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Mainstream, Vol XLVI No 1

National AIDS Control Programme-Phase III: A Socio-Political Disaster in the Making

Tuesday 25 December 2007, by Rami Chhabra

Introduction

There cannot be—should not be—two views on the need for India to implement an effective HIV/AIDS Programme to prevent this deadly disease and provide specific attention and assistance to those already afflicted. But the National Aids Control Programme-Phase III (NACP-III), quietly launched by the National Aids Control Organisation (NACO) in May this year, raises enormous disquiet on several scores. Foremost is the nature of the predominant substantive content of a $ 2.5 billion NACP-III World Bank-plus-donors-backed Investment Plan; further, the haste and casualness of clearances.

NACP-III clearly evidences a lack of awareness at the highest quarters of Indian policy-making of the complex socio-political implications of its proposed large-scale countrywide “Targeted-Interventions” (TI) programme concentrated on “High-Risk” populations—both euphemisms for a strategy that normalises high-risk sex behaviour and which is based on research evidence being contested as weak at best, manipulated at worst. Surreptitiously built through the largely externally-funded and externally-driven National Aids Control Programme-Phases I and II, TIs are now centre-stage primed with lush funding in Phase III.

Further, this time India is spending very considerable government funds on NACP-III— Rs 2860 crores through direct financial allocation in the Rs 11,585 crore-Investment Plan (besides unquantified diversion of scarce human/material state resources) at the cost of much else needed to be done in India’s grim public health scenario. This approach also goes against the grain of India’s considered health policies promising integrated health services as it seeks to implement HIV/AIDs work through a further enlarged vertical structure whose past performance and supervision has been well-critiqued by the government’s own audit and accountability institutional systems—the Comp-troller and Auditor General (CAG) and Public Accounts Committee (PAC)—as leaving much to be desired. Why and how this is happening are questions that need to be vigorously raised—and answers demanded.

Indeed it is to be recognised that HIV/AIDS is one of the most critical political—indeed, civilisational—issues of our times. The strategic paradigm selected to deal with this deadly disease and resources heavily-biased for its implementa-tion, determine not just the sought-after public-health outcome but inter alia impact and shape the social worldview/lifestyle of society as a whole. HIV/AIDS deals with the most controversial intimate aspects of human existence, power and gender relationships. Consequently, it is a powder-keg ready to explode if left unattended; but no less explosive if tackled wrongly. This makes it imperative that the right strategies are chosen to tackle HIV/AIDS, so that they do not backfire and derail the programme as happened with the misguided efforts to achieve accelerated family planning in the seventies; this time, with even deadlier consequences likely. There is reason to fear that we are forgetting history and would rue for long the mistakes being made today.

Part I—Looking Closely at NACP-III

Health Sector Controversies and NACP-III Finalisation

NACP-II officially closed on March 31, 2006—the original five-year project (1999-2004) having run through its two-year extension period. At the time of the NACP-II closure, the World Bank-aid to India’s health sector stood suspended as five health sector projects, including Reproductive and Child Health(RCH-I), were under investigation for corruption, since verified in a number of instances.1

Interestingly, the World Bank did not include in its further scrutiny the Second National HIV/AIDs Control Project, although this was also identified amongst “projects at risk”, flagging that its Procurement Support Agency (PSA)—Hindustan Latex Ltd.—was already charged in the World Bank investigation on RCH-I, it had received $ 206 million credit and a successor-project was scheduled to come up for World Bank Board clearances in the coming months.2 Earlier, the CAG had already documented issues with yet another PSA such as irregular award of contracts for refrigerators, deep freezers that did not match technical specifications, other infructuous expenditure, including purchase of Rs 60 lakhs worth of defective HIV test kits.3

Another interesting development to note: as NACP-II officially ended there was a virtual global media-blitz highlighting findings of a survey claiming evidence of HIV-decline in youth in South India and linking this with effective NACP-II TI strategies.4 Few reports mentioned that the lead co-author of the study was none other than the World Bank Task Force Leader for the Second National Aids Project formulation!
However, in the spring of 2006 there was enough internal resistance within the World Bank not to bypass the health sector credit-suspension even for HIV/AIDS. But as credit-funding resumed later—with the Indian Government exercising political pressure and providing assurances of instituting effective safeguards against corruption, streamlining of procurement procedures etc.—the Final-Appraisal Mission on the World Bank’s Third National AIDS Control Project took place in July/August 2006.

Meanwhile, NACP-III remained shrouded in secrecy for the general Indian public beyond NACO’s claimed “wide consultations with civil society”. Far from being readily available in the public domain as it should have been, the draft of the NACP-III Strategy and Implementation Plan and the supporting research for its formulation could only be obtained from NACO through a protracted Right to Information battle5 fought by this author and the Commission on Right to Information giving specific orders to part with the information.

NACP-III Receives Clearances with Curious Casualness

NACP-III was approved in May 2007 by the Cabinet Committee on Economic Affairs (CCEA). This was shortly after the World Bank Board cleared a $ 250 million credit-loan on April 26, 2007, curiously in the midst of the World Bank’s acute presidential turmoil, although there still remained then, as now, a significant gap in donor commitments towards the full proposed $ 2.5 billion investment, earlier waited to be filled.

