World AIDS Day: India's 3x5 Paradigm Shift..or does it?

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World Aids Day. 1st December 2004

THREE BY FIVE SPARKS 'PARADIGM SHIFT' IN INDIA.. .OR DOES IT?

India's drive to produce cheap generic drugs for its five million people

living with HIV/AIDS has hit a glitch: energetic economic reforms in the

1990s have left the country with one of the lowest pubic health outlays in

the world and a rapidly privatising health delivery system that ignores the

poor. It's a challenge for India's new centre-left government.

By T K Rajalakshmi

Third World Network Features

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New Delhi: The new government in India, led by a centrist-left formation

called the United Progressive Alliance, says it is serious about health.

It has recently announced plans that include:

* Increasing public spending on health from the current 0.9% of Gross

Domestic Product to 2-3% over the next five years;

* A focus on primary health care;

* Stepping up public investments in programmes to control all communicable

diseases and providing 'leadership to the national AIDS effort'; and

* Making life-saving antiretroviral (ARV) drugs available at reasonable

prices.

But critics say much more than promises are needed if decent health care is

to be delivered to all Indians, some 80% of whom live on two dollars or

less a day.

The Jan Swasthya Abhiyan (JSA, or People's Health Movement), a campaign led

by a group of health professionals, says that healthy living conditions and

access to quality health care for all citizens are not only basic human

rights but also essential prerequisites for social and economic development.

At present, the government's health statistics make for dismal reading.

Infant and child mortality claims the lives of 2.2 million lives every year

(a 1983 target to reduce the infant mortality rate to less than 60 per

1,000 live births remains unrealised). More seriously, the rate of decline

in infant mortality, which was significant in the 1970s and 1980s, slowed

down in the 1990s.

Maternal mortality has jumped from 424 deaths per 100,000 live births in

the 1990s to 540 per 100.000. Nearly half a million Indians die of

tuberculosis every year as the nation witnesses a disturbing resurgence of

communicable diseases such as Kala Azar, Dengue, Encephalitis and malaria.

Environmental and social dislocations combined with weakening public health

systems have contributed to this resurgence, the JSA says.

The public health infrastructure has been unable to keep up with this

situation. While healthcare facilities have grown substantially since the

1990s, they are mostly in the private sector - often beyond the reach of

the poor. According to the Central Bureau of Health Intelligence at the

Ministry of Health and Family Welfare, the private sector accounted for 57%

of the 11,174 hospitals that existed in 1991. In 2000, however, the

proportion of privately run hospitals grew to 75% of a total of 13,218

hospitals.

Only 17% of all health expenditure is borne by the government, which makes

India's health sector one of the most privatised in the world. The World

Health Organisation standard for expenditure on public health is 5% of GDP.

India's 0.9% expenditure of GDP is less than the average for poor countries

- 2.8%.

Some critics say India's health took a knock in the 1990s - the era of

economic liberalisation, when stagnant public health budgets and decreasing

government expenditure in public health facilities were worsened by the

introduction of user fees at various levels of public health facilities.

Now, a new initiative by the WHO and UNAIDS - the United Nations agency on

HIV/AIDS - to increase access to ARV drugs to three million HIV/AIDS

patients around the world by 2005 has galvanised the government and public

opinion.

The so-called Three by Five initiative, launched in September 2003, has led

to what the government's National AIDS Control Organisation (NACO) calls a

'paradigm shift'. Until 2003, India's AIDS policy did not support the

provision of ARV treatment through the public health delivery system.

After the Three by Five initiative the then health minister Sushma Swaraj

declared a strong policy-cum-programme commitment to provide free ARV

treatment to 100,000 AIDS patients. This began in April 2004. Government

hospitals were to provide treatment in six high-prevalence states, and

within them to three vulnerable groups: HIV-positive mothers; HIV-positive

children below the age of 15 years; and AIDS patients who seek treatment in

government hospitals.

The number of patients who had received ARV treatment till 10 June was 874.

NACO project director Meenakshi Datta Ghosh says: 'A first line regimen of

fixed-dose combinations of three ARV drugs is being promoted with a lot of

effort by NACO. The pharmaceutical industries have reduced the cost of ARV

drugs which on an average cost approximately Rs.10,000 ($222) per patient

per year.'

Datta Ghosh says the government acknowledges that scaling up ARV treatment

should not be at the expense of prevention activities: 'We have to mobilise

additional resources for the expansion of the treatment programme without

slowing down our efforts towards the prevention of the spread of HIV

infection.'

Current official estimates are that there are 5.09 million HIV-infected

people in India - up from 3.58 million in 1998, 3.72 million in 1999, 3.86

million in 2000, 3.97 million in 2001 and 4.58 million in 2002.

'These figures are a cause of increasing concern to the government because

people infected with HIV during the I980s and 1990s will progress to AIDS,

resulting in a steep increase in the number of AIDS patients,' admits Datta

Ghosh.

Today access to treatment has become the subject of a major debate in

India, fuelled by a public interest litigation filed in India's highest

court last August demanding treatment for HIV/AIDS patients and provision

of infrastructure.

Shruti Pandey, a lawyer working for the human rights group that filed the

petition, says: Our principal prayer was that the government should provide

ARVs within the public health system and create an infrastructure, as

sticking to the regimen is important'

But the government's position, Pandey says, is ambiguous: 'It has not spelt

out measures on how it plans to maintain confidentiality and manage

toxicity (of drugs) and neither is it clear on how they plan to raise the

resources.'

'Where are the attempts to build a conducive atmosphere for AIDS patients?'

asks Pandey. 'Every day, we hear of some instance of discrimination against

HIV-positive people. They are being treated like untouchables. Their right

to employment is being denied and the orphaned children are not given any

support.'

These are urgent questions in India, which, along with China, is expected

to emerge as the biggest Asian AIDS hotspot in the coming years.

'Ninety-five per cent of people with AIDS are poor, and most of them do not

even know about the first line regimen,' says Ricki Tombing from the state

of Manipur - one of the six focus states in the government's AIDS strategy.

'Either the government should get fully involved or it should get NGO

counsellors to assist the patients as they are more sensitive. Government

counsellors at testing centres only fill up forms.'

Tombing, a former drug user, was diagnosed with HIV three years ago. 'In

2002, when I went for a second test, the counsellor who filled up the form

asked me how many sexual partners I have had. I told him and he ticked the

column saying " sex workers " . He assumed - wrongly - that I had visited sex

workers,' he said, pointing to only one of many common biases in India.

Amit Sen Gupta of the JSA says the government cannot go on using the plea

of lack of infrastructure when it comes to treatment issues. 'This is a

pernicious argument. If there are no treatment facilities, even detection

will become difficult,' Sen Gupta, a critic of privatisation, says. The new

government, he adds, should spell out exactly how much it plans to spend

each year on health.

Most of all, argues the JSA, there needs to be a 'pro-poor bias' in India's

health policy, including access to AIDS treatment.

'Entering into a system of targets where people are just numbers and health

care a convenient jargon is not going to do anyone any good,' says Sen

Gupta. 'Health programmes need to be integrated within the primary

healthcare system with decentralised planning, decision-making and

implementation with the active participation of the community. The top-down

approach has to go.'

It's the one 'paradigm shift' that the majority of Indians are yet to see.

- Third World Network Features.

-ends-

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About the writer: T K Rajalakshmi is a correspondent for the Indian

newsmagazine, Frontline.

The above article first appeared in Panos Features (July 2004).

When reproducing this feature, please credit Third World Network Features

and (if applicable) the cooperating magazine or agency involved in the

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Cross Posted from HealthGap

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