Re: NRHM, NACP Convergence Policy

[Guest guest]

Dear friends,

Re: /message/11949

HIV Exceptionalism or primary-health non-exceptionalism: The NRHM, NACP

Convergence Policy a path to normalizing comprehensive, quality, responsive

health care for all?

A group of concerned agencies (listed below) came together to discuss ways civil

society can support GOI in the long awaited, Ministry of Health’s policy on

National Rural Health Mission (NRHM)HRM and National AIDS Control Program (NACP)

convergence.

Praxis provided an analytical brief on the context with suggestions on how to

move forward.

The aim of the group is to engage civil society to support government to this

end. We are not so interested in supporting or opposing " HIV exceptionalism, "

as much as helping to support health standards and rigor in all health sectors

improve, without losing what we have struggled for in the HIV sector.

In light of The Ministry of health Circular regarding NRHM and NACP convergence,

the group agreed that the convergence effort is indeed a welcome endeavour. WHO

and donors, such as DFID and the EU, are supporting convergence plans. Until

now, civil society, communities, beneficiaries and PLHIV have not adequately

engaged themselves to support government to this end.

While many in civil society welcome this shift, we have several concerns

including (but not limited to):

(i) Rationale for integrating two vertical programmes. Evidence is required;

(ii) The need to build on and develop best practices with benchmarks to allow

for systematic and rigorous evaluation;

(iii) Involvement of all stakeholders, including ASHA workers and HIV civil

society, among others.

In the absence of civil society engagement, interventions suggested by the

recent government memo raise concerns.

For example, " how can OST function through NRHM agency? " " How are Asha workers

going to assume responsibilities that were once the responsibilities of sex

workers, IDU and MSM outreach workers? "

We agreed that first and foremost there is a need to generate public debate and

believe this forum may be one way in which to do this.

Following, we would like to be more inclusive and action oriented. We would like

to broaden this group and invite donors, civil society and other stakeholders to

a National consultation on convergence in light of combined PHC and HIV

responses, in India in February 2011.

We propose to precede this with a number of preparatory meetings, followed by

state-level consultations. We feel that this would benefit vulnerable

communities and the government's effort towards a smooth implementation of NRHM

and NACP Convergence Policy.

Group of concerned agencies participated in the initial meetig;

Oxfam GB

Praxis

365x6 network

Sangama

Prayas

NHSRC

FHB Suraksha

Jodhpur School of Public Health

INP+

r e a c h (365x6)

Praxis

DNP+

AIDS INDIA

-----------------------------------------

Magar, Dr PH

Director

r e a c h

research and action for change

http://researchaction4change.wordpress.com/

e-mail: vbmagar@...

+91 11 41826130

+91 9999788711

[Guest guest]

Dear & others,

Re: /message/11949

If we analyse the historical progress of HIV program in India, it

appears “exceptional”.

The very nature of HIV transmission and influences from International agencies

made it possible to have engagement of civil society organizations with

Governement program in case of HIV.

It does not mean that this has happened spontaneously.

There has been tension between affected groups and government in many

occasions. But any way, collectives like INP plus which engages with

program became unique among service users’ organizations in the field

of health.

HIV program is unique in many other ways like speaking the language of justice,

taking it beyond biomedical paradigm, empowerment

of affected groups, community led advocacy etc.

If convergence results in the infiltration of these into the health system, it

is well and good. To happen this, there should be active involvement of groups

like INP plus, sex workers organizations, MSMs group etc in the program.

Making the (health) system sensitive about the justice issues of them

may widen the scope of practice in public health ethics.

The success of convergence depend on, how far we are committed to this

Regards

Dr. Jayasree.A.K

Associate professor

Community Medicine

Academy of Medical Sciences

Pariyaram. Kannur. Kerala

e-mail akjayasree@...

[Guest guest]

Dear Dr Jayasree,

Re: /message/11949

I am not sure if you are really into the program and sensing the slow and steady

changes happening in the program and HIV response over the last few years.

There is a strong momentum away from the " exceptionalism " you mentioned these

days.

Now very few are worried about " the many other ways " you have

mentioned.(speaking the language of justice, taking it beyond biomedical

paradigm.... ).

Probably there are various social, administrative and economic reasons behind

this. Also the paradigm shift in the way HIV being projected; from a deadly

disease to a chronic manageable infection.

The resource crunch, attention to other diseases, also contributed to this.

I also feel there a slow shift from public health approach to

individualistic approach in the management of epidemic and ART and (other

interventions are projected as measures to reduce the circulating viral load in

individuals than as social vaccine to address the epidemic in as socio political

issue).

The possible impact of addressing human rights, reducing stigma,

destigmatization and decriminalization of MARP s, etc are on epidemic control

and shaping health care delivery response of the sociality as a whole is

probably being sidelined.