Thereafter, the Ministry of Health moved, and in turn, the CCEA approved the overall Rs 11,585-crore Investment Plan, committing Rs 2860 crores as direct GOI contribution, amounting to nearly 25 per cent of the total investment and 42 per cent of committed funding so far.6

Rs 11,585 crores is a five-fold increase over the NACP-II investment with NACP-III seeking mainly to “intensify and upscale” the NACP-II strategies. Curiously again, the CCEA did not choose to wait even the few weeks needed for the NACP-II end-evaluation report—well underway at the time—to assess whether strategies being intensified and upscaled merited such faith (setting aside for the present other issues such as NACO’s past record of lack of transparency, the absence of the data available in the public domain as also a public debate on the evaluation findings that should be the prerequisite for such massive funding for a programme impinging on people’s lives).

Cleared to Tackle HIV-Infected Numbers Known Uncertain, Prior End-Evaluation

Nor, again curiously, did the CCEA bother about the HIV-estimates figures, mired at the very time of clearances in considerable media-controversy. The results from two major population-based surveys conducted in India in 2004/2005 were then being widely discussed by experts and the media—that is, NFHS-III, the Third National Fertility and Family Health Survey, that had examined over 100,000 representative blood-samples for HIV-infection and the Administrative Staff College of India’s population-based survey of high HIV-prevalence Guntur District, both having uncovered drastically lower infection-rates than being projected by NACO.7
Moreover, a number of global experts, including Dr James Chin, the former WHO global surveillance-chief on HIV-estimations, were already backtracking substantially on HIV-estimates across the developing world, including raising issues on India’s figures.8 Nearly 30 countries had/were in process of reducing HIV-estimates, many by half.

But the CCEA ignored all this. It blandly directed mid-course “incorporation of recommendations, if any” from the NACP-II end-evaluation; sidestepped the estimation controversy; approved the investment-plan and committed the GOI’s whopping Rs 2860 crores upfront—of which Rs 2031 crores is for condoms alone; Rs 418 crores for NACO to increase its already 800-strong force with 1300 posts/1200 contractual assignments and vertical district units.9 All under a government committed to downsize and integrate health services!

It may also be noted that the current direct national contribution is more than the sum of money mobilised from the World Bank and all other external funding in the previous two NACP phases and yet does not include the additional infrastructure/human resources costs/other inputs that willy-nilly are diverted from the States’ resources as vertical Centrally-funded programmes are mandated and expanded to every village and kasba. In the much smaller NACO-II these were estimated by the government at over $ 221 million.10

Disproportionate-Funding, Vertical-Deepening for One Disease

Not disputing the acute need for HIV prevention and management, there remains the serious point of contention on how this is best done and on what the resources go. Ironically, the WB’s own analytic assessment in the appraisal document reveals that:

“In the last two years of NACP-II, domestic expenditure by GOI already averaged nearly $ 55 million a year and amounted to 32 per cent of total public health expenditure and 4.75 per cent of the total GOI expenditure on health. It constituted 76 per cent of expenditure on all central disease control programmes put together.”11

With further five-fold increase of the NACP-III budget over NACP-II, the World Bank admits that this significant scaling up of expenditure on HIV/AIDS may affect resources available for diseases such as tuberculosis, malaria, leprosy and other vector-borne diseases, but anticipates increasing health budgets for other diseases with which HIV/AIDS proportion of public health expenditure could downturn to 23 per cent of the public health expenditure by the end of NACP-III.12

A third of all public health expenditure in recent years, possibly more now, a quarter later if resources increase—frightening that, while much is made of HIV/AIDs figures as being high, other diseases even more widely prevalent are deprived of scarce resources.

Consider just these few facts on the size of some aspects of the disease load in India to place into perspective the enormity of deprivation that occurs when lopsided attention is given to one disease in a resource-constrained scenario:

• TB: one-third of world cases—15 million cases; largest number of multi-drug resistant cases.
• Acute respiratory diseases: 950,000 deaths per year.
• Acute diarrohea: 19 crore illness-episodes a year; estimated mortality of one lakh children each year.
• Malaria, especially falciparum malaria, estimated two-to-three million cases per year; estimated mortality 20,000.
• Chronic respiratory diseases: 65 million cases and the cause for 2.5 per cent of all deaths in 2000.
• Parasitic infections, including hookworm infections, contributing in major to iron-deficiency anaemia and filariasis.
• Kala Azar: significant public health problem in certain States and causes.
• Anaemia: 74.3 per cent prevalence in children; 49-56 per cent in women—contributing to one-third maternal mortality.13

What Are India’s Compulsions for Accepting Narrowly-Earmarked External Funds?

But not only has the GOI no qualms about according such distorted funding pre-eminence to a single infection/disease and magnifying its vertical organisational structure, it has also had no compunction about agreeing to an External Aid component that principally straitjackets the external support to a still narrower part—the controversial strategic thrust of Targeted Interventions for High Risk Groups (TIHRG).

Further, external-aid has insisted on as much as Rs 2589 crores outside the national budget, even though there exists a Rs 1146-crore gap within the national budgeted-outlay itself. (See Table I) The “finance-gap” will be further considered by the WB for “supplemental financing” in later years, “only when satisfied that implementation of the project, including disbursement and substantial compliance with loan covenants, is satisfactory”.14

Now why should an embarrassingly foreign-exchange-rich India—currently sitting on several hundred billion dollars—allow itself to be dictated to on what it should do in a very sensitive societal area, and that too for small crumbs? A considerable part of the external-credit-cum-external-aid currently committed was reportedly available only for a TI-dominated conceptualisation of NACP-III on a take-it-or-leave-it basis. The matter of comp-liance of loan covenants needs greater attention, on which a little later.

