The HIV/AIDS funding farce

Health Minister Anbumani Ramadoss is quoted as having said, "We have spent so much on the programme and finally the results are there" ('India's Aids Scare Just Got Halved', IE, July 7). Results? Is the health minister kidding? India's HIV/AIDS re-estimates, conceded after getting National Aids Control Programme-III (NACP-III) approved by the Cabinet Committee on Economic Affairs for a programme based on 5.2 million HIV-numbers, is a long overdue correction of inaccurate estimates, arbitrarily boosted since 1998 and long challenged by many experts. Ramadoss needs to do serious introspection on his ministry's functioning.

The large population-based blood-test sampling from the National Health Fertility Survey and the Guntur district community study, highlighting a 60 per cent difference from surveillance estimates put forward by NACO, has for the past year provided incontrovertible, large-scale evidence of inflated HIV-estimates. This was critically documented as early as 2000 by the Independent Commission on Health in India (ICHI) Experts Consultation in a report that was provided to the health ministry and NACO.

The ICHI report pointed to arbitrary hikes: NACO's end-1994 estimate of 1.75 million HIV-infected spiralled to 4 million by 1998. Challenged, NACO temporarily downplayed the figures. Then another NACO Expert Group (1999) developed a different estimation process that placed HIV-infected in the range of 2.4 to 3.7 million in 1999. Subsequently, NACO arbitrarily picked the higher end, adding a 20 per cent variable. This base figure has steadily grown. Alongside, the steady expansion of sentinel surveillance sites - 55(1994) to 703 (2005) - diminished scientific longitudinal tracking. The ICHI had noted at the start of NACP-II: "Flawed estimates at the outset could result in scams of enormous public expenditures vindicated through notional reduction of 'infections averted' from levels not scaled in the first place!"

The point bears repetition as NACP-III launches with a seeming correction of the statistical parameters. The AIDS scare has halved but the health minister's gung-ho response to the changed figures is scary. He appears to be claiming results from large sums of money spent in controlling numbers that did not exist in the first place. He also promises more "vigorous funding", despite overwhelming evidence of mismanagement during NACP-II and even while other vital areas of healthcare perceptibly lag.

Just as pertinent are the issues surrounding NACP-III's strategic thrust. Two-thirds of Rs 11,585 crore are earmarked for prevention but the bulk is for the NACP-III centrepiece: Targeted Interventions for High-Risk Persons (TIHRP) focus on three major categories: commercial sex workers (CSW); men having sex with men (MSM); and injecting drug-users (IDU). It is a minimal package but is ironically termed comprehensive. Altogether, Rs 6,000 to 7,000 crore is allocated for the narrow "non-judgmental, non-interfering" servicing of high-risk persons even as there is nothing to proactively reduce high-risk exposure or promote alternative low-risk lifestyles, despite specific directives to NACO for broadening prevention issued by the HRD parliamentary standing committee examining immoral traffic prevention act amendments.

The TIHRP operational targets are prime indicators for monitoring NACP-III achievements. But how realistic are the targets set? The NACP-III Expert Group on High Risk Persons Estimations dismisses out of hand as "crude estimates" the "mappings" of high-risk persons conducted by each state through expensive, extensive research comprising major NACP-II activities.

Other financial points require scrutiny: only Rs 8023 crore are within the national budget. Of this Rs 5162 crore is from external aid and is concentrated on TIHRP/condom-provision/STD-services, with just token attention being paid to care treatment, exposing India's sleaziest aspects to outsider involvement. India's contribution - Rs 2861 crore - absorbs Rs 2,400 crore from the National Rural Health Mission, suborning it to HIV/AIDS as primary healthcare is already to contraception/immunisation/pulse polio. The biggest outlay - Rs 2000 crore - is for condoms, with just Rs 24 crore for clean blood storage! Further, a government committed to downsizing provides Rs 418 crore to a manifold increase in NACO's strength of 800, with 1,371 new posts and 1,200 contractual appointments.

What are these figures really based on? The fiscal farce arising from showering scarce resources on inflated numbers is one part of the story. The other is the social, ethical and law and order implications of such unprecedented and large-scale collectivisation of high-risk individuals. The whole approach needs deeper consideration lest the whole strategy boomerangs.