There is requirement to conduct concurrent and periodical evaluation of the AIDS Control Programmes throughout the country, so that the real financial achievements could be assessed.
|
|
Anup K. Karan
|
The National AIDS Committee was set up in the year 1986, which was the year of identification of first case of HIV infection in Chennai followed by Mumbai. Following the recommendation of the Committee, a cell on National AIDS Control Programme was instituted in 1987, whose primary objective has been to collect information through setting up epidemiological surveillance network (Sentinel) that would help assess the spread of HIV and give an account of the routes of HIV infections. In 1992 the National AIDS Control Organization (NACO) was established. NACO carries out Indias National AIDS Programme, which includes the formulation of policy, prevention and control programmes. During the same year the Government launched a Strategic Plan for HIV/AIDS prevention under the National AIDS Control Project. The Project established the administrative and technical basis for programme management and also set up State AIDS bodies in 25 states and 7 union territories. The Project was able to make a number of important improvements in HIV prevention such as improving blood safety (NACO, 2003).
The First National AIDS Control Project (NACP-I) was funded, primarily, by a World Bank IDA Credit of USD 84 million (1992-99)1. NACP-I was the first major intervention in India in the direction of HIV prevention, in order to slow the spread of HIV, and mitigate the impact of AIDS. The Second National AIDS Control Project (NACP-II), for the period November 1999- March 2004 (recently extended to March 2006), also received initial help of IDA World Bank funding. The outcomes envisaged in the NACP-II are to keep HIV sero-prevalence below 5 per cent of the adult population in high prevalence states, below 3 percent in the moderate prevalence states, and below one percent in the low prevalence state. The Targeted Intervention (TI) project aimed at interrupting HIV transmission among highly vulnerable populations is an important component of the NACP-II. The NCAP-II has already entered the last phase of its operation and it is high time to evaluate the financial provisions to fight against HIV/AIDS and the success achieved so far.
Financial provisions
Government of India takes concerted measures to combat communicable, non-communicable and other major diseases by making financial provisions as per the need for delivering primary, secondary and tertiary health care services throughout the country. Towards this purpose, several National Health Programmes are directly run by the center in consultation with respective state governments. These programmes are expected to have a bearing in the reduction of mortality and morbidity and also have salutary effect on efforts to improve the quality of life of the common man (GOI, 2003). Among the National Health Programmes, National AIDS Control Programme has begun to occupy a prominent place since the beginning of the Ninth Five Year Plan, i.e. 1997.
In the absence of any vaccine to protect the population from HIV/AIDS, preventions remain the most important tool to fight the dreaded and the probable outbreak of the epidemic. Accordingly, India is making all efforts to inform the general population, without disregarding the most vulnerable population groups, about who are the main vectors of the spread of the disease. In order to meet the objective, INR 40 billion has been spent on the two programmes ( i.e. NCAP-I and NCAP-II) since 1998. These funds came essentially from various international agencies primarily during the last decade. A break-up of the financial provisions during the Ninth Five Year Plan (1997-2002) across key National Health Programmes is presented in Table 1.
Table 1: Outlay (in INR millions) under different national health programmes during the ninth five year plan(1997-2002)
|
|
1997-98
|
1998-99
|
1999-2000
|
2000-01
|
2000-02
|
Total
|
|
Malaria
|
1430
|
2280
|
1770
|
1950
|
2210
|
9630
|
|
Tuberculosis
|
800
|
720
|
950
|
1250
|
1360
|
5080
|
|
Leprosy
|
790
|
790
|
820
|
740
|
750
|
3900
|
|
Blindness
|
700
|
750
|
840
|
1100
|
1270
|
4660
|
|
HIV/AIDS
|
1220
|
1110
|
1400
|
1450
|
2100
|
7280
|
|
All
|
4350
|
5650
|
5660
|
6700
|
7830
|
30200
|
|
Source:
GoI, 2003
|
It can be seen from Table 1 that among the major National Health Programmes, financing for HIV/AIDS stands at second position only next to Malaria. Not only the financing for HIV/AIDS has taken precedence over almost all other National Health Programmes, but also by the end of the Ninth Five Year Plan, the financial allocation to AIDS was almost equal to that of the most important programme on Malaria eradication. Over the years the financial allocation to the HIV/AIDS has recorded the highest growth (approximately 100 per cent rise during 1997-2002) among all the National Health Programmes.
