The Global HIV/AIDS Epidemic- a Time Line of Key Milestones

Status, Prospects and Challenges to Private Sector & Public Private Partnership (PPP) models in combating the HIV/AIDS in India

(Draft)

For

World Bank Institute

Anurag Sinha (MPA, 2006)

School of International and Public Affairs

Columbia University

May 2006

ACKNOWLEDGEMENTS

I am deeply indebted to my faculty adviser, Professor William B. Eimicke, Director, Picker Center of Executive Education, SIPA for his continuous support, patience and guidance. I am grateful to the World Bank Learning Institute for providing me a wonderful opportunity to undertake this study. I wish to thank Professor Cristian Pop-Eleches for his suggestions and guidance.

I want like to express my gratitude to Ms Debpriya Sen (Indian Business Trust for HIV/AIDS, Confederation of Indian Industry), Dr. Homyar K. Gardin, Convener Core Group – AIDS, Tata Steel Industries, Mr. Shadab (FICCI Socio Economic Development Foundation), for providing useful information on private sector initiatives to combat HIV/AIDS. My Special thanks to Mr. Michael Kaplan (Futures Group Center for HIV/AIDS) for sharing useful documents regarding workplace policy on HIV/AIDS

Last, but not the least, I would like to thanks the CCSRN - Columbia Corporate Social Responsibility Network and its key representatives Ms Nadiya Satyamurthy, Ms Christine Chase and Ms Sanjana Khoobchandani for coordinating the research program.

Anurag Sinha

05/01/2006

TABLE OF CONTENTS

Acronyms and Abbreviations

ACHAP: AFRICAN COMPREHENSIVE HIV/AIDS PARTNERSHIPS

AIDS: ACQUIRED IMMUNE DEFICIENCY SYNDROME

ART: ANTI RETROVIRAL THERAPY

CII: CONFEDERATION OF INDIAN INDUSTRY

DAVP: DIRECTORATE OF AUDIOVISUAL PUBLICITY

DFID: DEPARTMENT FOR INTERNATIONAL DEVELOPMENT

FICCI: FEDERATION OF INDIAN CHAMBERS OF COMMERCE AND INDUSTRY

GDP: GROSS DOMESTIC PRODUCT

GFATM: GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA

HIV: HUMAN IMMUNODEFICIENCY VIRUS

IAVI: INTERNATIONAL AIDS VACCINE INITIATIVE

ICMR INDIAN COUNCIL OF MEDICAL RESEARCH

IEC: INFORMATION EDUCATION AND COMMUNICATION

IDU: INJECTING DRUG USERS

IMR: INFANT MORTALITY RATE

MMR: MATERNAL MORTALITY RATE

MSM: MEN WHO HAVE SEX WITH MEN

NACO: NATIONAL AIDS CONTROL ORGANIZATION

NGO: NON GOVERNMENTAL ORGANIZATIONS

NFHS: NATIONAL FAMILY HEALTH SURVEY

NARI: NATIONAL AIDS RESEARCH INSTITUTE

NCERT: NATIONAL COUNCIL OF EDUCATION RESEARCH & TRAINING

NSS: NATIONAL SERVICE SCHEME

PLWHA: PEOPLE LIVING WITH HIV/AIDS

PMTCT: PREVENTION OF MOTHER-TO-CHILD TRANSMISSION

PPP: PUBLIC PRIVATE PARTNERSHIPS

STD: SEXUAL TRANSMITTED DISEASES

TRC: TUBERCULOSIS RESEARCH CENTRE

TRG: TECHNICAL RESOURCE GROUP

UNDP: UNITED NATION DEVELOPMENT PROGRAM

UTA: UNIVERSITY TALKS AIDS

VCT: VOLUNTARY COUNSELING AND TESTING

UNAIDS: UN JOINT PROGRAMME ON HIV/AIDS

USAID: UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT

WHO: WORLD HEALTH ORGANIZATION

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Executive Summary

This paper presents the findings of an independent research project carried out for the World Bank Institute. The study seeks to analyze the status, prospects and challenges to private sector involvement and public private partnerships in combating HIV/AIDS in India. The study is primarily based on an exhaustive literature survey of reports, concept papers and publications. Electronic interviews were conducted with representatives of corporate houses and industry coalitions

HIV/AIDS has been recognized as the most formidable disease to confront modern medicine, with the potential to undermine the massive improvements that has been made in global health in the last hundred years. According to National AIDS Control Organization of India, there are around 5.1 million people living with HIV/AIDS in 2003. India has the second highest number of people living with HIV/AIDS in the world after South Africa.

