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Is HIV/AIDS skewing the priorities of the public health system?

By T K Rajalakshmi

The bulk of health problems facing Indian people are simple -- malnutrition, malaria, diarrhoeal diseases, etc – and they require simple solutions -- food, mosquito control and clean water. But the government’s approach to public health increasingly focuses on vertical programmes to tackle each disease instead of comprehensive healthcare. The AIDS control programme is another vertical programme that reinforces our misplaced priorities, and also puts more pressure on an already crumbling public health infrastructure

  

The year 2008 will mark the 30th anniversary of the World Health Organisation’s declaration at Alma Ata, then in the USSR. Many governments including the Indian government promised to provide Health for All, setting a date for this, the year 2000. This was not only an expression of intent; it was a slogan reiterating a serious commitment to health issues.

Health was defined as a state of complete physical, mental and social wellbeing, not merely the absence of disease and infirmity. Health was a fundamental human right and the attainment of the highest possible level of health was an important social goal whose realisation required the action of the health sector as well as many other social and economic sectors.

The Alma Ata declaration was made just as the global health divide between rich and poor countries reached a flashpoint. Thirty years down the line, there is an increasing awareness that the economic divides within countries and between countries have worsened. Health priorities are no longer set by countries themselves; they are often dictated by international funders and agencies.

What are our health concerns?

Despite attaining a certain degree of wellbeing, as reflected in their growth rates, much of South Asia and Africa continue to grapple with simple health issues even today. In a country of 1.1 billion we don’t even have public urinals for women (the Indian census also notes the abysmal lack of such facilities in most rural Indian homes). And without clean water, women are especially vulnerable to genital and reproductive tract infections. Such important issues are glossed over because in some South Asian countries, especially  India, the health agenda is set by the well-off and endorsed by the government.

The growing emphasis on lifestyle-related diseases and the new priority given to health tourism do not recognise the ground realities today, 30 years after the Alma Ata declaration and 60 years after Independence. Every seven minutes one woman in India dies from pregnancy-related causes. According to the third (latest) National Family Health Survey (NFHS-3) (2005-06), one-third of Indian women have a lower-than-normal body mass index; more than 56% of all women and more than 58% of rural women suffer from anaemia. Worse still, there has been an 8% increase in the prevalence of anaemia among pregnant women over the last decade, since NFHS-2 (1998-1999). Fifty children below the age of five die every half-hour. A shocking 79.2% of infants (6-35 months) are underweight, an increase of 5 percentage points since NFHS-2. Barely 26% of the millions of children under three who suffer from diarrhoea receive something as basic as oral rehydration.
 
In essence, the promises made 30 years ago at Alma Ata remain unfulfilled. Despite official declarations of a paradigm shift in health to holistic healthcare, health programmes are becoming increasingly vertical.

The AIDS programme is one such vertical programme. It is also an instance of misplaced priorities at the national and international levels.

Rather than view healthcare as a part of a holistic package of treatment that includes improving people’s nutritional status -- which itself is a function of both their purchasing power and the extent of help extended by health agencies -- the approach has focused on the problem as one of ‘access to treatment’ alone.

The burden of communicable diseases

The government does not seem to be terribly bothered about the continuing burden of other communicable diseases.

According to the WHO, approximately 988,000 Indians die of all causes, annually. About 462,000 of these die from communicable, maternal and perinatal diseases. An estimated 34,000 die of AIDS according to this report (though the source of this estimate may be debated). Respiratory infections account for 107,000 deaths.

Take the example of tuberculosis. India ranks first among the 22 high-burden countries in the world, with some 364,000 deaths annually. According to the WHO’s Global TB Report 2006, there were 1.8 million new cases in 2004, of which 5% were in people with HIV and 2.4% were multi-drug resistant (MDR) requiring very expensive treatment. The government’s revised national tuberculosis programme does not provide free treatment for MDR TB.

More than one-fifth of the burden of communicable disease is related to the basic problem of clean drinking water. Look at the impact of diarrhoea which, the WHO estimates, killed an estimated 700,000 Indians in 1999 – over 1,600 deaths each day.

Such diseases are mainly an outcome of an inaccessible and unaffordable health system and a debilitating socio-economic environment. But these diseases are not on the international radar of any funding agency or government.

