Avahan Interview HIV in India

Health Affairs Blog

This is a very interesting interview of perhaps India's best funded AIDS program. Ashok Alexander was a McKinsey consultant and now has become involved in NGO work. I was quite interested in reading his views about the epidemic and prevention.

The first question about prevalence estimates of HIV is very interesting because the Indian authorities have consistently argued that the WHO estimates have been inflated and wrong. I must admit that that I did not believe the Indian figures as I never trust the Indian government, but they seem to have come out on the right side of this argument and have found that the numbers are much reduced.
As an aside, there are some seriously weird people in the world. When this preliminary report based on the national Family Household survey was made public there were some civil society interest groups who believed this was a conspiracy between pharma companies and the Indian government to allow pharma companies to patent drugs and reduce the Indian government's spending on AIDS drugs. Here is their point of view and all I can say is considering what happened to Novartis quite recently I cannot see how these intelligent, educated people can make such absurd accusations.

I digress. Returning to this interview, the other interesting observation that Mr.Alexander makes regards the apparent North-South divide regarding HIV prevalence. The southern states have much higher HIV prevalence and he attributes this to greater economic development which leads to increased migration to these states, more slums, sex workers and human mobility. I think thats an interesting argument although I would also argue that your data from the Northern states are probably not very accurate and better education in the south would probably lead to better reporting and surveillance.

He also states "I would go so far as to say India has one of the most balanced and holistic national programs. Now one the biggest challenge is to implement it at scale and with quality. That remains to be done."
The greatest stumbling block in India's public health system is size and therefore I think we are looking at a difficult task in trying to scale up the problem. Take some basic health system indicators and you will realise the problem. USA has 730,000 physicians at a density of 2.65/1000 people while India has 645,000 at a density of 0.6/1000 while China has over 1 million physicians at a density of 1.06/1000. My point is that almost 90% of our doctors are concentrated in the urban areas so in essence you are probably only getting about 1 doctor per 10,000 people in the rural area and thats a conservative estimate. So, there is almost no way you are going to be able to reach the required people simply by using the already existing health set up. It is arguable that you do nor really require physicians for behavioural interventions. I agree and would be even more worried if you look at the numbers of health workers the government has recorded. It is close to 82 for every 10,000 people. This number is almost too small to be able to control, undertake surveillance,educate and implement a health program.

I would argue the way to manage our health system is in effect to break in down into local systems. Alexander alludes to this in the interview indicating the reason why Avahan's prevention program has been so successful. He gives two reasons - community participation and a "basic common policy" which is adapted at the local level. If we are to push our prevention programs forward and scale it up to the national level, perhaps we should try and break every metropolis into smaller sections each having its own unique millieu, issues and social dynamics that need to be understood, leveraged and encompassed for the success of the program. Similarly, the same needs to be done in towns and districts.

I wonder how it is going to happen. If I were the GOI I would look at two national programs to learn my lessons. The polio eradication program which was a massive success and the national malaria eradication program which was a failure before embarking on another and I would argue even more important national health program. The strategy should encourage community participation and build a bottom-up approach.