Experts point out that there is no one single epidemic in India. Instead there are numerous sub epidemics which are localized in nature reflecting the diverse socio-cultural reality of the country. High poverty rate, skewed gender relations, cultural myths coupled with lack of awareness as well as large scale migration have provided the fuel for the rise of HIV/AIDS in India.

A National AIDS committee under the Ministry of Health & Family Welfare was formed in 1986, after first cases of HIV infection were reported amongst sex workers in Chennai in the Indian state of Tamil Nadu. The government of India launched National AIDS Control Program in 1987 with the initial focus on public awareness, screening blood banks in urban centers and surveillance activities. Later, National AIDS Control Organization (NACO) was established in 1992 with the mandate to reduce the spread of HIV infection in India and to strengthen capacities for coordinated response. State AIDS control societies were also formed in all the 32 states and Union Territories, as well as 6 big cities, to build local capacities to respond to the HIV/AIDS crisis.

The government adopted the National AIDS Policy in 2001 with the goal of containing infection levels, creating enabling environment for individuals and families affected with HIV/AIDS and improving services for People living with HIV/AIDS. India has received funding and technical assistance from various bilateral and multilateral agencies including World Bank, UNAIDS, WHO, USAID, DFID. Several of these agencies have been involved in supporting initiatives both at the national and state levels. Hundreds of NGOS in India have been leading the response to HIV/AIDS at the grassroots level. At a more macro level, several NGOs have been also been involved in advocacy and have been influencing the resource allocation of NACO and bilateral agencies.

The private sector in India is extremely diverse. This study differentiated the private sector into two broad categories a) Private Health Service Providers b) Private Sector enterprises to analyze their role and response to the HIV/AIDS crisis. The private health sector in India has grown, without much state support, as direct fallout of the failure of the public sector to meet the health needs of the people. The private sector accounts for 82% of the overall health expenditure in the country and 4.2% of the GDP as opposed to public sectors’ curative and health services which accounts for mere 0.9% of the GDP. While, private sector health care is almost ubiquitous in India, there is a huge variation in the quality of services offered. There has been a surge in corporate social responsibility activities, including HIV/AIDS prevention and care activities, by the prominent business houses Industry coalitions like Confederation of Indian Industry (CII) and Federation (FICCI) have been also been at the forefront of the private sector response to HIV/AIDS. However, there are huge gaps between the responses of formal and informal sectors.

Public Private Partnerships have gained ground as a new mechanism to deliver services and develop infrastructure through collaboration between public and private sector. The idea of public private partnership represents a shift from an approach where the public sector and the state were solely responsible for delivery of basic services and developing infrastructure. The approach calls for a greater role of the private sector in delivery of service, while the public sectors play a supervisory and regulatory role. A strong case for public private partnerships in the health sector in India could be made by the fact that the government has not been able to mobilize adequate resources and personnel to address health challenges in India.

There have been few private public collaborative efforts with regards to HIV/AIDS in India. These efforts include NACO’s collaboration with business coalitions, like CII, and ILO to promote HIV/AIDS work programs. Several private companies have also been using resources and materials developed by NACO for their workplace programs.

CII had been also been involved in mobilizing corporate sector participation in the Government led national program for enhancing drugs availability, diagnostics facilities, care & support facilities for antiretroviral therapy.

Partnerships in strengthening surveillance systems would be useful as existing national HIV/AIDS surveillance data is collected only from public sites. Partnerships in information dissemination holds tremendous potential as the private sector workplaces can form important settings for providing reliable information on HIV/AIDS prevention. Partnerships could also be fostered in the area of drug provisioning. While, public private partnerships offer tremendous opportunities for collaborative action, there are several challenges owing to basic differences in the partnering organizations. These challenges become all the more critical in the case of HIV/AIDS as any sub-optimal arrangement has the potential of aggravating the crisis. Some of these challenges relate to:

Partnership issues: Inherent contradictions remain in public and private partnerships, giving the differences in the organizational values, purposes and structures of the two sectors.

While arriving at a common vision would be essential for fostering such partnerships, it becomes difficult due to differing motives and imbalance in power relations.

Absence of contractual and regulatory frameworks: Existing laws are inadequate and obsolete to regulate practices of laboratories, polyclinics, diagnostic centers and other types of health care centers. The enforcement mechanisms are extremely weak and existing laws do not get enforced.

Inadequate Monitoring mechanism and Quality Control systems: The poor quality of services offered by private health providers is clearly linked to the absence of adequate monitoring mechanisms and quality control systems.