There were 1.8 million reported cases of malaria last year. And this is an underestimation, as blood tests were carried out on less than 10% of people with suspected malaria. It is estimated that four people die due to malaria every day in the country. There are also the scourges of Japanese encephalitis, chikungunya and dengue. As many as 1,000 children died from Japanese encephalitis in Uttar Pradesh in two years, but these figures did not make the headlines or grab national or international attention in the way HIV/AIDS does.

While the figures for encephalitis, dengue, etc, seem irrelevant compared to tuberculosis and diarrhoea, they are important because they represent the impact of massive development programmes such as dams, which create the conditions for such outbreaks, as well as an ineffective disease control programme.

Finally, what can any health programme do when people are starving? People’s resistance to any illness depends on their immunity as well as their access to healthcare. There is enough evidence to show that the poor have less food to eat, and that the public distribution system has steadily reduced the distribution of grain per household.

Can the government provide second-line treatment?

Apart from a resurgence of many preventable diseases, the government also gets a lot of flak for refusing to guarantee second-line antiretroviral therapy (ART) to people with AIDS. Already there are reports that between 3,000 and 5,000 of those receiving ART under the National AIDS Control Programme (NACP) have become resistant to treatment.

The problem is that the government may not be entirely wrong, especially as the National AIDS Control Organisation (NACO) itself has clarified to the parliamentary committee that providing second-line ART is fraught with a number of operational difficulties and technical problems. Given the considerable difficulties encountered in reaching first-line ART to 60,000 patients, NACO felt that second-line treatment would require a far more intensive effort. It was therefore decided that second-line ART would be considered only after 100,000 people were covered under first-line ART.

Ambitious plans

The diffidence of the apex AIDS control body is understandable given the present conditions of the health system. In 2007-08, among the NACP’s priorities are: expansion of care and support and ART to cover the entire country; expansion of ART services through hospitals in other sectors like the railways, army, the public sector, corporate hospitals and NGOs; upscaling the existing 96 ART centres to 120 centres by March 2007; and providing free ART to 100,000 patients by end-2007 and to 300,000 patients by 2012. In order to improve access to safe blood, 3,070 blood storage centres will be established. Equipment for these centres will be provided through the National Rural Health Mission; NACO will provide training and annual recurring grants as well as facilities for transporting blood to storage centres. There are also plans to extend integrated counselling and testing centres and basic service facilities at the community health centre (CHC) level to ensure access to the rural population.

Will the National Rural Health Mission change things?

In 2004, the United Progressive Alliance government launched the National Rural Health Mission (NHRM) with a promise to undertake a paradigm shift in its approach to healthcare. The NRHM was launched in April 2005. This was preceded by feedback from, and interaction with, public health activists. The second phase of the reproductive and child health (RCH) programme, the flagship programme under the NRHM, commenced on April 1, 2005, with a focus on seven empowered action group (EAG) states and northeastern states, with a special emphasis on rural healthcare. The EAG states are those states showing weak socio-economic indicators.

Infant mortality rate (IMR) is the most significant indication or measure of the overall health and socio-economic condition of a society. But, three years after the launch of the NRHM, at least 10 states (including the seven EAG states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh as well as Assam, Haryana and Jammu and Kashmir) have not been able to achieve the goals related to IMR. Nor have they been able to reach the goals on maternal mortality rate (MMR) or total fertility rate for 2007 under the Tenth Plan.

These facts were revealed to the parliamentary standing committee on health and family welfare, in May 2007. During 2004-05, the IMR remained stagnant at 58 per 1,000 live births. The IMR in Madhya Pradesh, Orissa, Rajasthan, Assam, Chhattisgarh, Bihar and Haryana remained higher than the national average. While the national average for institutional births is itself low, at 40.7%, in many states it hovers between 20% and 30%. Similarly, while the average number of women receiving antenatal care showed a slight improvement between NFHS-2 (1998-99) and NFHS-3 (2005-06), in many states it ranged from 30% to 40% with Bihar and Uttar Pradesh at the bottom, at 16.9% and 26.3% respectively.

