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Three by Five sparks 'paradigm shift' in India...Or does it?

By T K Rajalakshmi

In December 2003, the Indian government declared a strong policy-cum-programme commitment to provide free ARV treatment to 100,000 AIDS patients. But important issues related to the creation of a conducive atmosphere for AIDS patients, confidentiality and the creation of a health infrastructure within the public health system have still to be addressed

The new government in India, led by a centrist-left formation called the United Progressive Alliance, says it is serious about health.

It has recently announced plans that include:

  • Increasing public spending on health from the current 0.9% of Gross Domestic Product to 2-3% over the next five years;
  • A focus on primary health care;
  • Stepping up public investments in programmes to control all communicable diseases and providing "leadership to the national AIDS effort"; and
  • Making life-saving antiretroviral (ARV) drugs available at reasonable prices.

But critics say much more than promises are needed if decent health care is to be delivered to all Indians, some 80% of whom live on two dollars or less a day.

The Jan Swasthya Abhiyan (JSM, or People's Health Movement), a campaign led by a group of health professionals, says that healthy living conditions and access to quality health care for all citizens are not only basic human rights but also essential prerequisites for social and economic development.

At present, the government's health statistics make for dismal reading.

Infant and child mortality claims the lives of 2.2 million lives every year (a 1983 target to reduce the infant mortality rate to less than 60 per 1,000 live births remains unrealised). More seriously, the rate of decline in infant mortality, which was significant in the 1970s and 1980s, slowed down in the 1990s.

Maternal mortality has jumped from 424 deaths per 100,000 live births in the 1990s to 540 per 100,000. Nearly half a million Indians die of tuberculosis every year as the nation witnesses a disturbing resurgence of communicable diseases such as Kala Azar, Dengue, Encephalitis and malaria.

"Environmental and social dislocations combined with weakening public health systems have contributed to this resurgence," the JSA says.

The public health infrastructure has been unable to keep up with this situation. While health care facilities have grown substantially since the 1990s, they are mostly in the private sector - often beyond the reach of the poor. According to the Central Bureau of Health Intelligence at the Ministry of Health and Family Welfare, the private sector accounted for 57% of the 11,174 hospitals that existed in 1991. In 2000, however, the proportion of privately-run hospitals grew to 75% of a total of 18,218 hospitals.

Only 17% of all health expenditure is borne by the government, which makes India's health sector one of the most privatised in the world. The World Health Organization standard for expenditure on public health is 5% of GDP. India's 0.9% expenditure of GDP is less than the average for poor countries - 2.8%.

Some critics say India's health took a knock in the 1990s - the era of economic liberalisation, when stagnant public health budgets and decreasing government expenditure in public health facilities were worsened by the introduction of user fees at various levels of public health facilities.

Now, a new initiative by the WHO and UNAIDS - the United Nations agency on HIV/AIDS - to increase access to ARV drugs to 3 million HIV/AIDS patients around the world by 2005 has galvanised the government and public opinion.

The so-called Three by Five initiative, launched in September 2003, has led to what the government's National AIDS Control Organisation (NACO) calls a "paradigm shift."

Until 2003, India's AIDS policy did not support the provision of ARV treatment through the public health delivery system.

After the Three by Five initiative the then health minister Sushma Swaraj declared a strong policy-cum-programme commitment to provide free ARV treatment to 100,000 AIDS patients. This began in April 2004. Government hospitals were to provide treatment in six high-prevalence states, and within them to three vulnerable groups: HIV-positive mothers; HIV-positive children below the age of 15 years; and AIDS patients who seek treatment in government hospitals.

The number of patients who had received ARV treatment till June 10 was 874.

NACO project director Meenakshi Datta Ghosh says: "A first line regimen of fixed-dose combinations of three ARV drugs is being promoted with a lot of effort by NACO. The pharmaceutical industries have reduced the cost of ARV drugs which on an average cost approximately Rs 10,000 ($222) per patient per year."

Datta Ghosh says the government acknowledges that scaling up ARV treatment should not be at the expense of prevention activities: "We have to mobilise additional resources for the expansion of the treatment programme without slowing down our efforts towards the prevention of the spread of HIV infection."

Current official estimates are that there are 5.09 million HIV-infected people in India - up from 3.58 million in 1998, 3.72m (1999), 3.86m (2000), 3.97m (2001) and 4.58m (2002).

"These figures are a cause of increasing concern to the government because people infected with HIV during the 1980s and 1990s will progress to AIDS, resulting in a steep increase in the number of AIDS patients," admits Datta Ghosh.

Today access to treatment has become the subject of a major debate in India, fuelled by a public interest litigation filed in India's highest court last August demanding treatment for HIV/AIDS patients and provision of infrastructure.

Shruti Pandey, a lawyer working for the human rights group that filed the petition, says: "Our principal prayer was that the government should provide ARVs within the public health system and create an infrastructure, as sticking to the regimen is important."

But the government's position, Pandey says, is ambiguous: "It has not spelt out measures on how it plans to maintain confidentiality and manage toxicity (of drugs) and neither is it clear on how they plan to raise the resources."

"Where are the attempts to build a conducive atmosphere for AIDS patients?" asks Pandey. "Everyday, we hear of some instance of discrimination against HIV-positive people. They are being treated like untouchables. Their right to employment is being denied and the orphaned children are not given any support."

These are urgent questions in India, which, along with China, is expected to emerge as the biggest Asian AIDS hot-spot in the coming years.

"Ninety-five per cent of people with AIDS are poor, and most of them do not even know about the first line regimen," says Ricki Tombing from the state of Manipur - one of the six focus states in the government's AIDS strategy.

"Either the government should get fully involved or it should get NGO counsellors to assist the patients as they are more sensitive. Government counsellors at testing centres only fill up forms."

Tombing, a former drug user, was diagnosed with HIV three years ago. "In 2002, when I went for a second test, the counsellor who filled up the form asked me how many sexual partners I have had. I told him and he ticked the column saying 'sex workers'. He assumed - wrongly - that I had visited sex workers," he said, pointing to only one of many common biases in India.

Amit Sen Gupta of the JSA says the government cannot go on using the plea of lack of infrastructure when it comes to treatment issues.

"This is a pernicious argument. If there are no treatment facilities, even detection will become difficult," Sen Gupta, a critic of privatisation, says. The new government, he adds, should spell out exactly how much it plans to spend each year on health.

Most of all, argues the JSM, there needs to a "pro-poor bias" in India's health policy, including access to AIDS treatment.

"Entering into a system of targets where people are just numbers and health care a convenient jargon is not going to do anyone any good," says Sen Gupta. "Health programmes need to be integrated within the primary health care system with decentralised planning, decision-making and implementation with the active participation of the community. The top down approach has to go."

It's the one 'paradigm shift' that the majority of Indians are yet to see.

(TK Rajalakshmi is a correspondent for the Indian newsmagazine , Frontline)

Panos Features, July 2004