/AIDS contingent on the number of State AID

Societies (i) functioning, and (ii) efficiently managing TIs implemented through

NGOs. NACO claims successful implementation of 1000 TIs, covering 660,000 core

high-risk person over Phase II.

However, the two evaluations done of the TI component — one, by the NACO/ Sexual

Health Resource Centre and the other by DFID, principal funder and technical

adviser of this component — tell another story.

Both are equally devastating. Both evaluation teams — while openly-biased for TI

approach — severely faulted its implementation. SHRC rated the average

efficiency level of TIs at a poor 37 per cent across the country; DFID raised a

whole host of issues pinpointing poor quality but also poor financial

accountability.

It assessed TI effectiveness in HIV transmission prevention, as also cost

effectiveness, to be low in India, but among other things prescribed more as

needed. This latter advice has been lapped up over Phase II’s extended two

years. Additionally, since 2004 Gates Foundation’s (GF) $200 million commitment

reducing the World Bank to smaller-player-status in AIDS-prevention games has

exclusively concentrated on TIs (in six southern states). Information on GF

implementation /impact is not in public domain. But a huge vested interests bank

in TI strategy now exists.

NACP-III has Rs 7, 786 crore for prevention that is virtually synonymous with

condom-centric TIs. Nearly Rs 6000 crore is earmarked for “saturation” of the

country with narrowly-focused TIs.

These will fund into existence several thousand organisations of high-risk

individuals, mobilised and organised into distinct-collectives only by virtue

(?) of their high-risk-sexual-behaviour-identity.

As many as 2.3 million — 1 million prostituted-women, 1.2 million homosexuals

and 190,000 IDUs — are the focus of this mega-funding, not for any ambitious

rehabilitation/alternative life-skills/style plan for such vulnerable groups but

to conduit condoms/STD treatments to prevent further HIV infection. Rs 50 crore

is earmarked to create “enabling environment”, including addressing laws that

“hamper” such limited interventions.

Past “enabling environment” efforts are already paying off.

Parliament has before it amendments to the Immoral Traffic (Prevention) Act

(ITPA), presently referred to the HRD Standing Committee. The Bill piloted by Ms

Renuka Chowdhary is poorly drafted legislation with sufficient grey areas to

allow prostitution a free run even as it ostensibly pitches to strengthen its

prevention.

Currently, the Standing Committee examining ITPA is flooded with 500-plus

memorandums, mostly from pro-prostitution lobbies developed in recent years,

including within leading women’s organisations/lawyers’ bodies. These seek to

dilute its only teeth: penalisation of “clients” and brothel-keepers; and to

create the perception that prostitution — as differentiated from trafficking —

has always been legal in the country!

These developments come under the noses of an unexceptional personally ethical

ruling-political-triumvirate: a high-thinking Muslim at India’s helm; a

Roman-Catholic-cum-well-acknowledged-paragon-of-Hindu-pativrata/bahu steering

the ruling coalition; and the head of the government a Sikh gentleman whose

ethics and Brahminy-Duck-spousal-relationship is without reproach. Bizarre!

They need to heed; ahead is chaos such as will put Delhi’s lawless urban

development breakdown and consequent lawbreakers’ vice-grip seem like a picnic.

Also it is time the householder-citizen with conscience and values spoke up

before the highly flawed disease-prevention strategies swamp to premium

macho-sexual-predatory-behaviours that disempower the right-thinking, disrupt

family-households and amplify the very conditions that spread HIV/AIDS.

http://www.tribuneindia.com/2006/20061012/edit.htm#4

________________________

" Dr. Avnish Jolly "

e-mail: <avnishjolly@...>