AIDS and India: Funding its way to the forefront

Not very long back, a strange controversy engulfed the Indian health ministry prior to and during the Microsoft magnate's visit to the Subcontinent. The subject was HIV/AIDS and apparently Mr Gates had alluded to a CIA report in one of his widely circulated write-ups on the magnitude and the trajectory of the infection. Two reports, one of the National Intelligence Council (NIC), a United States government organisation, and the other by a private institution, partly funded by the Bill and Melinda Gates Foundation, had predicted a large number of HIV/AIDS cases in some developing countries including India and China. Mr Gates had extensively quoted from the former report, which was titled 'The next wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China'.  The next wave countries, the report noted, were likely to seek greater technical assistance from the US in tracking and combating the disease. For many it did not seem an irony that despite a being self-sufficient democracy and a sovereign state, India had in the new millennium to take counsel from corporate heads on how to manage and prioritise its health sector.

The NIC report also suggested that if an effective vaccine were to be developed in the coming years, Western governments and pharmaceutical companies would come under intense pressure to make it widely available. The two reports projected India as one of the biggest pockets of the infection by the year 2010; the NIC report put the number at 20 to 25 million HIV cases, the highest estimate for any country. The Bharatiya Janata Party (BJP) led government, which otherwise goes completely ballistic with jingoistic fervour on issues of cultural nationalism, found nothing amiss in these prognostications as long as they had not entered the public domain of discussion. Once they became known, much credit for this goes to a non-governmental organisation called the Joint Action Council, it became difficult to obfuscate the implications of such intelligence reports for any sovereign state. The union health ministry, under the charismatic Bollywood actor Shatrughan Sinha (who was recently relieved from his cabinet responsibility), issued a denial regarding the 2010 projections.

But interestingly, the prognosis of the NIC and similar such reports have been taken very seriously by the Global Fund for AIDS, Tuberculosis and Malaria, a multilateral public-private partnership, and coincidently, the United States recently assumed the chair of the Global Fund board. This fund has committed USD 866 million over the next two years in the form of grants to 60 countries, India included, and a major part of the funding will go to non-government organizations, leaving elected governments very much without control. The Indian government has of course welcomed this largesse – national pride can be set aside – and is willing to play second fiddle or what is called in sanitised terms – a complementary role. Currently, India spends USD 300 million on the National AIDS Control Programme, and has taken a World Bank loan of USD 191 million. Multilateral and bilateral development agencies support the HIV/AIDS response at state and central levels.

Threats from the second wave
But what is left unsaid is that even if the Indian cases constitute 10 percent of the global HIV burden and are deemed to merit global sympathy and largesse, the government's national health policy recognises a totally different list of priorities for the health sector. And AIDS is only one of those concerns, though most of the time it seems to be getting all the attention. If tuberculosis (TB) has attracted attention, it is mostly because of its association with AIDS. Another aspect is that since there has been a resurgence of communicable diseases even in the developed world, the global concern should reflect as much. The developing countries are after all seen as pockets of disease. Therefore, if HIV/AIDS has become a national security threat to the US, as per a paper (jointly funded by the Gates' foundation and the Catherine Marron Foundation) prepared by a Task Force of the Centre for Strategic and International Studies – a Washington DC based organisation – then it becomes a global threat. The paper is called 'The Destabilizing Impacts of HIV/AIDS – First wave hits eastern and southern Africa, Second wave threatens India, China, Russia, Ethiopia, Nigeria.

But as the developed world, and in particular the US should know, HIV/AIDS is not India's only priority. In GDP terms, health expenditure in the country (already one of the lowest in the world) has declined from 1.3 percent in 1990 to 0.9 percent in 1999. While central budgetary allocation has remained stagnant at 1.3 per cent of total outlay, the budgetary allocation to health in state budgets (which account for over 70 percent of total health care expenditure of the country) has fallen in this period from 7.0 percent to 5.5 percent. This is a direct consequence of the squeeze imposed on the finances of the states by the economic liberalisation policies. In reaction to this, desperate state governments are queuing up in front of the World Bank to receive bank-aided projects. This is proving even more disastrous as these projects impose strict conditionalities such as cost recovery.