It may be pointed out here that the above noted increase in the financial allocation to HIV/AIDS has been witnessed despite the fact that the allocation was far lower in comparison to the provisions made by different international agencies towards the fight for AIDS in India. A break-up the total funds made available to India to fight HIV/AIDS is presented in Table 2.
Table 2: Sources of funds allocated to combat HIV/AIDS in India (in INR million )
| Source
of Funds |
NCAP-I (1992-97) |
NCAP-II (1999-2006) |
% Contribution NCAP-II |
| IDA
(World Bank) |
3864 |
9591 |
464.6 |
| WHO |
69 |
-- |
0.00 |
| USAID |
-- |
2305.8 |
111.7 |
| DFID |
-- |
4870 |
235.9 |
| CIDA |
-- |
378.1 |
18.3 |
| AusAID |
-- |
246.5 |
11.9 |
| UNDP |
-- |
64.7 |
3.1 |
| GFA |
-- |
1227.4 |
59.5 |
| GOI |
648.6 |
1960 |
94.9 |
| Total |
4581.6 |
20643.5 |
100 |
| Source: NACO, 2002 |
As indicated in Table 2, the allocation of financial resources to fight AIDS in India witnessed sharp increase from INR 4580 million during 1992-97 (NCAP-I) to more than INR 20 billion during 1999-2006 (NCAP-II). This is also evident that among different agencies the World Bank alone contributed approximately half of the total funding to AIDS in India. The next major contributor has been Department for International Development (DFID), which contributed approximately one-fourth of the total fund and has been supporting sexual partnership projects in the states of Orissa and Andhra Pradesh. United States Agency for International Development (USAID), which is contributing up to 11 per cent of the total fund, has specific projects in Maharashtra (AVERT) and Tamil Nadu (APAC). The pattern of utilisation of funds under NCAP-II since 1999-2000 is presented in Table 3.
Table 3: Year-wise allocation and expenditure ( in INR million ) of funds under NCAP II
| Year |
Budget Estimate (BE) |
Revised Estimate (RE) |
Expenditure Incurred |
Percent utilisation |
| 1999-2000 |
1400 |
1400 |
1352.5 |
96.61 |
| 2000-01 |
1450 |
1800 |
1790 |
99.44 |
| 2001-02 |
2100 |
2250 |
2250 |
100.00 |
| 2002-03 |
2250 |
2420 |
2420 |
100.00 |
| 2003-04 |
2250 |
2250 |
2330 |
103.56 |
| 2004-05 |
2590 |
Not available |
Not available |
Not available |
| Source: Ministry of
Health, Annual Report, 2001-02 and NACO website |
For the last four years of the Ninth Five Year Plan, the budget allocated to the NACO was INR 7200 million (INR 7870 million-RE) against the total project assistance of INR 14251 million, for prevention and control of HIV/AIDS in India. The balance fund was transferred to the subsequent two years of the X Five Year Plan. This implies that of the total fund of approximately INR 20000 million, approximately two-thirds ( i.e. more than INR 13000 million) has to be spent during the last two years of the NCAP-II ( i.e. 2003-04 and 2004-05). Although NACO has been able to utilise the funds fully over the years, the allocation has not been proportional across the years and hence a large balance has been created. The broad pattern of expenditure of the allocated funds to the NACO shows that prevention has been the important component of expenditure, constituting more than half of the total fund allocated to the NACO.
Along with the major funds allocated by large international agencies, several other international institution and enterprises have also contributed to the total funds available to India to fight HIV/AIDS. The inflows of these funds have been largely periodic and irregular. For example, the Global Fund for the Fight against Malaria, Tuberculosis and AIDS allocated USD 186 million for the years 2002-2003. Parts of these funds were earmarked for the struggle against HIV/AIDS. In the same way, BBC World Service Foundation provided USD 5.25 million in aid between 2001 and 2003. The European Commission released an envelope of USD 2.02 million. And in December 2003, the Bill Gates Foundation announced an aid package of USD 100 million for India. Availability of these funds at one point of time or other has helped Indian planners in financing different new short-term projects or complementing the existing programmes. Although the contribution of GoI increased from approximately INR 650 million during 1992-97 to INR 1960 million during 1999-2006, it remained less than one-tenth of the total funding. However, total funds available to the government of India during the NCAP-II have been substantial, particularly in the light of existing problem to fight with.