Finally, how could a clearly colossal expenditure within the health sector outlay get speedily cleared on the basis of dealing with a stated HIV-infection-load of 5.2 million persons—and mathematical models projecting to avert 9.4 million new HIV-infections through its implementation—when these basic figures are known to be clouded in controversy and the independent end-evaluation report is still unavailable?

HIV-Estimates Halved Immediately After NACP-III Clearance

Within weeks of the NACP-III clearance a drastically revised HIV-infection-burden is announced. The Expert-review group is convened only in the wake of NACP-III approval. This is part of the strategy. For referring to Component 4: Strengthening Strategic Information Management, the WB document states: “The models used to generate national and state estimates on the basis of surveillance data will be reviewed.” So with NACP-III instituted NACO finally convened the review to examine data known to the organisation for a year or more and presto! HIV-estimates are halved! India is now estimated to have two-to-3.1 million HIV-infected, 2.5 million median figure.16 A lower estimate also for new infections expected to be averted is concomitant to this development but no statements have yet been issued on the new “infections-averted” projections.

Thereafter, Union Health Minister Anbumani Ramadoss and NACO officials go on a media-blitz—emphasising lowered figures do not minimise the challenge and assuring there will be no budget cuts in NACP-III following drastic curtailment of problem-size, simply more money available to do more, better, for fewer numbers!17

GOI Abdication of National Sovereign-Right to Independent Decision-Making

Not revealed to the public by the Health Minister, NACO officials or anyone else at any level, while government secured media mileage with statements on the issue, is the real reason for such spendthrift generosity: the amazing fact that the GOI, while accepting this paltry $ 250 million credit with its elaborate donor-line-up, actually signed away India’s sovereign right to decide its own future course of policy-making and action on this domestic front that constitutes one of the most intimate, controversial matters in Indian society. The GOI is in no position to change any part of its cleared plan, notwithstanding changed HIV-estimates, which were actually anticipated even as it consciously abdicated sovereign decision-making.

Categorically stipulated as the final of the nine Credit Conditions and Covenants to which the GOI put its signature-seal to receive the US $ 250 million equivalent credit for the Third National HIV/AIDS Control Project and its accompanying external aid commitments is the following: “The GOI throughout the duration of the program shall cause the executing agencies to implement the GAAP, refrain from taking any action which shall prevent or interfere with the implementation of their Plan, not waive, amend or abrogate the Plan and, provide a written report on progress achieved in the implementation of the Plan semi-annually.”18 (Emphasis mine—R.C.)

GAAP is the acronym for Governance Account-ability and Action Plan. However, the fact that the operative highlighted follow-up sentence uses the word Plan instead of using language referring to its implementation or reiterating the acronym GAAP obfuscates what is being bound down—the plan for accountability and procedures as the GOI/NACO could well claim in response to this open criticism, or the entire Programme Implementation Plan (PIP)? Having observed the World Bank and NACO’s record of masterly subterfuge in the Second National Aids Control Project document—in which Targeted Interventions, although initially allocated less than a quarter of the loan-credit budget, were insidiously made the operative cornerstone through not only grant add-ons but the device of Key Indicator monitoring to assess project objective fulfilment—this is unlikely to be a loose drafting slip! (I might add that when NACP-II was challenged by women activists on the Targeted Interventions issue the then Health Secretary—
who went on to a prime WHO assignment on retirement from the Health Ministry—officially contradicted the TIs as having a large determining role in NACP-II!)

Now, why else should Dr Ramadoss and NACO officials be falling backwards to insist that revised estimates do not change anything?

What Is this Plan and Why Is It So Sacred That It Must Not Be Changed in Any Way?

So let us see what is this precious Plan for which India, while receiving a pittance it does not need, takes the unprecedented step of compromising national sovereignty, political capital and intellectual capability by foreswearing inherent rights to prevent, interfere with implementation, waive, amend or abrogate the agreed Plan in any way. The public needs to know why and how such unprecedented steps have been taken. What are the pressing reasons for which the authorities well-cognisant of the possibility of much lower estimates existing disregarded the same to hastily sign and bind the nation to such an emasculating clause?

Table II giving Core Indicators for Monitoring NACP-III for Achievements of Targets by End of Project (2012) approved by the CCEA, together with Table III presenting the summary of financial requirements in the NACP-III Strategy and Implementation document provide a clear portrait of the Plan made “sacred”.

Strategic Thrust: “Prevention Package for High Risk/Vulnerable Population”

From the Core Indicators it can be well-gauged that the Plan accords top-primacy to what it calls a Prevention Package for High-Risk/Vulnerable Population, constituting principally of what are called “Targeted Interventions” (TIs). (TIs are euphemistic shorthand for the strategy of “non-interfering, non-judgmental” identification, mobilisation and association into organisations of “high-risk” persons to receive selected services termed “comprehensive” seeded and nurtured through NACP-I and II.)

As Table II shows, NACP-III aims to cover one million “Commercial Sex-Workers” (CSW) and their clients; contact 1.5 million “Men-Having-Sex-With-Men” (MSM) and 0.19 million “Intravenous Drug-Users” (IDU). The financial break-up of this TI approach further reveals that while 1260 TIs—to cover 0.60 million CSW, contact 0.90 million MSM and 0.14 million IDU—will be through Government Budgetary Support, another 840 TIs—to cover 0.40 million CSW and their clients, contact 0.60 million MSM and 0.05 million IDU—are to be organised and implemented through Extra Budgetary Support. These comprise the major targets for the external aid component and so obviously absorb the bulk of Rs 3500 crores placed outside government budgeting. So, same of the sleaziest activities to be conducted in India will be funded from foreign sources and outside budgetary purview. Also to be noted is the fact that monitorig goals differentiate—“CSWs” and clients reached by intervention, “MSMs” only “contacted”.