Unfortunately, many involved in the program and advocacy failed

to recognize or correct this slow change . Let us see how the history is going

to unfold itself.

I believe that we should not fail to use the lessons we learned from the history

and should be able to translate it to other public health programs while making

use of the strengths of those programs.

Dr Ajith

Thrissur

--

Dr Ajithkumar.K

Asst Professor In Dermatology and Venereology

Medical college Chest Hospital

MG Kav,Trichur, Kerala ,India

Ph 04872333322 (res)

9447226012

e-mail: <ajisudha@...>

[Guest guest]

Dear Moderator,

Re: /message/11949

It is good that the civil society groups that have held the initial

discussion have put up some of their ideas on this forum. I have a points to

raise regarding this:

1. The GOI, in its delivery of HIV responses has been using money that is taken

from the World Bank, bilateral money and GFATM funds as well as its own money.

All of this is managed by the government on the behalf of thee affected people

and the larger community and when changes are made to the way the programme is

structured, there is a need for discussion, for taking the people into

confidence and getting an agreement to move forward.

None of this was done and if done was done with a small group of civil society

representatives.

2. Now we have a group of civil society representatives coming together to

support the convergence with an understanding that there are issues and so we

need to discuss this widely.

This group of civil society has already accepted that convergence is a 'fait

accompli'.

3. Why is it not possible for these civil society representatives to

actually have a debate on this forum to understand the civil society's view

whether convergence is viable or not. By viable, i mean would it meet the needs

of the MARP, PLHIV, and the bridge population.

4. By jumpin the gun and accepting this as a fait accompli the civil society

members have fallen prey to the way the government operated in muzzling the HIV

advocacy.

First, it got the major donors to channel the money through the

government. Second, the CCM is completely biased in favour of teh

government. Third, the main critics have been silenced by giving them

projects both GFATM and through SACS.

Now with convergence, there will be no advocacy money, and no community voices.

And voluntary testing can be bid goodbye for all practical purposes except on

paper.

Can we really debate this rather than succumbing to the government. It is still

not too late.

regards

Sasi

e-mil: <sasiontheweb@...>

[Guest guest]

Dear Dr Jayasree,

Re: /message/11949

We agree with you. As NACO moved ahead on convergence and according to my

knowledge without any consultation with civil society it would be nice to engage

with NACO to understand the rationale.

Also to be proactive to participate and influence the debate on convergence,

which leads to better health system and effective HIV and AIDS response.

warm Regards,

Rajiv

e-mail: <rajivdua@...>

[Guest guest]

Dear Sasi,

Re: /message/11949

Apart from NACO nobody has accepted NRHM and HIV convergence as a 'fait

accompli' as you put it - not even NRHM and civil society.

So the civil society group met to understand what is the rationale before we

jumped to a conclusion and took a stand.

So we do want to understand the rationale, debate and then take a stand. I am

sure you will agree that NACO needs to explain the rationale and discuss the

issue with stakeholders. The group of civil society that came together tries to

provide that platform to debate and understand.

I did try to initiate a debate sometimes earlier and what i got was a lot of

person phone calls and emails. So bringing civil society together to discuss was

the only logical next step when people want more clarity before deciding on a

stand.

This is exactly this forum strives to achieve.

Warm Regards,

Rajiv

" Rajiv Dua "

e-mail:<rajivdua@...>

[Guest guest]

Dear All

Re: /message/11949

I must thank Dr. Jayashree for her thoughts on the convergence policy of the

NACP and NRHM. She is precise and perceptive regarding some of her observations

on the " exceptional " nature of the HIV/AIDS prevention program but i would have

liked some projection of what is happening in the matter.

We must understand that the HIV/AIDS prevention program is seeing a modicum of

success because it managed to draw in a huge segment of civil society into the

government's health delivery policies. This is where it is 'exceptional'

compared to the Malaria and the anti-TB programs of the government.

As someone who saw the HIV prevention program progressing from total

invisibility to the high profile nature of the MSM sector in this program today,

i agree that there was nothing " spontaneous " about any aspect of the program but

there was a Bohminian law here in that the government and state had hoped to

control and harness civil society to its own program using all kinds of

strategies but it did not wholely succeed.

And what happened is that the huge energies of the HRGs were released in every

which way into other directions as well.

For example, it expected to be hegemonic in dealing with delivery systems

wihtout being sensitised to the sexual minority and gender issues. Here it was

over-whelmed by the empowered groups themselves due to the democratisation and

dedication of these segments to live a life of dignity and discipline in

accordance with our Constitutional rights.

These " upsurges " from hiterto unknown and unheard of popuation segments is what

is the biggest dividend of the investments in NACP.