Further, many other government and/ or quasi government organisations have also joined hands with NACO in fighting HIV/AIDS. Important among these organisations are Steel Authority of India Limited (SAIL), Indian Railways (IR), Employees State Insurance Scheme (ESIS), Defence Ministry etc. These organizations have been participating in the NACOs efforts in various capacities and forms. For instance, SAIL has been organising and conducting different training and orientation programmes for doctors, school children and teachers. SAILs activities have been concentrated largely around its different steel plants. The ESIS on the other hand, aims to reduce the spread of HIV among those ESI beneficiaries who are poor, marginalised and at highest risk of HIV infection, especially, migrant workers and industrial labourers. Also ESIS is one of the few organisations which provide the antiretroviral drugs to AIDS patients (65 patients at present) from their own funds.
The Indian Railways has initiated training programmes for its medical and paramedical staff and provided Preventing Mother-to-Child Transmission (PMTCT) services. Similarly the activities of Ministry of Defence (GoI) are related to planning, developing, executing and evaluating the impact of IEC interventions aimed at prevention of HIV/AIDS at various military stations in the armed services. It needs to be mentioned that all these organizations have made significant financial provisions, largely from their internal funds for various related activities. An overview of the financial provisions of these organizations is presented in Table 4.
Table 4: Funds release and expenditure (in INR million ) by different government agencies for HIV/AIDS during 2001-02 to 2004-05
| Agency |
Funds released |
Expenditure reported |
% utilisation |
| Steel
Authority of India |
27.94 |
7.75 |
27.74 |
| Employees State Insurance Scheme |
43.25 |
11.50 |
26.59 |
| Indian
Railways |
42.11 |
19.12 |
45.41 |
| Ministry
of Defence (GoI) |
60.00 |
35.42 |
59.03 |
| Source: NACO, 2003 |
The total amount released for HIV/AIDS initiatives by all these organizations together amounts to more than INR 170 million during the period 2001-02 and 2004-05. This amount is over and above the financial provisions made through NACO but the expenditure made by these organisations complements the efforts of NACO in different ways. However, it is important to note that the rate of utilization of funds released by these organizations has been poor. SAIL and ESIS have been able to utilise only a quarter of the total funds released and the Railways and the Ministry of Defence have been able to utilize approximately half of the funds released for this purpose.
Besides the above mentioned major sources of financing of HIV/AIDS in India, there are several other smaller organisations, such as national and international non-governmental organizations (NGOs) and charitable institutions involved in awareness building and different kinds of prevention mechanisms through their internal funds. Although these expenditures are reflected in their respective balance sheets, such information is not available at the macro level in the aggregate form. It may be noted that on several occasions the activities of these institutions overlap with the national level programmes of awareness generation and prevention mechanisms.
Financing pattern of HIV/AIDS in India essentially shows that there are several national and international level agencies involved in financing for fight against HIV/ AIDS. However, there is little coordination among them besides the fact that there has not been a well planned strategy for financing of the efforts. At the national level NACO is responsible for all types of financing, which shows almost full utilisation of the funds allocated to it on yearly basis. As the utilisation records of the funds by NACO conveys little about the exact direction of the flow of fund at the micro level and the fact that utilisaton is based mainly on the basis of the expenditure booked on different heads by partner agencies of NACO, much details of real utilisation of the funds does not appear to be transparent. In the light of the gigantic size of Indian population and the magnitude of the problem at hand, although the available funds may not be sufficient enough to address the growing problem of HIV infection, a transparent and better use of available money may be considered as inevitable in order to have better control over the problem.
With regard to general health care services, Working Group 5 of the Commission on Macroeconomics and Health (CMH), WHO, Geneva, noted that while lack of funding is often the ultimate constraint, it couldnt be assumed that progress is ensured if money becomes available. It further notes, without a health system that can use money well, spending will not merely be inefficient it may be useless and conceivably counterproductive.
ICTs in financial monitoring
As far as financing of HIV/AIDS in India is concerned, a better monitoring system can be developed through the use of Information and Communication Technologies (ICTs). ICTs can be used both for development of Management Information System (MIS) as well as user friendly Data Query System (DQS). In general, MIS is supposed to strengthen and streamline internal monitoring system, the DQS is considered as a system with high level of use of ICTs for the purpose of evaluating efficiency and efficacy of the system. The DQS is also considered as user friendly particularly from the point of view of retrieval of data and information. Presently NACO is running a Computerised Management Information System (CMIS). Its objectives are to:
-
ensure that a program is appropriate and relevant to the needs of the local population
-
provide evidence on whether a specific intervention is effective
-
permit appraisal of process, inputs and outputs
-
compile data which can be used for advocacy
-
track trends in utilisation of services
-
map behaviour changes concurrently
In the NACO run CMIS, there is a mechanism of data flow from 5000 primary data units spread over the country to State AIDS Control Societies (SACS) and ultimately to NACO and vice versa. NACO has designed a data input format for all the data generating units to be filled by the end of every month and sent to the SACS, which in turn is sent to NACO after processing and standardising in computerised data entry format. Based on this database, NACO and SACS brings out different reports at the national as well as state levels. NACO and SACS also produce various maps and charts focusing on specific themes. Even though the present MIS needs refinement and strengthening, it is a crucial support to the NACO in administering its intervention programmes and devising strategies for evidence based programming.
