Systemic ills

Print edition : August 24, 2007

Aids patients and activists demonstrate in New Delhi on December 1, World AIDS Day, asking the government to ensure supply of second-line AIDS drugs.-V.V. KRISHNAN

Preoccupied with AIDS control, government and funding agencies gloss over other health priorities.

Aids patients and

It was a revelation of sorts when, on July 6, Union Minister for Health and Family Welfare Anbumani Ramadoss, along with experts from the National AIDS Control Organisation (NACO) and the UNAIDS, declared that India now had fewer than half the number of human immunodeficiency virus (HIV) cases estimated earlier. The latest figures show that 2.5 million people were infected with the virus; two earlier estimates put the number at 5.2 million and 5.7 million. The prevalence rate of HIV, too, came down to 0.3 per cent from the previous 0.9 per cent. The announcement coincided with the launch of the third phase of the National AIDS Control Programme (NACP), which would extend until 2012 and for which an allocation of Rs.11,585 crore has been made.

The numbers game began in early 2002 following a United States National Intelligence report that there would be 20-25 million HIV infections by 2010 in India (Frontline, November 23-December 6, 2002). The same year, the Indian gover nment got a $100 million largesse from the Bill and Melinda Gates Foundation. Surprisingly, international donor agencies and a section of non-governmental organisations (NGOs) seemed to want the projections to remain so despite NACO insisting there was a slowdown in HIV infections.

The climbdown in the latest figures has therefore been more startling as only last year did the UNAIDS announce that the country had 5.7 million HIV infections, a figure higher than South Africas. The Indian government promptly rejected it, but supported an earlier estimate of 5.2 million HIV cases in a population of 1.1 billion. The latest figures bring India to the third position after South Africa and Nigeria in the number of HIV-infected in the world.

Both the earlier estimates, 5.2 million and 5.7 million, were based on tests done on pregnant women, intravenous drug users and other high-risk groups visiting the surveillance centres. In 2005, a major debate ensued after Richard Feacham, chief of the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria, said that the number of people with HIV/AIDS in India had exceeded those in Africa. He put the figure at 8.5 million. The Indian government and the UNAIDS maintained that it was 5.134 million, a figure endorsed by the World Health Organisation (WHO). Such was the brouhaha over the correct figures that a former Health Minister, C.P. Thakur, said he was exasperated to find different estimates by different U.N. agencies.

The current figures have been arrived at not just from data in the 1,122 NACO sentinel surveillance sites but also from the largest-ever household survey on HIV, conducted by the National Family Health Survey-III (NFHS-III). Funding for NFHS-III came from donor agencies such as the United States Agency for International Development (USAID), Department for International Funding (DFID) of the United Kingdom, Bill and Melinda Gates Foundation, the United Nations Childrens Fund (UNICEF), the United Nations Population Fund, and the Government of India. The National AIDS Research Institute and NACO gave assistance to the HIV component in the survey.

The UNAIDS has backed the Health Ministry and NACO in their claims that population surveys are more representative and accurate for rural areas and the male population. Some 18 research organisations were involved in conducting interviews with and collecting blood samples of more than 2.3 lakh women in the 15-49 age group and men in the 15-54 age group. More than a lakh women and men were tested for HIV and more than two lakh adults and young children tested for anaemia. Random blood samples were collected from people in 29 States.

At least some people doubt the representative character of the sample. But, in fact, the NFHS-III covered Uttar Pradesh, one of the largest States in the country, and the five high-prevalence States of Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu and Manipur. Data were collected in two phases for the entire survey from December 2005 to August 2006.

Of course, the sample size in some States was higher than others. This was because of sample size adjustments required to meet the HIV prevalence estimates for the high-prevalence States, and for slum and non-slum areas in select cities. NACO Director-General Sujatha Rao told Frontline that since most of the donors themselves were involved in funding the study, there seemed to be little objection from at least those quarters.

People queueing up for dengue screening at the All India Institute of Medical Sciences in New Delhi in October 2006.-V.V. KRISHNAN

People queueing up

Even as the NFHS-III survey was on, a population-based study of Guntur district in Andhra Pradesh by Lalit Dandona, a former professor of Health Studies Area, Centre for Human Development, Administrative Staff College of India, Hyderabad, demonstrated that the official method used in India to estimate the number of HIV cases had led to the three-fold increase in estimates. The method was to extrapolate the annual sentinel surveillance data from large public sector antenatal and sexually transmitted infection clinics.