Knowing full well the way NACP III was planned and budgeted for, many

self-serving elements now are worried if the same process were to take place in

NHRM and thence the unhealthy conspiratical silence over the NHRM strategies.

It is impossible to see how the three hiterto criminalised groups --- sex

workers, MSM and transgender and IDU -- will ever be included into NRHM when we

know the full feudal nature of the lower end of the pyramid of Indian society.

I find it laughable that any Panchayat chief, male or female, would ever dare

openly to work with this population or allow them access to DAPCU forget sit on

district councils for that matter.

Presenlly the whole structure of the NRHM is downright feudal and

non-participatory. The power seems to be resting within coteries of oligargic

intellectuals in pendulam swings between the JNU complex and Nirman Bhavan.

The lowest rung of the NHRM rests on the slender shoulders of a vast slave cadre

of ASHAs who will not be paid a living wage at all.

This is like asking the IAS officers not to be paid a salary to run India from

their little air-condtioned cabins in Delhi and State capitals.

The very idea of how this will play out is going to be fascinating.

But it would be foolish to think that NACP IV and NRHM plannning will follower

convergence policies. In fact NRHM cannot but gather momentum without

canibalising the NACP in its entirety like the Indian python.

Both cannot co-exist in their present state without the HRGs being brought into

the planning stage for NRHM.

Regards

Ashok Row Kavi

Chair,

Humsafar Trust,

Mumbai

e-mail: <arowkavi@...>

[Guest guest]

Dear All,

Re: /message/11949

Dr. Jayshree's understanding and perception was bang on ! Ashok Row Kavi has

seconded it in his usual eloquent style .

I wish to add a few thoughts on the subject to add to the debate.

Having been associated with HIV/AIDS over the last 2 decades it is sad to see

how as over the last couple of years how a vibrant and dynamic and successful

convergence of civil society in addressing NACP has been torn to shreds as part

of the governments so called strategy of control and harness civil society.

The new found policy and strategies within NACP (as quoted " dictated by

coteries of oligargic intellectuals in pendulum swings between the JNU complex

and Nirman Bhavan ?? ) further ensure that the larger fabric of established

credible civil society organisations are alienated or fall out of the much

needed experience and support that is necessary for NACP to achieve its objects

and goals.

In most states there seems a process of roping in lesser known small

organisations who would toe the line of their " masters "

Many NGOs and other civil society in various states have been reporting that the

concerned officials at state sacs are literally hounding them.It now seems that

it is the survival of organisations who can compromise the most and who are

willing to play the game

to satisfy the powers that be.

Even the advent of many large faith based organisations are feeling the pinch,

in the current scenario it is predictable to a point of surety that they too

will back out.

Many civil society organisations have backed out of NACO and SACS supported

projects, I fear it is only a matter of time before the rest follow. This to my

mind is a national disaster!

It is time that the policy makers and strategists out there take cognizance of

this.

The days of on going effective consultations with civil society organisations

and people who matter in the formation of policy, strategy, design, and

implementation is history.

The process now is of " convieniance' and tokenism. (if ever there are any)

feedback from so called civil society consultative process is hardly ever

incorporated.

I am not sure if it is part of a strategy or is it a distorted perception. For

example all targeted intervention sites have been turned around to become points

of identifications of affected communities, and on identification, referral to

CCC (where there is no element of care or support) for further identification

and so called observation and bingo 1 the magic bullet is referral to ART

centers (at any cost).

This is the scenario on the ground. At this point I will not even attempt to

comment of the governments ART centers !! (that's a mess by it self)

As part of Health Systems strengthening, the strategy seems to be for

government to move further into implementation.

Now it is a known fact (there are enough studies on the existing health Systems

in the country) that the existing public health system in the country is either

defunct or non existent.

It is also known that governments have failed miserably in addressing this core

issues of capasity and capability of the system in the past and in the here and

now !

In this context how can piling on sensitive health related issues like HIV/AIDS,

TB, and Malaria further strengthen the system ?

The day is not far off when whatever resemblance of a public health system we

have in the state and country will be falling down like a house of cards.

And now the new found magic bullet " NRHM and NACP IV convergence "

Surely you must be joking !

Cheers anyway

Dr.Ashok Rau

Executive Trustee/CEO

Freedom Foundation-India

(Centers of Excellence- Substance Abuse & HIV/AIDS)

Head Office: 180, Hennur Cross, Bangalore - 560043, India

Senior Research Fellow, The Terry Sanford Institute of Public Health,Duke

University(USA)

Visiting Faculty, Yale University (USA)

Phone (O) +91 80 25440134, 25449766, 25430611, (Direct) 25443114

Fax (O) +91 80 25440134

email:freedom_ho@...