What Fiduciary Oversight of Extra-Budgetary Expenditure?

A number of conditionalities relating to financial and management reform and audit, including the development of a Governance and Accountability Action Plan (GAAP), imposed by the WB this time round testify eloquently to the considerable laxity in implementation and supervision hallmarking NACP-II—and an attempt to improve the situation.

The fiduciary oversight to be provided on the huge investment outside government budgets is however unknown. The WB qualifies its statement: “Project performance (through monitoring and evaluation arrangements and indicators used) will measure performance of the entire country program including interventions by all players.” (A pointer to this not being the case in NACP-II.) But a tiny footnote amplifies that the WB’s fiduciary oversight is limited to the “pooled funding column” (g) while monitoring and evaluation will cover the “entire country plan”. Col (g) is only for “balance pooled financing by GOI, partially through DFID and WB”.19

(Despite efforts to find out from concerned officials, including several attempts to seek a meeting with the India Director of the Gates Foundation’s Avahaan Initiative who was consistently unavailable, there is no information in the public domain regarding the expenditures incurred and outcomes achieved through the considerable non-government investment made by the Gates Foundation (GF) and other donors during NACP-II, although technically key officials of the Ministry of Health/NACO have oversight roles on the Board(s). This must not be dismissed as a question of the payers’ rights to determine what they want to do with their own money—for the socio-cultural and political impact of the strategies being implemented under the HIV/AIDS mantle are directly borne by the Indian people.

Huge Investment for What?

The Summary of Financial Requirements of NACP-III20 (Table III) giving the investment break-up further illuminates the now “sacred” Plan, including what the Core Indicators cover/contact will consume and seek to achieve.

In monetary terms, it is to be noted that Prevention is accorded two-thirds of outlay; the direct earmark for TIs as much as 20 per cent or one-fifth of the overall investment. Further, the “Package of Services” servicing high risk persons absorbs another 12 per cent and Condom Promotion alone a whopping 17.3 per cent. Together these account for over 50 per cent of the investment—Rs 5681 crores out of the Rs 11,585 crores, not yet counting other elements from Communication, Advocacy and Mobilisation (Rs 1018 crores) that will indirectly and directly support this priority to High Risk Population strategic thrust, create “enabling environment” and “grassroots-linkages”.

By contrast, Care Support and Treatment of the disease-affected receives less than 17 per cent of the total outlay, care and support per se being only 4.3 per cent with 12.5 per cent on Auto Retroviral Therapy (ART). Coverage is modestly targeted to 340,000 persons including 40,000 children. Extra budgetary sources contribute only to 30,000 or about nine per cent of this humanitarian coverage.

The Core Indicators chart zooms in clearly on the strategic-priorities: three billion condoms distributed a year including two billion by social-marketing through Government Budgetary Support, while Extra Budgetary Support will finance another 0.5 billion condoms. “Basic Services” constitute of establishing another 2000 or so Integrated Counselling and Testing Centres (ICTC)—to escalate HIV-testing to 22 million persons; 15 million are expected to be treated for Sexually Transmitted Infections (STIs); 7.5 million pregnant women given testing/counselling and as needed prophylactic treatment. Other aspects of the NACP-III core-work, that is, Blood Safety Measures are modest in terms of raising transfusion units but after 15 years finally aim towards more comprehensive targeting of infectivity-reduction through this most potent of all routes.

High Risk Numbers Inflated Based on Unverified Assumptions

Closely linked to this enormous funding for TI operational targets—the hinge of NACP-III—are issues of the veracity of the high-risk estimates on which they are based, as also the coverage already claimed to have been achieved under NACP-II. (Given the estimation-process followed for NACP-III planning there are also issues on the validity of the previous “mappings” research, a key indicator activity of measuring India’s capacity to respond to HIV/AIDS, with huge amounts spent on these exercises during NACP-II.)

The Report of the Expert Group on Size Estimation of High Risk Groups for NACP-III—secured only under the RTI—offers fascinating insights on the numbers-estimation.21 It dismisses as “crude estimates” the figures arrived at by NACP-II-funded “mappings” research—a key task and output indicator of TI-implementation in NACP-II, on which each State spent Rs 5-15 lakhs per exercise.22 Then through untested assumptions/macro extrapolations from micro-mini studies/range-estimates instead of point-estimates, self-selection of high-end-range-processes uncannily similar to those earlier utilised in making the HIV-infection estimates that now stand drastically downscaled— high-risk-person-estimates escalate dizzily.

Consider: baseline mapping-estimates for women-in-prostitution, made available by nearly all States (except poster-State Tamil Nadu, besides Tripura, Dadar and Nagar Haveli, Lakhshadweep) and key international agencies—totalled 5, 23,000 prostituted-women in the country for all “mapped” areas. These were then refined on the basis of several assumptions (including, 33 per cent prostituted-women in rural areas by averaging feedback from three States providing rural figures) to reach 750,000. Then argued that figures need range-presentation rather than point-estimate: so a range of 831,677- 1,250,115 calculated—but leaving out “indirect sex-workers”.23 Finally, NACP-III picks the high-end of range as universe, yet leaves indirect “sex workers” for a later date.

