International donors are driving India's national health agenda in the wrong directions, says a growing movement of Indian health policy experts and nongovernmental organizations (NGOs). For example, although AIDS mortality is still low in the country, there is an excessive focus
on HIV/AIDS prevention, with little linkage to primary treatment, they say. Meanwhile, grassroots concerns and larger immediate public health needs are being ignored, they claim.
The recent visit of the Microsoft tycoon Bill Gates, with his US$ 100 million grant for AIDS prevention in India, sparked the debate. At that time, the view of the Government of India and part of the Indian media was that they should not "look a gift horse in the mouth". Public health experts, however, argued that this was a myopic approach that failed to recognize grassroots reality.
Alka Gogate, director of the Mumbai AIDS Society, says that those who have direct contact with this reality recognize the importance of ensuring that AIDS funds are used to strengthen general health services, even while ensuring care and support for AIDS patients. There have been several meetings on this issue with the deans of public hospitals in the city, she said. She claimed that it was "well recognized" that if primary health services were neglected, the huge load of infectious disease patients would be pushed onto the city's tertiary services--which cannot cope with this pressure.
The top killers in India were classified in the 1994 survey of the Indian Registrar General as: "senility or old age" 21.2% (1.8 million); "cough" 19.3% (1.6 million); "circulatory disease" 11.2% (940 000), and "causes peculiar to infancy" 9.6% (810 000).
The epidemiology of HIV/AIDS in India has recently generated heated controversy between the Government of India and international agencies. India urgently needs a new system of disease surveillance, according to Anish Mahajan, AIDS researcher with a Chennai-based AIDS support group and Brown Medical School in the US. The present system extrapolates data from high-risk groups, and has no community-based information from the private sector--which is the country's largest health provider.
The National AIDS Control Organization (NACO) estimates that four million people suffer from HIV infection in India. AIDS is not reported as a cause of death in the death registers, but NACO states that between 1986 and November 2002 there were 42 411 cases of full blown AIDS in the country. NACO also claimed that the epidemic is now plateauing because of its efforts. Others are sceptical, and reliable data, that all sides can agree, are urgently needed.
As for finance, according to the Central Government's Expenditure Budget for 2000-01, India's health and welfare budget was some USS 1.2 billion. The disease control programme received some US$ 170 million, around 14% of this. AIDS and sexually transmitted diseases got some US$ 30 million, 2.5% of the health and welfare budget.
But the current donor interest in HIV/AIDS in India is boosting HIV/ AIDS spending by approximately an additional US$ 80 million a year, causing spending on this one disease to reach US$ 110 million a year, thus making HIV/AIDS the main target of India's spending on disease control. …