The Guntur study reduced the 2005 official sentinel surveillance-based HIV estimate of 3.7 million (15-49 age group) in four major States (Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu) to 1.5 to two million. Based on this, the total estimate of 5.2 million came down to 3-3.5 million. Yet, this was higher than the NFHS-III estimates.

According to Sujatha Rao, similar community-based studies done in other countries have shown a lowering of estimates. She said that in India it showed a drastic reduction because HIV was not a generalised epidemic but confined to certain sections. She added that Dandonas estimates could not entirely be correct as the groups where HIV was most prevalent would not be in the general population. An MSM (man seeking sex with man) is not going to admit to the surveyor and before his family that he has sex with men, she said. Similarly, it is also difficult to capture the [sexual] behaviour of migrant workers.

Sujatha Rao said NACO had decided to do a community-based surveillance in 2004. We got experts from outside as well, and they took estimates from both sentinel and household surveys. We had some other data like the behavioural surveillance data on sex workers, she said.

While Sujatha Rao is clear that the NFHS data are absolutely sound, she is somehow cautious about underplaying the disease burden of HIV. We do not say that the prevalence is 1 per cent. It is still 0.9 per cent, she said, reiterating the old prevalence rate that corresponds to the 5.2 million figure. She added that the reduced estimates would not result in any slackness in the third phase of the National AIDS Control Programme (NACP-III). The success of NACP-III, however, will depend on the overall health infrastructure, which sadly is far from satisfactory.

While the reduced estimates of HIV infections may be a cause of jubilation among sections within the government and disappointment for those seeking to benefit from the inflated figures, the government seems to be glossing over the increased prevalence of vector-borne diseases that are far more serious than HIV/AIDS. There is even a National Council on AIDS headed by the Prime Minister with Chief Ministers of select States and representatives of 30 ministries, the private sector and the NGOs as its members. But the government does not seem to be bothered about the resurgence of several diseases which are mainly the outcome of an inaccessible and unaffordable health system and a debilitating socio-economic environment. Neither are these diseases on the radar of any funding agency.

There were 1.8 million reported cases of malaria last year and the blood examination rate was less than 10 per cent. It is estimated that on average, four people in the country die of malaria every day. In addition to this are cases of Japanese encephalitis, chikungunya and dengue. Though a thousand children died of Japanese encephalitis in Uttar Pradesh in the past three years, these figures never made headlines the way HIV/AIDS did in the same period. The government has set up a national disease surveillance system to monitor the spread of epidemics but has kept chikungunya and Japanese encephalitis out of its ambit.

The skewed priorities are obvious. The allocation for the NACP in the current Budget (2007-08) is Rs.719.5 crore; the total allocation for all the national disease control programmes, such as those for tuberculosis, leprosy, trachoma, blindness, and iodine-deficiency disorder, and the drug de-addiction control programme is only Rs.884.06 crore.

Of equal concern is the neglect of routine immunisation programmes for infants and pregnant women to control six vaccine-preventable diseases. According to the district-level household survey of 2002-03, the immunisation coverage in the country was only 47.6 per cent. The NFHS-III data say the all-India average is 43.5 per cent, which is a nominal improvement from the 42 per cent in the NFHS-II in 1998-99. Polio immunisation has been given overwhelming importance; while the allocation for routine immunisation is only Rs.300.5 crore in this years Budget, it is Rs.1,289.38 crore for the pulse polio programme.

In other words, there has been no significant improvement in full immunisation figures all over the country. In the case of Maharashtra, Gujarat and Punjab, the NFHS-III figures reflect a regression in the NFHS-II levels. In States such as Uttar Pradesh, Bihar, Jharkhand, Rajasthan, Nagaland and Arunachal Pradesh, the immunisation level is between 20 and 35 per cent.

