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A recent audit of the National AIDS Control Organisation (NACO) by the country's Comptroller and Auditor General uncovers serious gaps in the performance and attitudes of both the organisation and the Indian health ministry
The National AIDS Control Organisation (NACO) failed to spend more than half the World Bank money available to it in the year 2002-03, even as the number of people infected with the HIV virus in India continues to grow, claims a recent audit of the organisation’s programme implementation and public expenditure by the country’s Comptroller and Auditor General (CAG). The functioning of India’s health ministry and, specifically, the performance of NACO, set up by it to combat AIDS in India in 1992, have both been questioned in light of the findings. The CAG’s ‘Performance Appraisal Report No 3 of 2004’, which was tabled in the Indian parliament in July 2004, calls into question NACO’s policies and programmes as well as the manner in which funds allocated for various AIDS control programmes were spent. NACO’s cavalier attitude towards scarce resources is evident from the fact that it failed to spend more than half the money available to it on credit; it claimed less than three-fourths of reimbursable expenditure from the World Bank. In its defence, the organisation claims that Rs 184 crore was released in grants only in March 2003. And that it failed to receive reimbursement for the Rs 50 crore it did claim. Since its inception in the early 1990s, the professed aim of this donor-created institution has been to effectively use the nearly $300 million secured since then -- in addition to the Government of India’s own inputs -- to implement selected AIDS awareness strategies. However, the CAG does not enquire into the soundness of the policies whose programme implementation and public expenditure it audits. Although it relies heavily on desk research and does not touch upon the intricacies of issues such as numbers’ surveillance and the efficacy of targeted interventions (TIs), it does offer specific advice on other technical matters. The CAG notes that Rs 783.66 crore was spent on Phase II of NACO’s programmes till March 2003 -- just 46% of the available credit -- although four of the five-year project period are already over. The watchdog points out the “failure in generating sufficient awareness among the masses and slow implementation of the components of the programme”. The CAG adds: “Various activities under the programme could not be conducted efficiently for want of infrastructural facilities, drugs, equipment, trained manpower, etc. The programme could not achieve the target of providing STD clinics, modern blood banks and voluntary counselling and testing centres in every district.” Wasted expenditure through uninstalled equipment (worth over Rs 60 lakh) and, in many cases, the malfunctioning of installed equipment is another cause for concern, the report notes. Faulty Elisa test kits had severe consequences. By June-July 2002, several state societies complained of false HIV-positive results and demanded replacements, which were not taken care of until nearly a year later, in June 2003. Other specific losses/irregularities in the purchase of technical equipment are also noted. Information, education and communication consumed the bulk of the $84 million in Phase I, and absorbed large chunks in various Phase II components. Yet, the audit claims, there is still only superficial awareness about HIV/AIDS, many misconceptions and low levels of knowledge particularly about the links between sexually transmitted diseases (STDs) and HIV. NACO’s use of the electronic media highlights “utter whimsicality and selective patronage in decision-making,” the report observes. The NACO-BBC-Prasar Bharati awareness partnership, reported to cost over Rs 100 crore (most of it outside the NACO budget), does not figure in the audit. But, details of smaller media expenditure are illuminating -- Rs 4.27 crore on sponsored telecasts of classical music and dance concerts at a particular cult shrine for short-message inserts; Rs 2.24 crore on just two chat shows. “Poor viewership,” is the CAG’s assessment. Similarly, the audit notes, there is poor listenership for radio programmes that cost Rs 5.78 crore. Some programmes like the NACO Film Hit Parade are not even evaluated. On family health awareness campaigns, the CAG observes: “Short notice and wrong selection of places failed to attract even 20% of the targeted population.” As for information and broadcasting field media units, Rs 5 crore was spent with no monitoring, the audit reveals. The computerised management information system, developed as an institutional framework for objective concurrent monitoring and evaluation, became operational much behind schedule and continued to be dysfunctional with less than 40% of the required reports received as late as early 2003. With respect to monitoring, the National AIDS Control Board did not conduct any national performance reviews between 1998 and 2003. The National AIDS Committee -- the highest-level body overseeing NACO’s performance, required to meet at least once a year -- had not met since 2001, the CAG found. The CAG also highlights considerable delays in the formulation and clearing of state action plans, resulting in large unspent balances with some state AIDS control societies. In 2002-03, as many as 21 state societies did not utilise even 50% of the released grants. At the same time, over Rs 80 crore was irregularly released. Widespread non-reconciliation of statements of expenditure at the state level and municipal societies and their final audited statements of accounts is noted. Differences were found in as many as 46 of the 49 checked. Take the case of Haryana. NACO released Rs 2.46 crore to the Haryana State AIDS Society in 2002-03, although the approved annual action plan was for Rs 2.24 crore and Rs 2.33 crore was already available with the society as unspent money! Further differences were noticed in the figures supplied by NACO and those by the state accountant general indicating “deficient maintenance of accounts”. Punjab features a difference of Rs 1.28 crore between its statement of expenditure and the audited statement of accounts remaining non-reconciled from 1998-2003. Sexually transmitted diseases are established as a major multiplicative factor for HIV/AIDS infection. But, of the 339 additional STD clinics proposed for strengthening in Phase II, by March 2003, only a quarter of the goal has been met while funds languish. NACO was unable to furnish state-wise details of the 594 equipped and functional STD clinics in the country, as of March 2003. The CAG’s scrutiny of STD clinics that received financial support in 2003-04 showed many districts without any facilities whatsoever. Where clinics do exist, missing or malfunctioning equipment is a prominent feature. The CAG’s findings on the progress of modernising and strengthening blood banks, long considered a NACO success story, are revealing. Phase II was supposed to ensure a modernised blood bank in every district by 2002. NACO had no list of the districts yet to be covered as of March 2003. The audit reveals 84 districts without a modern blood bank and as many as 44 districts in the country with no blood banking facility. In some states, the number of blood banks stated to be modernised exceeded the number registered/licensed! As many as 86 blood banks in eight states, including high-prevalence states like Maharashtra and Nagaland, were non-functional or not fully functional. Targeted intervention -- the focus of Phase II’s strategic thrust -- numbered 792 by June 2003. But NACO had no data on population coverage, with the compilation of output-monitoring reports still in its trial stage in the fourth year of the five-year project period. Accessing a national TI evaluation, the CAG found the average quality of TIs rated “a poor 37.8%”. Condom promotion -- the mainstay of the current government’s AIDS prevention initiative (given that 85% of AIDS cases are through sexual transmission) -- has not taken off effectively, the CAG notes. NACO failed to procure, much less distribute, the 3.3 million condoms it had estimated for social marketing. While NACO spent large sums of money on condom vending machines, the CAG reports that 140 machines in Haryana, Himachal Pradesh and Chandigarh have been inoperative since 1997-99; in Punjab , 55 of the 85 machines went out of order immediately. Despite a NACO directive for an evaluation of the design, delivery was taken of another 300 machines! Therefore out of a total of 385 machines purchased, at a cost of Rs 22.6 lakh, 230 have not been functional as of May 2003. Promotion of condom use among 90% of the population in high-risk categories like commercial sex workers is a key programme goal. But, the CAG quotes only 46-57% of female sex workers reporting consistent use with paying clients and a far lower average of 20-21% with non-paying clients. Condom use across the country actually declined in 2003. The CAG audit also found that the ‘AIDS care’ component was being seriously neglected and under-funded. Of the meagre allocation, a mere 14% (amounting to Rs 15 crore) was spent. Even in high-prevalence states, the shortfall in establishing care centres ranged between 17-78%. InfoChange News and Features, October 2004
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