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| 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.
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