By contrast, the forthcoming Independent Evaluation of NACP (2007)24 creates a Table on Coverage of Vulnerable Population through TI Projects by quoting NACO’s UNGASS India Report 2005 to display the estimated size of “sex workers” as 292,058 with 152,943 (52 per cent) coverage over NACP-II.25 It specifically lauds the “impressive success regarding the coverage of female sex workers with more than half of them covered under the interventions”. (See Table IV)

So, within a year NACO has shifted from its earlier estimation of under three lakh “sex workers” to 5,23,000 “mappings” to a final estimation of 1.2 million “commercial sex-workers” not “correcting” for “indirect sex workers”.

The coverage numbers and proportions also zoom in different reports, within a year. In contrast to the 152,943 covered quoted in the UNGASS India Report 2005 (as also in the Independent Evaluation) the NACO Strategy and Implementation Plan is actually claiming coverage of 4,44,186 “sex workers”. Interestingly, the World Bank Implemen-tation Completion and Results Report on the Second National Aids Control Project (September 29, 2006) which provides a Table on Estimated Size and Coverage of High Risk groups by NACO uses the figures of the Expert High Risk Estimation Group for Estimated Size, but sources the same to the mappings of HRGs conducted by SACs, and then sourcing from the Consolidated CMIS reports December 2005 gives a coverage figure of 4,44,186 “sex-workers” amounting to 35-45 per cent coverage of the 831,677-1.2 million estimated size!26 (See Table IV)

Estimations and Coverage of Men-Having-Sex- With- Men (MSM)

Even more extraordinary estimates-escalation has taken place in calculating men-having-sex-with men (MSM).

The High-Risk Estimation Report, through a series of arbitrary assumptions, zooms “mappings” of just 0.01 per cent of male adult population to as much as five per cent of two-thirds of all adult males (ages 15 onwards) who are considered sexually active as having same sex activity; twenty percent or one in five of homosexually active men are then again assumed—on the basis of one small study— to have more than five partners in the previous month, available at cruising-sites, of which ten per cent (again one funded organisation’s feedback) are male “sex-workers”. Based on these assumptions and adjustments, a figure of 2.3 million MSM (with-five-plus-partners) and ten per cent or 235,213 male sex workers needing attention of NACP-III TIs is worked out!27

The Independent Evaluation of NACP report table for Coverage of Vulnerable Population (Table IV A) has the estimated figure of 89,967 MSM in the country with 40,315 or 45 per cent covered, a proportion it additionally shows as only 11 per cent according to the PIP for Phase-III.28 Even accepting the 11 per cent afterthought figure, total estimation of MSM would not exceed four lakhs or so. But a year later it has zoomed to 2.3 million. Here again, the World Bank Implementation Report picks the 2.3 million estimated size of the Expert Group Estimation (of course sourced to mappings conducted by SACs) and through Consolidated CMIS reports claims 1,26,883 or six per cent covered.29 (Table IV C)

The Independent Evaluation of NACP does make a mild admission in its chapter on surveillance and estimations that “there is limited detail on how the sizes of the risk groups are obtained”.30 This is about the major paradigm and key operational thrust of NACP-III and the Independent Evaluation team has limited detail available? Why?

With NACP-III’s key operational targets being the mobilisation, collectivisation and servicing of 80 per cent of such unscientifically-estimated universes, what sanctity to these key targets? And further, what sanctity to the effective—and honest—utilisation of huge funds earmarked to mobilise and service persons whose numbers have been literally conjured out of the air?

Regulatory Norms Relaxed for TI Interventions

Half the TIs are to be through newly created Community Based Organisations (CBO). The existing regulatory practices for NGOs/CBOs to demonstrate a track-record of a minimum three years service are being waived for CBOs created under NACP-III. Further, one-time costs are to be given to such newly set up organisations, together with generous fixed annual costs irrespective of numbers, plus more variable numbers-linked recurring-costs! These are not small sums: Rs 2.5 lakhs for one-time cost; Rs 11 lakhs annual fixed costs (besides slightly higher variable annual recurring costs—for each formation of 800-1200 “high-risk” persons).31 With such munificence far from available to others tackling hunger and destitution, it needs to be asked: are we tackling HIV/AIDS or putting a premium on high-risk behaviour through such well-heeled approaches, which given the nature of the work and the ambiguity on the actual numbers lie open to misuse?

“Regularisation of CSW and MSM” part of WB “long term reform agenda”?

The World Bank Technical justification analysis in NACP-III PAD backing the overwhelming thrust for Targeted Interventions for High Risk population notes: “The National Strategic Framework for Action assumes that the underlying constructs of vulnerability will be challenged and changed through the implementation of the strategies laid out in the document moving from criminalisation to regulation of Commercial Sex Workers (CSW) and MSM.”32
But there are no strategies, much less provisions, in NACP-III to challenge “the underlying constructs of vulnerability” or the structural pushes into vulnerability that should be addressed to prevent women—and men—to be sucked into prostitution, pull out those trapped and provide alternative life skills to eliminate the constant risk-exposure.

The Parliament Standing Committee examining amendments to the Immoral Traffic Prevention Act (ITPA) had categorically asked NACO to ensure the above in future plans, stating that there was need for NACO “to broad-base its current approach to include important aspects such as rescue, skill-building, rehabilitation and reintegration of vulnerable populations”. It called on NACO to “revisit the strategy and evolve suitable methodologies”, including an “inbuilt component” for work with Women and Child Development Ministry (WCD).33 (A recent countrywide study supported by the GOI/WCD highlights a disproportionately high rise in prostitution in the last 10 years,34 while, the WCD is on record protesting the NACO programmes at cross-purposes with its anti-trafficking work. But to no avail.)

