India HIV Response Theory: The Politics of Receptivity and Resistance

[Guest guest]

India HIV Response Theory: The Politics of Receptivity and Resistance

The Politics of Receptivity and Resistance: How Brazil,

India, China, and Russia Strategically use the International

health Community in Response to HIV/AIDS: A Theory

GÓMEZ, POLITICS OF RECEPTIVITY AND RESISTANCE

GLOBAL HEALTH GOVERNANCE, VOLUME III,NO. 1 (FALL 2009) http://www.ghgj.org

J. Gómez

Little is known about how emerging nations, such as Brazil, Russia, India and

China (aka, B.R.I.C.), strategically use the international health community in

order to strengthen their domestic HIV/AIDS programs. In this article, I

introduce a new theoretical framework, strategic " receptivity " and " resistance, "

in order to explain how and why this process occurs. Brazil emerges as the most

successful case of how this process leads to the formation of international

partnerships and domestic policies strengthening its AIDS program, with India

gradually building such a response, followed by China and Russia. This article

closes with an explanation of how this strategic interaction reflects the

growing

independence and influence of BRIC while highlighting how this framework

applies to other cases.

(Excerpts)

INDIA

Like Brazil, India also shares a rich history of working with the international

community. While it did not join Brazil and China during the formation of the

World Health Organization in 1948, it was the first in its region to participate

in

the creation of the South-East Asia regional office of the WHO in 1948.37 Since

then, India has worked closely with the WHO to eradicate disease in South-East

Asia.38 At the same time, it has worked closely with the WHO to eradicate

smallpox by working with health officials to strengthen India's National

Smallpox

Eradication Program (NSEP).39 India viewed the WHO and other nations, such as

Russia, as key partners in finding and distributing vaccines for smallpox

eradication.40

In addition, the government has been concerned about its reputation. In

recent years, it has strengthened the AIDS program and engaged in partnerships

with donors in order to enhance its reputation.41 The government has not

responded favorably towards criticism, such as the Gates foundation's statement

in 2001 that India would have 25 million cases of AIDS by 2010.42 Responding

through an aggressive AIDS program has therefore been viewed as an important

way to prove the international community wrong. As India strives to make its

mark on the global sphere and enhance its regional influence, reputationbuilding

has motivated the Prime Minister and AIDS officials to work with the

donor community to strengthen its response.

In addition, institutional designs did not influence the Prime Minister's

engagement with the international community. After a long delay in the PM's

attention to AIDS, in 2001 PM Atal Vajpayee made proactive efforts to engage the

international community and to increase the government's commitment to AIDS.

While he obtained parliamentary and bi-partisan support for his statements,43

they were by no means the main reason for why he responded. Vajpayee and PM

Manmohan Singh were essentially working on their own.

Receptivity

Nevertheless, the two dynamics mentioned earlier, i.e., reputation building

and historic legacies, provided incentives for the government to work

closely with the donor community. India's partnership with donors began during

the early-1990s. State governments received technical and financial assistance

from bi-lateral agencies, such as USAID and DFID. USAID was particularly

instrumental in providing assistance to NGOs for AIDS prevention,44 and

continues to do so.45 During the early-1990s, DFID also played a key role in

providing the states with prevention and treatment services.46 Since 1999, DFID

has provided funding to NACO and state governments. More recently, DFID has

provided funding to the NACO in order to strengthen its intervention at the

statelevel.

At the multi-lateral level, India entered into several early partnerships. In

1985, the WHO provided support for AIDS research. In 1987, the WHO helped

the government create the National AIDS Control Program for strategy and

planning prevention.48 By 1989, the WHO started working with state

governments to implement prevention policies.49 The WHO continues to provide

support, mainly through surveillance and technical assistance.50

In 1992, the World Bank also began to provide support. That year, the

Bank provided a loan of $84 million, followed by yet another for $191 million in

1999, with the government contributing $14 million from its budget. These

projects were aimed at improving the blood supply, increasing awareness of HIV

transmission, and creating State AIDS Control Societies (SACS) to help

implement prevention policies.51

By 2002, the bulk of funding for NACO came from the World Bank, an

estimated $38.2 million, followed by the government at $7.8 million and

approximately $10 million from other bilateral donors.52 When compared to

other more burdensome diseases, however, the government commits most of its

resources to AIDS.53

Similar to Brazil, NACO officials and the PM continued to strengthen its

partnership with the World Bank. In 2007, NACO approached the Bank for a

Phase III credit of $250 million dollars.54 The goal of this project is to

create a

more comprehensive AIDS program, where NACO, SACS, and NGOs work

together;55 this partnership persists.

