Mainstreaming HIV/AIDS in India’s health sector

Experiences and lessons learnt

Vijay Aruldas

Christian Medical Association of India

Bonn, Germany

29 November 2004

India is a country with low prevalence: < 1% among adults

Estimated numbers: 2001: 3.97 million2002: 4.58 million 2003: 5.1 million

Based on data from surveillance centres: 455 centres in 2003 and 44 targeted intervention sites• 271 ANC clinics• 166 STD clinics• 13 IDU• 3 MSM• 2 CSWs

States categorised as high, medium and low prevalence states according to estimated prevalence of HIV infection

Prevalence Category

High Risk groups

Antenatal women

No of states High Prevalence Dists

High Prevalence

> 5 % > 1 % South - 3West - 1North east - 2

45

Medium prevalence

> 5 % < 1 % South – 1West – 2

4

Low Prevalence

< 5 % < 1 %

% Prevalence among FSW

% Prevalence among ANC

Andhra Pradesh 19.4 1.25

Karnataka 14.4 1.00

Tamil Nadu 8.80 1.00

Maharashtra 54.29 1.25

Manipur 12.5 1.25

THE CONTEXT:

Strong Public, For-profit and NGO sectors• Government• For-profit• NGOs

India’s public spending on health: • 0.9% of its GDP (rank 171/175 in UNDP Human Dev. Report)• Rs 5,720 crores (2002)• Strong public health infrastructure

India’s private healthcare spending:• 4.2 % of its GDP (Rank 18th)• Rs 69,000 crores (2002)• For-profit sector mostly clinics and hospitals• NGO involvement in hospitals and community programmes

THE CONTEXT (contd):

Health financing:

• 15% publicly financed• 4 % social insurance• 1 % private insurance• 80 % is out-of-pocket expenditure

• 2/3 rd of all cases access private care; 90% of them are from poorer sections

• 50% of the bottom quintile of patients (poorer), sell assets or take loans to access private hospital care

Ownership Differences:

• Government• For-profit• NGO

• Church / faith-based / religiously-influenced

Differences:

• Financial Resources• Power of the professionals• Value systems • Linkages with communities• Impact of HIV/AIDS on their work• Ability to insulate themselves from HIV/AIDS

Modes of healthcare involvement:

Hospitals

• Don’t have a defined community

• Focus on individuals and sometimes immediate family

• Focus on the disease and the symptoms

Community-oriented initiatives

• Sensitivity to needs of the Community

• Service provision approach

• Empowerment approach

Advantages of mainstreaming in the health sector:

• High exposure of the health sector to the issue

• Reach is high

• Receptivity of clients is high • Condition of client• Availability of time• Goodwill of counsellor towards client is assumed• Confidentiality presumed• Community need not know

• Credibility with other sectors

Mainstreaming HIV/AIDS:

• means that the topic HIV/AIDS becomes part of the ‘mainstream’ of organisations

• is about growing organisational consciousness and culture towards integrating HIV/AIDS

• involves bringing the issues surrounding the pandemic into all strategic planning, and internal day-to-day operations inside an organisation, in its programmes, and in its relationships with others

• the process of analysing how HIV/AIDS impacts on all sectors, now and in the future, both internally and externally, to determine how each sector should respond based on its comparative advantage

Mainstreaming HIV/AIDS:

In the health sector, mainstreaming should also include challenging other sectors

Mainstreaming: trends in the health sector

1.0 Broadbasing the Involvement

• 1.1 Organisation’s own programmes• 1.2 Dialogue with others

2.0 Broadening the basis of discussion (the messages)

• 2.1 Biomedical• 2.2 Individual • 2.3 Societal, cultural and economic norms and issues

1.0 Broadbasing the Involvement:

1.1 Organisation’s own programmes• Special team approach• Others get involved • Design changes (possible only when there is internal

conviction and common understanding of the issue)

Challenges:• Relevance• Logistics• Competence• Institutional• Moral• Self

1.0 Broadbasing the Involvement:1.1 Organisation’s own programmes: Challenges:• Relevance

• Is it a significant problem in my area? • It is not a significant problem among the people I see in

my work • It happens only to “them”

• Logistics• If I care for them, how can I say I cannot treat them?• If I cannot offer them help, why get involved at all? • Where will I admit them?

•Technical reasons•Class of patients (CSWs and IDUs)

1.0 Broadbasing the Involvement:1.1 Organisation’s own programmes: Challenges:• Relevance• Logistics• Competence

• It is a specialised area• I am a social mobiliser, not a ‘carer’• If I cannot offer them help, why get involved at all?

• Institutional• Other patients will stop coming; hospital will close• Too costly for the hospital• Who will pay for them?

• Moral• They enjoyed themselves .. now let them suffer• Why should we spend our limited charity on them? there

are more deserving cases• Self

• I / my staff will get infected• Will you pay for my care if I get infected ?

1.0 Broadbasing the Involvement:

1.2 Dialogue with others • Schools and colleges • Faith settings: churches, mosques, temples, gurdwaras• Companies

Challenges• Denial of the problem• Keeping within the sensitivities of the ‘organisers’• Convincing that it should be talked about in faith

settings and by faith leaders

2.0 Broadening the basis of discussion (the messages)i.e. the content of what is discussed:

2.1 Biomedical: How the disease spreads, etc• Highest level of comfort• Neutral ground

2.2 Individual / personal issues• Questions about sex and sexuality, ABC • requires taking a ‘stance’ and some are uncomfortable• “hosts” may be uncomfortable

2.3 Societal, cultural and economic norms and issues • ‘cutting edge’ of “broadening the basis of discussion”• questions notions of masculinity, gender structures,

social and cultural practices

Core issues in strategising to mainstream HIV/AIDS:

a. Understanding of the country situation: • AIDS situation, epidemiology, etc• Understanding of the sector players and their

dynamics• Understanding of people’s relationship with the

sectors and the players

Core issues in strategising to mainstream HIV/AIDS:

a. Understanding of the country situation:

b. Foundations of mainstreaming:• Change perceptions of prevalence• Enable understanding of the dynamics of the issue • Stimulate acceptance of the implications of the

issue • Inculcate conviction of “I must act”

Core issues in strategising to mainstream HIV/AIDS:

a. Understanding of the country situation:

b. Foundations of mainstreaming:

c. Strategies must be people centred:• “Players”• “People”

Thank you….