WB-backed Plan at Cross-Purposes with Parliament Standing Committee/ ITPA

The ITPA amendment proposals seek to decriminalise soliciting and the person selling sex while criminalising the demand for commercial sex by making explicit and more stringent penalisation of the client.35 The underlying logic is to move upstream to cut the demand, curb the supply routes and provide safe viable exit to those trapped so that risk-exposure itself stands reduced, not just harm-minimisation (at considerable cost) within continuing risk.

But as the WB technical analysis evidences, strong invisible lobbying influences are at work, militating against nationally conceived wisdom and laws to move the country into “regulation of commercial sex workers and men-having-sex-with-men”.

The ITPA amendments referred to the Cabinet for clearance after the Law Ministry and Women and Child Development Ministry had finalised these on the basis of the recommendations of the Parliament Standing Committee examining ITPA did not clear the Cabinet. These are further referred to a Group of Ministers, including the Health Minister.

Principally at issue is one key recommendation, 5C, that seeks to penalise the “client” or buyer of commercial sex, clearly enunciating and amplifying the country’s existing law that criminalises organised commercial sex-activity although other amendments now move to decriminalise the person selling sex in recognition of the rampant exploitation and victim-status of such persons, their need for relief, rescue and amelioration of their condition with solid alternative rehabilitation. In the absence of 5C the other amendments will only open the floodgates for open prostitution. But HIV/AIDs-funded sex-worker networks are now actively lobbying against Clause 5C claiming it impedes their “trade” and demanding recognition of prostitution as a legitimate livelihood avenue.

The remarkably skeletal Key Indicators listed by the WB’s project document to track the project development objectives of the WB-support to NACP-III well focus the unfolding agenda and illuminate the source of strength of the “sex-worker networks”, just as TIs became the password in NACP-II!.

The WB will now monitor the NACP-III success by:
• Percentage of female sex workers who report using a condom with their most recent client;
• Percentage of male sex workers who report using a condom with their most recent client;
• Percentage of injecting drug users who have adopted behaviours that reduce transmission of HIV, that is, who avoid both sharing injecting equipment during the last month AND who report using a condom with their most recent sexual partner; and
• Number of people with advanced HIV-infection receiving anti-retroviral combination therapy.36

HIV/AIDS—A Holy Cow!

International donors and the national establishment alike have made NACO and the NACP efforts a holy cow—to be fed, fussed and fattened with no questions asked. Few dare to query the over-funded, under-performing HIV/AIDS prevention initiative, for it has also become a bonanza for those sections that could—Civil Society and the Media.

NACP funding for NGOs started out with a relatively modest disbursement of Rs 1.8 crores to carry out awareness during NACP-I, scaled to an astounding Rs.801 crores disbursed for TIs in NACP-II37 and is now in NACP-III budgeted at a mind-boggling Rs 2288 crores for the proposed 2100 TIs to be sustained/established within the next two years.

The presence of such large funds for a particular type of activity alongside resource-lack for other approaches, indeed other key development needs, is a particularly negative development within civil society whose talents and loyalty are being diverted to a given philosophy and narrow work-agenda to the detriment of wider interests. Alongside there are reports that recent evaluation-exercises by SACs of NGOs/CBOs funded under NACP-II for eligibility under the new GAAP conditions have disqualified a very large number—reportedly, as many as half— for future support. If correct, this also raises interesting questions on past performance claims, while throwing into flux future trend monitoring of “outcomes”.

The media is another major beneficiary. Budgets for communication and mobilisation, already generous in the past two phases, have zoomed to a neat Rs 1000 crores plus in NACP-III, virtually two-thirds of it for media and special events. It is increasingly difficult for dissenting viewpoints to find space and forum for expression in such contexts.

Backlash to NACO’S Adolescent Education Programme: Taste of Future

At the same time, ten States across the country are reported to have already thrown out NACO’s Adolescent Education Programme(AEP), as public protests are mounting on its contents. The Rajya Sabha Committee on Petitions is currently examining the matter; reportedly, it is flooded with over four lakh letters from all corners of the country. The whole issue of sex-education, delicately negotiated into school curriculums in earlier years, stands threatened by a backlash arising from NACO’s insensitive thrust. The baby is now being thrown out with the bathwater.

But AEP is only a minor-key backlash compared to the volcanic-volatility of public opinion that could explode as NACP-III proceeds to organise several thousands collectives of “commercial sex-workers”, “men-having-sex-with-men” and intravenous drug-users, with aggressive, blanket- promotion of condoms: altogether, an unprecedented scale of socially-contrary operations, untested and untried on this scale anywhere in the world; rocking the personal as never before. It took the family planning programme nearly a decade to recover from ham-handed handling in the Emergency era. This would be worse. Can we afford it? The time to rethink is— now.

Part II—The Need: An Alternative Holistic-Ethical-Wholesome Paradigm

NACP-III brings us to the cross-roads. It forces confrontation with HIV/AIDS issues, particularly Prevention. With 99 per cent plus unaffected-population this is yet a moment of choice: a predominant path for responsibility and restraint recognising means as equally important to reach the desired ends, or the seemingly-easy, slippery slope of “pragmatism”?

Hind-sight Shows Heavy Costs to the so-called “Cost Effective” Strategies

Fortunately, at this juncture we have the gift of hindsight. The Thai-experience reveals “pragmatic” “cost-effective” “rapid-blanket-saturation-TI-methodologies” are at very best a temporary reprieve carrying expensive end-tags, most particularly for future generations. As with environment-issues, tampered inner-environments—of which sexuality is an intrinsic core-element—carry individual/social costs, most severe to the poor, gender and inter-generational interests.