The problem is as much of misplaced priorities as of resources. Even the reduced allocation is not utilised. Then, there are the unfilled vacancies of auxiliary nurse midwives (ANMs) and district immunisation officers. This despite the fact that one woman in India dies every seven minutes because of maternity-related problems, and 50 children under five die every 30 minutes.

According to the NFHS-III data, one-third of all women in India have a body mass index lower than the normal, and 56.2 per cent of all women and 58.2 per cent of rural women are anaemic. There has been an increase of 8 percentage points in the number of pregnant anaemic women since the NFHS-II.

The percentage of underweight infants (between 6 and 35 months) is a shocking 79.2, an increase in 5 percentage points since the previous survey. Only 26 of 100 diarrhoea-affected children got something as basic as oral rehydration therapy (ORT) last year.

The government is also under attack for denying the second line of treatment to HIV/AIDS patients. NACO itself has clarified to the Parliamentary Standing Committee on health and family welfare that the second line of Anti Retroviral Therapy (ART) is fraught with a number of operational difficulties. After having rolled out and stabilised the first line of ART to 60,000 patients with considerable effort, NACO felt that the launch of the second line of treatment would require a far more intensive effort. It was decided that the roll-out of the second line of ART drugs would be considered only after one lakh persons were covered in the first line of ART. There were reports that of the 47,000 patients receiving ART under the NACP, around 3,000-5,000 patients had become resistant to treatment. Given the present condition of the health system, NACOs diffidence is understandable. During 2007-08, the priorities of the NACP are to extend ART services to the entire country through the hospitals in the Railways, the Employees State Insurance Corporation, the Army and public sector undertakings, and corporate hospitals and NGOs; to increase the number of existing 96 ART centres to 120 by March 2007; and to provide free ART to one lakh patients by 2007 end and three times that by 2012. To improve access to safe blood, 3,070 blood storage centres are to be established and the equipment for these centres provided through the National Rural Health Mission (NRHM). NACO will provide training and annual recurring grants as well as facilities for the transportation of blood to storage centres. There are plans to extend Integrated Counselling and Testing Centres (ICTC) and basic service facilities to the Community Health Care (CHC) centres to benefit the rural population.

The NRHM was launched in 2004 and operationalised a year later in April 2005. Three years down the line, at least 10 States including seven Empowered Action Group (EAG) States namely Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh, Assam, Haryana and Jammu and Kashmir, have not been able to achieve any of the three goals with regard to infant mortality rate, maternal mortality rate and total fertility rate (IMR, MMR and TFR respectively) 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 stuck at 58 per thousand live births. The IMR in Madhya Pradesh, Orissa, Rajasthan, Assam, Chhattisgarh, Bihar and Haryana was above the national average. While the national average for institutional births itself is low at 40.7 per cent, in many States it is between 20 and 30 per cent.

Similarly, while the overall average of women receiving antenatal care showed a slight improvement between the NFHS-II and the NFHS-III, in many States it ranged between 30 and 40 per cent; Bihar and Uttar Pradesh were at rock bottom with 16.9 and 26.3 per cent respectively.

One of the basic aims of the NRHM is to strengthen the primary health infrastructure and improve service delivery in health care. According to the 2001 population norms, there is still a shortfall of 21,983 sub centres, 4,436 primary health care centres (PHC) and 3,332 CHCs in the country.

At least nine States and the National Capital Territory of Delhi, have failed to set up a single sub centre, PHC or CHC during the Tenth Plan until March 2006. Evidently, with the NRHM failing even to put in place some of its basic objectives, it is anybodys guess how it will provide equipment for the blood storage centres as envisaged under the NACP. The Department of Health admitted to the Parliamentary Committee on health that the shortage of health functionaries and poorly staffed PHCs were the major causes of such a baleful condition of maternal and child indicators in the EAG States.

The year 2008 will mark the 30th anniversary of the Alma-Ata Declaration in which many governments made the promise of providing health for all. This was not only an expression of intent; it was a slogan underlying a serious commitment on health issues. Health was defined as the state of complete physical, mental and social well-being and not merely the absence of disease and infirmity.

Thirty years hence, there is an increasing awareness that the intra- and inter-country gaps have worsened. There is also a growing concern that health priorities are no longer set by countries themselves but often dictated by international funding agencies and others.

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