Yet another multilateral agency that has provided assistance is the Global

Fund to Fight AIDS, TB, and Malaria. Since 2004, the Global Fund has provided

the Department of Economic Affairs with grants to help mothers with HIV,

PLWHA, and ARV treatment.56 In addition, in 2004 the Global Fund provided

the Department of Economic Affairs with a grant to address the TB-HIV

coinfection problem. Since 2004, several grants totaling US$ 505,653,939.00 have

been provided.57

Private philanthropy has also been helpful. In 2002, the Bill & Melinda

Gates foundation provided $258 million for the Avahan initiative. This is a HIV

prevention program aimed at Indian truck drivers and the six highest prevalence

states in India.58 And in 2006, the Clinton Foundation provided funding to help

NACO work with nurses in small communities.59

India's continued partnership with the Global Fund, the World Bank and

other donors seems to suggest that NACO officials are benefiting from an ongoing

partnership. AIDS officials continue to be employed and advance within NACO as

long as donor aid persists. In addition, NACO officials have increased their

partnership with AIDS NGOs. This has occurred mainly between SACS, as they

rely on NGOs to reach distance municipal districts.60 As SACS continue to face

technical and administrative difficulties, the NACO has continued to rely on

NGOs.61

It is important to note, however, that donor aid assistance on its own has

not been the key catalyst to government response, or to the subsequent formation

of a tripartite partnership. Despite early donor assistance, the government did

not begin to aggressively respond until 2001.62 Before then the states responded

on their own, while the Ministry of Health and PM seemed to ignore the

situation.63 While the recent arrival of funding from the Global Fund, the World

Bank, and the Gates foundation has certainly helped, the government's response

was very much delayed.

When it comes to working with NGOs, the government's record has not

been as stellar, though it is certainly improving. The absence of institutions

such

as a national AIDS commission mandating the representation of NGOs has

limited NACO's ability to work closely with NGOs and to use them in order to

increase NACO's influence. Moreover, NACO's commitment to working with

NGOs only recently emerged in 2003.64 A National AIDS Committee exists; but it

was not explicitly designed to insure NGO representation. Some officials have

stated that there has been a consistent lack of clarity and interest on the part

of

NACO and local government officials to incorporate NGOs into the policy-making

process.65 There is now a stronger commitment to clearly delineate and increase

NACO's partnership with NGOs, as well as including them in the National

Strategic Plan on AIDS.66

Resistance

While India has demonstrated receptivity to the international community,

there have also been instances of resistance. Until recently, for example, it

has

gone against the international community's endorsement of harm reduction.67 As

part of NACO's second phase response in 1992, it essentially avoided this issue

by

devolving this responsibility to the states.68 To this day, no federal harm

reduction program exists, though recently NACO has considered developing such

a program.69 Alternatively, when it comes to prevention, India has resisted

international suggestions for increased sex education in schools.70 With the

recent exception of some states, such as Maharashtra, Gujarat, and Madhya

Pradesh, sex education has not been allowed, nor has NACO sought to enforce it.

When it comes to harm reduction, some attribute resistance to the fact

that drug use is viewed as a social evil, and that the government does not want

to

condone such behavior.71 With regards to sex education, analysts attribute

resistance to the government's view that it encourages the immoral act of sexual

promiscuity.72 Both impulses suggest that the government's resistance is heavily

influenced by deeply inculcated moral views.

When it comes to acquiring ARV medication, however, India has not

shown as much resistance. This is particularly alarming considering the long

history that India has of producing generic medication and distributing drugs

throughout Asia.73 Since agreeing to join TRIPS in 1995, the government has not

tried to issue threats of compulsory licensing. This mainly reflects the

government's fear of tainting its image of being a fair trade partner. The

closest

the government has come to resisting markets is to amend patent legislation in

2005 indicating that only new drugs deemed to be " new and innovative " can be

patented and sold in markets. India's recent denial to recognize the patented

drug Novartis for Leukemia in January 2006 suggests that the government may

start doing the same for ARV mediation.74

Even more puzzling is the fact that India has a very strong domestic

infrastructure for producing drugs.75 Pharmaceutical companies such as Cipla,

Ranbaxy Laboratories, Matrix Laboratories, and Hetero drugs all produce ARV

medicine at cheap and affordable prices. In the future, India could very well

use

these laboratories to its advantage by threatening to issue compulsory

licenses.76

India also has superb medical research institutions, such as the National AIDS

Research Institute (NARI), and gifted scientists. Under these conditions, India

may eventually be in a good position to guarantee and provide ARV mediation.

Yet another differentiating factor between India and Brazil is the fact that

the evolution of India's national health insurance program was not born out of

democratization processes. Efforts to provide a national based primary

healthcare system originated shortly after India gained political independence

in

1947.77 The government's provision of healthcare was driven mainly to ensure

socioeconomic development. Later in 1983, through the creation of the National

Health Policy, the government mandated the creation of a universal healthcare

system. Since then, healthcare delivery has been the primary responsibility of

states, though most of the funding comes from the center.78

In contrast to Brazil, the challenge is that because India's universal

healthcare system was not born out of democratization processes, there were no

incessant pressures and expectations that the government provide universal

healthcare. Consequently, when AIDS emerged, India's political elites did not

feel

that it was their responsibility to ensure that all citizens have equal access

to ARV

medicine. Moreover, what this meant was that the pharmaceutical industry's

imposition of high prices was not perceived as threatening the government's

ability to maintain their normative democratic commitments. Consequently, the

impulse to resist markets for the sake of democracy and human rights simply was

not there.