State-Abdication of Responsibility and Fillip to Anti-Social Elements

State and societal acceptance of casual, commercial-sex is tantamount to state-abdication of constitutional responsibilities to ensure a life of dignity, free from personal degradation for all citizens. The Indian Constitution explicitly prohibits trafficking which is inextricably bound with prostitution/ commercial sexual exploitation; equally, it obligates the state to proactively stop practices derogatory to women and children. In a country that is still battling to give women protection against bigamy, desertion and domestic abuse to argue for socially-sanctioned freedoms for all forms of “adult consensual sex”, as the media has begun to do, is regressive in the extreme to women’s status issues. Further, free commercial-sex and anti-trafficking efforts are by nature antithetical; the former magnetises human-trafficking. NACP-III “saturation” of high-risk-sex populations with condoms and pharmaceuticals and “empower-ment” of groups around risky-sexual identities therefore goes against the grain of state’s constitutional responsibility.

“Safe spaces” for commercial-sex also fillip unsavoury vested-interests: commercial-sex-sale is all-too-often accompanied by drugs/alcohol-abuse/gambling, even outright criminal activities from petty to grave. At a recent meeting of the Anti- Trafficking network persons working in “red-light” areas placed on record the growing concentration of “goondas” and potential-terrorists in these localities. Grappling rampant corruption and ill-governance can we afford the further compounding of problems as massive funds and public energies flow to break established norms of propriety, condone the hitherto unacceptable?

Build Win-Win Strategies to Grow Wholesome Cake

The enormous available public funds need to be channelled towards concentrating energies on positive win-win strategies that grow the wholesome-cake, enabling the vulnerable to find their rightful place in positive-destinies. These are no more pipe-dreams than the current economic breakthroughs undreamt of before—and far less difficult to publicly-seed than the proposed dis-regard of established public-norms of sexual-conservatism.

Sweden Provides One Model, Uganda Another

Wholesome models are available. Commercial-sex, pinpointed in NACP-III as a principal engine of HIV-spread, has been differently tackled by Sweden, one of the most modern, progressive countries in the world. Sweden has recognised prostitution as an extreme form of male violence, politically stated the sale of its citizens as totally unacceptable and brought the might of law to focus on eliminating demand—no one may assume the right to purchase persons to satisfy their sexual-urges. The gender-neutral Swedish law: Ban on the Purchase of Sexual Services (1999) provisions for effective prosecution and penalisation of the buyer—and the chain of exploiters—and ensures relief to the victims, thus addressing both root causes. Its implementation over the last six years has halved street-prostitution, stopped new sex-recruitment/ trafficking from the Baltic and other countries, while during the same period street-prostitution/underground-prostitution has tripled/quadrupled in neighboring Denmark, Netherlands, Germany, countries that normalised prostitution as “sex work” and took the regulation-route being advocated to us.

At the other end of the spectrum, Uganda, a high HIV/AIDS prevalence country, has achieved sizable reduction in HIV infection-rates with strong political will, proactive policies and popular communication persuasive of delay in sexual-initiation for young, “zero-grazing”/fidelity amongst adults—despite the fairly high levels of multiple-partner/ premarital/ extra-marital sex prevailing earlier. Many other African countries have self-awakened to what they call “social vaccine”.

Need for Holistic-Ethical-Wholesome Perspective

Experts and activists, including over 100 field organisations, have written several times to the Prime Minister who also heads the National Aids Council—but with no acknowledgement, much less response. The authorities’ attention has been repeatedly drawn to the enormous problems with NACO, NACP-I and II, the increasing distortion of the Primary Health Systems and the social set-up through its narrow, verticalised and socially-insensitive vision. A review and reformatting of HIV/AIDs policies and strategies through the prism of a holistic-ethical and wholesome paradigm has been urged.

Low-risk lifestyles remain universally applauded and overwhelmingly followed in India as yet, although they are now facing breakdown by onslaughts from varied forces, including ill-conceived NACO-originating communication. (Chalo-condom ke sath!) Low-risk lifestyles need appreciation and reinforcement, not challenge.

A holistic-ethical and wholesome paradigm is the crying need of the hour. What does this entail? First and foremost, a reorientation of the policy-perspective: the primary focus being accorded to the general population; policies, programmes (allocations accordingly) that reinforce/reward traditional behaviour-values of abstinence for the young, monogamy /fidelity/committed-relationships of human-intimacy as continuing cherished norms of Indian society: the “social-vaccine”. Massive mass-media communication campaigns to reinforce this perspective—not to promote condoms. Programmes devised to reduce and geared to monitor reduction in high-risk sex activity, not the numbers of condoms used, STDs treated. The media also needs persuasion from the highest levels to uphold these values as internalised social responsibility, or face the consequences of external regulation. All social/economic laws
reviewed/reformulated/strengthened to ensure implementation of a socially-responsible paradigm.

The “wholesome perspective” needs mainstrea-ming as the multi-sectoral responsibility of all sectors/ programmes. Holistic thinking requires HIV/AIDS care and treatment to be integrated into primary health systems, improving the same to ensure across-the-board functioning efficient services. Further, every sector/programme needs to be mandated to self-examine and identify every available opportunity within its purview to create circumstances/enabling environment that, first and foremost, reinforces primary prevention measures, while additionally creating effective linkages to secondary prevention.