The National Health Policy (NHP), drawn last year, admits that the morbidity and mortality levels in the country are still unacceptably high. But unfortunately, it pins the blame on the public health sector. "These unsatisfactory health indices are, in turn, an indication of the limited success of the public health system in meeting the preventive and curative requirements of the general population," it notes.

"Out of the communicable diseases which have persisted over time, the incidence of malaria staged a resurgence in the1980s before stabilising at a fairly high prevalence level during the 1990s. Over the years, an increasing level of insecticide-resistance has developed in the malarial vectors in many parts of the country, while the incidence of the more deadly P-Falciparum malaria has risen to about 50 percent in the country as a whole. In respect of TB, the public health scenario has not shown any significant decline in the pool of infection amongst the community, and there has been a distressing trend in the increase of drug resistance to the type of infection prevailing in the country. A new and extremely virulent communicable disease – HIV/AIDS – has emerged on the health scene since the declaration of the NHP-1983. As there is no existing therapeutic cure or vaccine for this infection, the disease constitutes a serious threat, not merely to public health but to economic development in the country. The common water-borne infections – Gastroenteritis, Cholera, and some forms of Hepatitis – continue to contribute to a high level of morbidity in the population, even though the mortality rate may have been somewhat moderated" (NHP- 2002).

While HIV/AIDS is seen as a threat to economic development, it is incomprehensible as to why the other communicable diseases, which have claimed many more lives till date do not seem to be a threat to economic growth. The current annual per capita public health expenditure in the country is no more than INR 200. Given these statistics, it is no surprise that the reach and quality of public health services has been below the desirable standard. In the constitutional structure, public health is the responsibility of the states. In such a framework, it has been the expectation that the principal contribution for the funding of public health services will be from the resources of the states, with some supplementary input from the centre.

Budgeting cares
Against this backdrop, the contribution of central resources to the overall public health funding has been limited to about 15 percent. The fiscal resources of the state governments are known to be very inelastic. This is reflected in the declining percentage of state resources allocated to the health sector out of the state budget. If the decentralised pubic health services in the country are to improve significantly, there is a need for the injection of substantial resources into the health sector from the central government budget. This approach is a necessity – despite the formal constitutional provision with regard to public health — if the state public health services, which are a major component of the initiatives in the social sector, are not to become entirely moribund, states the NHP 2002.

The technical network available in the country for disease surveillance is extremely rudimentary and to the extent that the system exists, it extends only up to the district level. The NHP admits that disease statistics do not flow through an integrated network from the decentralised public health facilities to the state/central government health administration. Such an arrangement only provides belated information, which, at best, serves a limited statistical purpose. The absence of an efficient disease surveillance network is a major handicap in providing a prompt and cost-effective health care system.

Evidently, public health infrastructure and preventive care as a whole needs to get a big boost in terms of investment. But if there is any disease prevention mechanism visible, it is in the arena of HIV/AIDS. Last year, the then union minister for health and family welfare, Dr CP Thakur, stated that the government had given priority to National AIDS Control Programme, as is evident from the fact that it receives the highest budgetary allocation of all health programmes. This has been done to contain the spread of HIV/AIDS infection which undermines social and economic development throughout the world and affects all levels of society, said the minister. Addressing a consultative committee meeting of the ministry, Thakur said that the sentinel surveillance data clearly indicates that even though the number of AIDS patients are still growing, the rate at which the infection is spreading was showing a declining trend in the last three years. There was a gradual decrease in the new infections. The minister also added that another major thrust during the 10th plan period would be on the elimination of kala-azar and filariasis. However, no generous budgetary allocation was made similar to that of AIDS.

The 1983 NHP had envisaged health for all by 2000. That has not happened obviously. In fact, more than a 1000 people have died this winter of poverty in the cold wave; several mysterious deaths occurred in Saharanpur late last year – viral encephalitis was suspected though, for several weeks, doctors remained clueless; and plague broke out in parts of Himachal Pradesh in March 2002 triggering widespread panic. Undoubtedly, the public health priorities have to be decided by governments alone. And there are no global takers for these diseases – the disease of hunger and consequent ill health.