The parliamentary committee observed that despite adequate funds in the RCH programme, funds to bring down the IMR during the Tenth Plan remained unspent. Most underdeveloped states (including Chhattisgarh and Orissa) and Assam have done poorly under the RCH I programme and have continued to do poorly under the RCH II programme as well. Interestingly, under the Janani Suraksha programme intended to boost institutional deliveries by giving incentives to the mother (in EAG states, Rs 1,400 is given while it is Rs 700 in other states and union territories), these incentives are given only for the first two children and not to women delivering their third child in a hospital. This is ironical given that the objective of the programme was to reduce the IMR and MMR by encouraging safe deliveries; instead, the focus has been on population control.

Infrastructure woes

The new initiatives planned under the NACP for 2007-08 are laudable, but a critical look at the present status of the National Rural Health Mission reveals that it will take some time for these initiatives to fructify as the basic infrastructure is not in place. One of the main aims of the NRHM was to strengthen the primary healthcare infrastructure and promote effective service delivery of healthcare. If one uses infrastructure norms based on 2001 population figures, there is a shortfall of 21,983 sub-centres (SCs), 4,436 primary health centres (PHCs), and 3,332 community health centres (CHCs). Many states, including some with a high prevalence of HIV, have not met the Tenth Plan targets for sub-centres, community healthcare centres and primary healthcare centres. At least 10 states, including the national capital Delhi, did not set up a single SC, PHC or CHC during the Tenth Plan period till March 2006.

Of the 144,988 functional sub-centres, the building status of only 144,171 was provided to the parliamentary committee. There is no information on the status of sub-centres set up in Arunachal Pradesh, Meghalaya and Delhi. Buildings are yet to be constructed for at least 68,848 sub-centres whose existence is marked only on paper. There is also a tremendous shortfall in the number of functional PHCs and CHCs. Of the 22,669 functional PHCs, the building status of 85 functional PHCs in Arunachal Pradesh was not known. Of the 3,910 functional CHCs, the status of 31 functional CHCs in Arunachal Pradesh and 126 CHCs in Punjab was not known.

According to the Rural Health Infrastructure Bulletin for 2006, 21% of sanctioned posts for doctors are vacant, 39% of PHCs have no lab technicians and 18% have no pharmacists. More than 54% of all sanctioned CHC posts were vacant. Of the sanctioned posts for specialists, 59.4% for surgeons, 45% for obstetricians and gynaecologists, 61.1% for physicians and 53.85% for paediatricians were vacant. There was a shortfall of 70.2% of specialists at the CHCs compared to the requirement for existing infrastructure on the basis of existing norms. The department of health admitted to the parliamentary committee on health that the shortage of health functionaries as well as poorly staffed primary healthcare centres was one of the “major causes of such a baleful condition of maternal and child indicators in the EAG states”. With 80% of medical colleges in the private sector, and concentrated in five states where students pay huge capitation fees for admission, health priorities can never be in favour of the poor.

Thus, with the NRHM failing to set in place even its basic objectives, one wonders how it will meet more ambitious targets such as providing equipment for blood storage centres as envisaged under the NACP.

Funding

A look at funding for HIV suggests that priorities are indeed skewed. While allocation for the National AIDS Control Programme in the 2007-08 budget is Rs 720 crore, only Rs 884 crore is allocated for all national disease control programmes (including the TB control programme, leprosy, trachoma, blindness, iodine deficiency disorder, and drug de-addiction control programme).

Table 1 shows the declining expenditure and budgetary allocation to some programmes as compared to the National AIDS Control Programme. For example, the National Integrated Disease Surveillance Programme provides for the surveillance of communicable diseases. Here the allocation for the year 2007-08 has actually gone down. A very marginal increase is also visible in the allocation to the overall National Disease Control Programme. Comparatively, funding for the NACP has risen steeply from the 2004-05 budget period till 2007-08. Again, not only has the expenditure for routine immunisation (this includes vaccination for six vaccine-preventable diseases -- tuberculosis, pertussis, diphtheria, polio, tetanus and measles -- to children in the 0-5 age-group and to pregnant women) gone down, but the budget allocation itself for 2007-08 has been reduced drastically as compared to the 2005-06 allocation. In contrast, the allocation for pulse polio has been increased rather disproportionately. 

