'Donors' emphasis on Aids skews Indian priorities'

MUMBAI: India’s Aids programme is flush with funds and celebrity endorsements, but is it in sync with the country’s wider public health agenda?
No, say health professionals. Even those working in the field of Aids care agree that Indian concerns and priorities are being undermined by some international funders who are ignoring grass-roots concerns.Aids, health professionals say, has skewed the Indian health care system.
The success of any public health programme depends on the creation of a solid primary health care system, these experts say. But this isn’t often on the donors’ agendas. Instead, they mainly channelise their massive funds through non-governmental organisations, which often don’t have the experience or the credibility to deliver results. In addition, such funding that flows to the public health sector is often in the form of loans rather than aid. As donors’ priorities have lurched from malaria, family planning, tuberculosis and now Aids, India’s public health priorities have been forced to change too, experts say.
Mohan Rao, associate professor of social medicine and community health, Jawaharlal Nehru University, complains that the goals of the Aids programme have been established without understanding the extent or character of the problem in India, its evolution or its links to other diseases.
Agreeing that Aids must be treated with the seriousness it deserves, Ravi Duggal, a researcher at the Centre for Inquiry into Health and Allied Themes in Mumbai said that India’s two-decade-old high-profile programme exclusively focusing on Aids isn’t grounded in data gathered from communitybased surveys. Instead, projections have been made—mistakenly in the view of experts— by extrapolating data about high-risk groups to the general population.
The top killer conditions in India during 1998 were cardio-vascular diseases (28,20,000 deaths), respiratory infections (9,87,000 deaths) and diarrhoeal diseases (7,11,000 deaths), according to the World Health Organisation. By comparison, 2,524 people died of Aids deaths between 1996-2001, according to the National Aids Control Organisation. Experts said that funding allocations don’t match the prevalence of these diseases. International funders will give India’s Aids programme Rs 19.25 billion between 1999 and 2004. But in the central government’s total budget of Rs 58.63 billion for health and family welfare in 2000-2001, the disease control programme received Rs 8.47 billion, or 15 per cent of the allocation. Aids and STD got Rs 1.45 billion, or two per cent of the allocation. Given that the government’s Aids programme only focuses on prevention and raising awareness, but offers nothing by way of treatment, this two per cent allocation is adequate, says Mr Duggal. But he suggests that the foreign contribution could be put to better use if it goes towards strengthening comprehensive health services.
While the Bhore Committee Report of 1946 assured universal and equitable access through a pyramid of public health services, this structure has been consistently undermined by international agencies, Mr Duggal contends. The donor focus on stand-alone programmes targeting individual diseases and Indian acquiescence to their priorities has gutted the primary health system, he adds. International donors have an influence on the Indian health system that is disproportionate to the relatively small amounts of money they contribute.
“The foreign component in our overall health budgets is not more than ten per cent, but the advice and influence weighs 90 per cent,’’ says Mr Duggal. A 1996 study conducted by Rama Baru, a health policy expert at JNU, placed donor funding at a mere 1.6 per cent of India’s total health expenditure. A survey of published studies by Ramila Bisht, a senior lecturer in the department of health services at Mumbai’s Tata Institute of Social Sciences, found that donor funding between 1985 to 1995 for specific disease programmes did not match evidence of the prevalence of these conditions in the community. For instance, despite being a major killer, TB was not a priority for funders until the ‘90s. With the World Bank’s dominance in foreign aid, there has been a decline in funds for diseases like TB, diarrhoea and malaria, experts said.
Although most Aids patients in India die from Aids-related TB infections, and while TB itself remains a major killer, the budgetary allocations to battle the disease are adequate for treating only 30 per cent of Indians with TB .
The huge amounts of funds to fight Aids has been accompanied by the absence of transparency in how this money is being spent, public health activists complain. A large part of these funds is channelled through the NGO sector, which has burgeoned with many fly-by-night operators, public health activists say.
Despite the huge sums reserved by donors for NGO allocations, Aids administrators admit that they are struggling to find credible NGOs and programmes. In a measure to disburse funds, they are now seeking to train NGOs to write project proposals.
The emphasis on Aids works to the detriment of communicable diseases, which could stage a resurgence,Ms Bisht says. “The need of the hour is to think of ways to integrate Aids funds into strengthening the general health services,’’ she adds. “Improving the primary health system will have an impact on a range of killer diseases, including Aids.’’
( This is the first in a series on India’s donor-driven health agenda.)