Print version ISSN 0042-9686
Bull World Health Organ vol.81 n.2 Genebra Jan. 2003
Donors are distorting India's health priorities, say protestors
International donors are driving India's national health agenda in the wrong directions, says a growing movement of Indian health policy experts and nongovernmental organizations (NGOs). For example, although AIDS mortality is still low in the country, there is an excessive focus on HIV/AIDS prevention, with little linkage to primary treatment, they say. Meanwhile, grass-roots concerns and larger immediate public health needs are being ignored, they claim.
The recent visit of the Microsoft tycoon Bill Gates, with his US$ 100 million grant for AIDS prevention in India, sparked the debate. At that time, the view of the Government of India and part of the Indian media was that they should not "look a gift horse in the mouth". Public health experts, however, argued that this was a myopic approach that failed to recognize grass-roots reality.
Alka Gogate, director of the Mumbai AIDS Society, says that those who have direct contact with this reality recognize the importance of ensuring that AIDS funds are used to strengthen general health services, even while ensuring care and support for AIDS patients. There have been several meetings on this issue with the deans of public hospitals in the city, she said. She claimed that it was "well recognized" that if primary health services were neglected, the huge load of infectious disease patients would be pushed onto the city's tertiary services which cannot cope with this pressure.
The top killers in India were classified in the 1994 survey of the Indian Registrar General as: "senility or old age" 21.2% (1.8 million); "cough" 19.3% (1.6 million); "circulatory disease" 11.2% (940 000), and "causes peculiar to infancy" 9.6% (810 000).
The epidemiology of HIV/AIDS in India has recently generated heated controversy between the Government of India and international agencies. India urgently needs a new system of disease surveillance, according to Anish Mahajan, AIDS researcher with a Chennai-based AIDS support group and Brown Medical School in the US. The present system extrapolates data from high-risk groups, and has no community-based information from the private sector which is the country's largest health provider.
The National AIDS Control Organization (NACO) estimates that four million people suffer from HIV infection in India. AIDS is not reported as a cause of death in the death registers, but NACO states that between 1986 and November 2002 there were 42 411 cases of full blown AIDS in the country. NACO also claimed that the epidemic is now plateauing because of its efforts. Others are sceptical, and reliable data, that all sides can agree, are urgently needed.
As for finance, according to the Central Government's Expenditure Budget for 200001, India's health and welfare budget was some US$ 1.2 billion. The disease control programme received some US$ 170 million, around 14% of this. AIDS and sexually transmitted diseases got some US$ 30 million, 2.5% of the health and welfare budget.
But the current donor interest in HIV/AIDS in India is boosting HIV/AIDS spending by approximately an additional US$ 80 million a year, causing spending on this one disease to reach US$ 110 million a year, thus making HIV/AIDS the main target of India's spending on disease control.
Moreover all AIDS funding is routed through NACO and state AIDS Societies, bypassing state health departments, so contributing little to improving the country's struggling health system.
Meanwhile, says Ravi Duggal, a health policy researcher at the Centre for Health and Allied Themes, Mumbai, treatment budgets are barely adequate to cover 2530% of TB cases, even though most AIDS patients in India die because of AIDS-related TB, and TB remains a major killer by itself.
"International donor influence in the Indian health system is disproportionate to the amounts of money they have contributed," says Duggal. "The foreign component in our overall health and welfare budgets is not more than 10%, but the advice and influence affects more like 90% of our spending."
Western and Indian government perceptions can differ widely not only from each other but from grass-roots realities, several studies have shown. A survey of published studies by Ramila Bisht, a senior lecturer in the department of health services at Mumbai's Tata Institute of Social Sciences, found that donor funding between 1985 and 1995 for specific disease programmes did not match evidence of the prevalence of these conditions in the community. For instance, despite being a major killer, TB was not a priority for funders until the 1990s, she says.
Morever, most international aid is not neutral, Duggal complains: it comes as soft loans with policy conditions attached, such as the introduction of user fees in government hospitals, policies that might attract more private sector participation in health, and emphasis on "vertical" health programmes.
A recent conference of the Asian Social Forum in Hyderabad saw several Indian health NGOs such as Swasthya Panchayat, Lokayan, and the Centre for the Study of Developing Societies, coming together to analyse what they considered to be the negative impact of the Indian AIDS programme, which they said had been shaped by the "monolithic, homogenizing nature of the response shaped by the perspectives of the 'north"'.
According to these NGOs this approach has isolated HIV/AIDS from other public health problems, and promoted technological and managerial solutions while ignoring the social and cultural roots of the problem.
"Unless we strengthen the primary health care base we won't go anywhere," says Sheela Rangan of the Pune-based Centre for Health Research. "There is an urgent need to build management systems, fill vacant posts and train front-line health workers in comprehensive care, so they understand the linkages between diseases."
"The emphasis on AIDS works to the detriment of other communicable diseases, which could stage a resurgence," claims Bisht. "We need to integrate AIDS funds into strengthening the general health services. Improving the primary health system will have an impact on a range of killer diseases, including AIDS."