Target Demand for Commercial Sex

In this scheme NACP-III’s predominant strategy for high-risk sex groups needs to be completely reworked to focus on elimination of demand for commercial/casual sex. An immediate priority is to ensure ITPA amendments currently with a Group of Ministers elucidate this perspective by:
• Categorically enunciating the constitutional obligation of the state not to allow the prostitution-trade in any form as it is derogatory to the dignity of women and degrading of all women and children.
• Effectively criminalising all demand for commercial sex including penalising the buyers of sex. This is most critical to root out the demand.
• Effectively decriminalising the prostituted person as a victim and making adequate provision for meaningful programmes of primary prevention, rescue, re-skill and reintegration.
• Creating mechanism(s) with adequate authority and adequate funds to implement on two different fronts: deterrent and rehabilitative.

A Metaphor for India’s Soul and Spirit

How we tackle HIV/AIDS is a metaphor of India’s soul and unique spirit and of her ability to show balanced pathways to a happier tomorrow in this globalised world. If external funds are available earmarked only for a narrowly conceptualised high-risk sex dominated paradigm this must be rejected. The National Aids Control Programme cannot be allowed to become a conduit for an extraordinary legitimisation of the sex and pornography industries under cover of warding off a dreaded disease! These are remedies worse than the malady they seek to cure—and the consequences of engineering such sociological shifts will be very far-flung. Therefore, this madness must be halted before it lumpenises vast sections of society. Is anyone listening?

REFERENCES

1. Report of Investigation into Reproductive and Child Health Project Credit N0180 India, Department of Institutional Integrity, The World Bank (2007), November 23, 2005.
- 2. Ibid.
- 3. Union Government (2004), Report of the Comptroller and Auditor General of India for the year ended 2003, No 3 of 2004.
- 4. R. Kumar, P. Jha et al, “Trends in HIV in Young Adults in South India from 2000-04”, The Lancet, Vol. 367, Issue 9517, pages 1164-1172.
- 5. RTI Matter No. T-11021/1/2006-NACO (Admn.).
- 6. World Bank (2007), Project Appraisal Document on a Proposed Credit in the Amount of SDR 167.9 Million to Republic of India for A Third National HIV/AIDS Control Project Report No 36413-IN, March 22, p. 40.
- 7. National Family Health Survey India-III ; Lalit Dandona et al. (2006), “A Population Based Study of Human-Immuno-Deficiency Virus South India reveals Major Differences from Sentinel Surveillance-based Estimates”, BMC Med: 2006; 4:31 published online 2006, December 13.
- 8. Dr James Chin, “Myths on Aids Prevalence”, Economic Times, April 22, 2007.
- 9. EFC and CCEA information accessed by author.
- 10. Ministry of Health and Family Welfare (2001), National Aids Control Project Phase 2 (1999-2004) National Project Implementation Plan, May 1999 (mimeo).
- 11. World Bank (2007), op. cit., p. 83.
- 12. Ibid.
- 13. Abdul Ghaffar, K. Srinath Reddy, Monica Singhi, ”Burden of Non-Communicable Diseases in South Asia”, BMJ, No. 7443, April 3, 2004.
- 14. World Bank (2007), op.cit., p. 15.
- 15. Note of the Ministry of Health and Family Welfare to EFC and CCEA.
- 16. NACO (2007) Press Release dated July 6.
- 17. The Indian Express (2007), July 7.
- 18. World Bank (2007), op. cit., page 14.
- 19. World Bank (2007), op. cit., pages 40-41.
- 20. NACO (2006), National Aids Control Programme Phase III (2007-2012) Strategy and Implementation Plan, November 30, page 216.
- 21. NACO (December 2005), Report of the Expert Group on Size Estimation of Population with High Risk Behaviour for NACP III Planning, Prepared by RCSHA, New Delhi (Mimeo).
- 22. RTI information to author.
- 23. NACO (2005), op. cit.
- 24. NACO (2007), Consortium of Johns Hopkins University, USA, Indian Institute of Health Management Research, Jaipur, Indian Institute of Management, Calcutta, Report on Independent Evaluation of National Aids Control Programme, Submitted to NACO, mimeo received under RTI.
- 25. Ibid., page 31.
- 26. World Bank (2006), Implementation Completion and Results Report on Credit in the Ammount of US $ 193.7 million equivalent to Government of India for the Second National Aids Control Project, Report No. ICR-000022,Human Development Unit, South Asia Region September 29 P 31.
- 27. NACO (2005), op. cit., pages 14-15.
- 28. Ibid.
- 29. World Bank (2007), op. cit. p. 31.
- 30. NACO, Independent Evaluation of NACP (2007), op. cit., p. 165.
- 31. NACO (2006), National Aids Control Programme Phase III (2007-2012) Strategy and Implementation Plan, November 30, page 216.
- 32. World Bank (2007), op. cit., page 16.
- 33. Report of the Immoral Traffic Prevention Amendment Bill 2006 of Ministry of Women and Child Development, Report No 182 tabled on November 23, 2006.
- 34. Dr K.K. Mukherjee and Dr (Mrs) Sutapa Mukherjee (2007), Girls and Women in Prostitution in India—A Report, Gram Niyojan Kendra, Adhyatmiknagar, Dasna, Ghaziabad, UP.
- 35. Immoral Traffic (Prevention) Amendment Bill, 2006—Bill No. 47 of 2006, as introduced in Lok Sabha, May 22, 2006.
- 36. World Bank (2007), op. cit., page 4.
- 37. Ministry of Health Note to CCEA including EFC papers, dated March 12, 2007.

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