According to the district-level household survey of 2002-03, only 47.6% of children and pregnant women received all six vaccines. According to NFHS-3 data, the all-India average for immunisation coverage is 43.5%, a nominal improvement from 42% in 1998-99 (NFHS-2). On the other hand, the oral polio vaccine for polio eradication has been given overwhelming importance at the cost of the immunisation programme for other diseases. While only Rs 300 crore is allocated for routine immunisation in this year’s budget, a whopping Rs 1,289 crore has been given to the pulse polio programme. In sum, there has been no significant improvement in the percentage of complete immunisation figures, and this is true across the country. In the case of Maharashtra, Gujarat and Punjab, NFHS-3 figures show a regression over NFHS-2 levels; states like Uttar Pradesh, Bihar, Jharkhand, Rajasthan, Nagaland and Arunachal Pradesh hover at between 20-35% of full immunisation levels.

While the allocation for routine immunisation has been going down, even these reduced allocations are not utilised. Personnel vacancies for auxiliary nurse midwives and district immunisation officers add to the problems of an inadequate infrastructure and are important reasons for the low rates of immunisation.

Certainly one can argue that, parallel to the increase in interest in and funding for the HIV/AIDS programme, there has been a decline in the attention and funding given to other diseases. It may also be reasonable to argue that the latter trend is a result of the former trend. Public health professionals working in the area of immunisation have conceded that the single-minded focus on the vertical programme of polio eradication through the pulse polio campaign, using the oral polio vaccine, has had an impact on immunisation levels of other vaccine-preventable diseases. One obvious reason for this is that the entire immunisation programme focuses on polio alone, and there are anecdotes of parents in remote areas who are aware of polio immunisation but whose children have not received other vaccines that could save them from disability and death.

In a similar manner, the single-minded focus on HIV/AIDS as a vertical programme has its impact on the availability of healthcare for other illnesses. This is not only because of the reduced funding for other diseases but also because the public health infrastructure that has been weakened over the years is unable to implement the AIDS programme while also doing the little that it can to prevent and treat other illnesses. So, for example, district hospitals are given the job of providing antiretroviral drugs, but without the additional personnel. Sometimes, antiretroviral drugs may be available, even as basic antibiotics, anti-rabies vaccines and snake venom antidotes are unavailable at primary health centres.

Conclusion

While HIV/AIDS is certainly a concern for us, it is not our only priority and we cannot focus on it at the cost of other visible challenges to public health. For the silent majority, healthcare is still about clean drinking water, adequate nutrition, proper sanitation and a secure income. Their main aspiration is to lead the bare minimum of what constitutes a decent existence.

TABLE 1

Selected heads of expenditure of central government (department of health and family welfare)

  2004-05 2005-06 2006-07 2007-08
  Budget Revised Budget Revised Budget Revised Budget
National AIDS Control Programme 232 422 476.5 476.5 636.7 636.7 719.5
National Mental Health Programme 30 30 36 36 45 40 58
Public Health Education - - 12.51 12.51 16.46 18.79 19.05
      NATIONAL RURAL HEALTH MISSION
National Disease Control Programmes              
National Vector-Borne Disease Control Programme 242.45 265.45 319.16 309.38 345.22 352.95 368.4
National TB Control Programme 115 129 166.39 166.39 184.17 206.5 249
National Leprosy Control Programme 53 40.84 38.57 25.82 38.25 35.41 34.65
National Trachoma and Blindness Control Programme 85 85 86 86 81 98.39 126
National Iodine Deficiency Disorders Control Programme 7.5 7.5 11 11 14 14.17 24
National Integrated Disease Surveillance Programme     80 50 93 33.36 72.01
National Drug De-addiction Control Programme - - - - - - 10
Total  (National Disease Control Programmes) - - 701.12 648.59 755.64 740.78 884.06
Reproductive and Child Health Project - - 267.25 32.85 235.88 5.27 196
Routine Immunisation - - 472.6 155.82 326.5 266 300.5
Pulse Polio Immunisation - - 832 806.83 1,004 1,006.72 1,289.38
Total (National Rural Health Mission) - - 6,508.05 6,075.17 8,141.9 7,190.37 9,839.08

Source: Expenditure Budget, Volume II (2005-06, 2006-07, 2007-08)

(T K Rajalakshmi is a correspondent for the Indian newsmagazine Frontline)

InfoChange News & Features, January 2008>