NACOs annual Report 2003-04 notes this system provides critical information continuously about the course of the AIDS epidemic in India and guides the NACO and SACS in making decisions and taking corrective measures, when necessary. The information generated by the M & E system indicates how well the programme is being implemented and helps identify bottlenecks. However, the effective functioning of the system is marred by lack of technically qualified personnel and strong coordination between data generating units and the SACS and further between SACS and the NACO. As the MIS is being used till now only for the internal monitoring process, it raises serious are doubts on the transparency in the whole system. Moreover, even in the internal monitoring process there has been little focus on financial discipline and financial progress is assessed mainly on the basis of ability to spend rather than ability to effectively utilise the funds.
In no way the present MIS helps in understanding one to one correspondence between financial and physical progress of the fight against HIV/AIDS. Further, the present MIS has been developed mainly for the purpose of internal monitoring and use of data for occasional publications. The system has not been developed in such a way that different stakeholders could use it in a user-friendly manner. Apart from this, the MIS is not net-enabled so that the information available with the system could be used and analysed for variety of purposes and wider dissemination.
The monitoring of the financial progress and effective use of the AIDS control programmes can be made efficient by exploiting the benefits of ICT in general, and by developing comprehensive data query and metadata systems in particular. While the data query system allows data storage and dissemination in user friendly manner, the metadata system helps to retrieve additional information that can better describe the numbers and other information. The rationale of developing data query and metadata systems is that a user can access the data from the users desk system directly. Although the efficiency of the system depends on the quantity and quality of data storage within the system, the mechanism of retrieval of data, particularly in public domain, is the most crucial aspect of the system. This not only speeds up the flow of information from one user to the other but also the whole system becomes transparent, ultimately helping in efficient monitoring of the programme.
Conclusion
The incidence of HIV/AIDS infected people has been on rise in India. During the last decade-and-a-half the rise has been phenomenal. Since the rise of HIV infection has taken place mainly through heterosexual behaviour, the Government of India is making all efforts to educate and inform people about the types and sources of HIV infection. In order to meet this objective, colossal amount of funds have been flowing in, which is largely contributed by international agencies such as the World Bank, USAID, DFID etc. Indian agencies, either the central government or any department or organisation of government are far behind in funding for HIV/AIDS in India.
Many people have been disappointed with the allocation of only INR 1960 million of the governments own funds and poor utilisation rates of different government agencies since 1999. Availability of funds from a variety of sources has made it difficult to assess the real achievements over the years. There is requirement to conduct concurrent and periodical evaluation of the AIDS Control Programmes throughout the country, so that the real financial achievements could be assessed. Moreover, there is need to sensitise different government organisations / agencies to make financial provisions for AIDS control and properly utilise the budgetary provisions more effectively.
Approximately half of the total fund available for AIDS is spent on prevention with another quarter on identification of new cases through sentinel. There is very little fund available for therapy and R&D for developing new medicines. This requires a proper reorientation, as in coming days much more funds may be required for treatment of HIV positive patients throughout the country. Government is also required to invest funds for developing medicines/vaccines for AIDS control. Even while international funds may be utilised for prevention and education, Government of India may be required to mobilise internal funds towards treatment of HIV infected people.
An efficient monitoring mechanism of HIV/AIDS can be developed through appropriate use of ICTs. Apart from dissemination of knowledge at various levels (as for example awareness generation), ICTs may be used as tools for effective monitoring. The existing MIS of the NACO does not provide broad based information base and the same is being used only for the limited purpose of internal monitoring. The system has to be diversified and it should be transformed based on a comprehensive database. A user-friendly data query system on the principle of metadata system may be a good approach to introduce ICTs in this. It is important to recognise that unless the HIV/AIDS data system becomes net-enabled, wider dissemination and various uses are not possible by different stakeholders.
Author: Anup K. Karan is Faculty, Institute for Human Development, New Delhi, India
|