Policy Recommendations

Recommendations comes with a caveat that there are no off- the- shelf solutions as partnerships needs to be built based on the local contexts. Given the limited experience of developing such partnerships, it would be important to adopt a gradual and iterative process.

The specific policy recommendations are with regard to:

Regulatory Mechanism

The government needs to set-up appropriate regulatory and policy frameworks, in consultations with various stakeholders.

Decentralized Schemes and Inter-department coordination

Development of decentralized schemes, providing substantial responsibilities and resources to state and local government, would ensure better coordination at the field level.

Integrating HIV/AIDS interventions with other health issues

While HIV/AIDS is a major concern for India and HIV/AIDS interventions have special requirements, it is important to integrate interventions with other public health challenges.

Tri- Sector Partnerships

Non Profit organizations, with their inherent strengths in community mobilization and public advocacy could play an extremely vital role in preventive activities, awareness generation, counseling and advocacy.

Engaging with Prominent Private sector companies/Business Houses

Public private partnerships models could be fostered to:

§  Develop a National Fund to finance research for vaccines and medicines.

§  Develop and maintain a broad based national surveillance system to regularly gather and analyze information on HIV/AIDS in India

Engaging with Medium/Small Scale Enterprises/ Informal Sector

New laws should be enacted regarding compulsory workplace policy and it should be enforced and monitored by relevant ministries dealing with these enterprises.

Engaging with private health care sector

The private health care sector could be involved in numerous incentive based partnerships-

§  Private sector laboratories, diagnostic centers should be involved in screening and testing services,

§  Private practitioners and private hospitals should be given the role of treatment provider. Quality guidelines need to be developed for these providers. Accreditation and monitoring systems need to be devised to monitor performance.

Chapter 1: Introduction

HIV/AIDS has been recognized as the most formidable disease to confront modern medicine, with the potential to undermine the massive improvements made in the last hundred years in global health. In June 2001, Heads of State and Representatives of Governments met at the United Nations General Assembly Special Session to acknowledge that the AIDS epidemic constitutes a “global emergency and one of the most formidable challenges to human life and dignity”.

The history of the epidemic[i] began in 1981, when the United States Centers for Disease Control and Prevention issued its first warning about a relatively rare form of pneumonia, later diagnosed to be AIDS related, among a group of men in Los Angeles. In the subsequent years, the HIV virus was isolated and the term Acquired Immune Deficiency Syndrome (AIDS) was formally recognized. Since that time, more than 60 million people have been infected with HIV worldwide, including 40 million estimated to be living with HIV/AIDS today. The disease has killed more than 25 million people, since it was recognized in 1981, making it one of the most destructive epidemics in human history. The UNAIDS AIDS epidemic Update 2005[ii] estimates that 40.3 million (36.7–45.3 million) people are presently living with HIV and that there were 4.9 million (4.3–6.6 million) people who were infected with HIV in 2005. The number of people living with HIV has increased in all regions, except Caribbean in the last two years. Sub-Saharan Africa remains the worst affected and is home to 25.8 million [23.8–28.9 million] people living with HIV/AIDS in 2005 and has an adult prevalence rate of 7.2%. The disease is assuming epidemic proportions in the South and South East Asia region as there are 7.4 (4.5-11) million people living with HIV/AIDS.

India-A study in contrast

India is the world’s largest democracy with a population of more than a billion people. The second most populous country in the world, it contributes to 20% of all global births[iii]. The economy of India is the fourth largest in the world as measured by purchasing power parity, with a GDP of US $3.36 trillion. Despite witnessing one of the fastest economic rates in the world since the 1980s, more than quarter of population still lives below the official poverty line. The country has the highest concentration of poor people in the world. According to the latest census[iv] in 2001, the literacy rate at 65.38% is characterized by huge gender gaps with male literacy (75.85%) being more than 20 percentage points higher than female literacy (54.16%). Bias against women and girls is clearly evident in the demographic ratio of 933 females for every 1,000 males.

Though life expectancy at birth has more than doubled in the last fifty years from around 30 years at the time of independence (1947) to over 60 years in 1992-96, the infant mortality rate remains high at 63 per 1000 births in 2003. Maternal mortality continues to be a major cause of concern with an extremely high rate of 540 per 100,000. Leprosy, tuberculosis, malaria and other preventable diseases also account for 470 deaths per 100,000. Despite serious health concerns, India is one of the five countries in the world with public spending on health being less than 0.9 percent of GDP