Author: Elizabeth Flock
Publication: Business.in.com
Date: June 5, 2009
URL: http://business.in.com/article/cross-border/how-bill-gates-blew-$258-million-in-indias-hiv-corridor/852/0
The purpose was noble, the money generous.
But the software mogul's charity for HIV prevention in India has failed to
make a lasting impact
On a humid afternoon, former sex worker Fathima
(name changed) welcomes a group of illiterate women - still in the trade and
needing protection from HIV - into the Mukta clinic in Pune. As a "peer
educator," it's her job to convey to them the message of safety. But
the visitors shuffle tentatively as expensive-looking posters in English paper
the walls around them.
Why would a clinic serving illiterate visitors use more English than Indian
languages?
The answer lies in where that money comes
from. The Pune clinic is part of a network one hundred-plus non-governmental
organisations (NGOs) working under the umbrella of Avahan, India's largest
HIV prevention initiative. Avahan, or "call to action," is a brain
child of the world's largest philanthropist: Bill Gates.
Gates had announced the 10-year, $100-million
initiative to stop the spread of HIV/AIDS in India during his much heralded
visit to the country in November 2002. This was to be the largest of its kind
for the Bill & Melinda Gates Foundation.
The timing couldn't have been more appropriate.
After nearly two decades of piecemeal efforts to counter HIV, India was hurtling
towards an AIDS epidemic. Millions of poor people exposed themselves to the
dreaded virus due to a lack of awareness. Government agencies and NGOs didn't
have the money to preach safety or treat the infected. Gates showed his seriousness
by later raising the budget to $258 million.
Seven years later, back at the Pune clinic,
Fathima has counselled the women, given them the sheaths of safety and sent
them back. It is time to worry about the future. The bad news is Avahan is
ready to pack and go; and Fathima is set to lose her income. She doesn't want
to slip back into prostitution. At the age of 45, she doesn't have much of
a career there anyway.
When it started on the ground in 2003, Avahan
set for itself three goals: Arrest the spread of HIV/AIDS in India, expand
the programme from the initial six states to across the nation, and develop
a model that the government can adopt and sustain so that the project could
be passed on to it. More than five years later, Avahan hasn't achieved any
of these goals. Doubtless, the initiative has made a dent into the HIV/AIDS
problem, but the impact is marginal for a bill of $258 million. And now Avahan
is leaving, handing over the reins to the government-run National AIDS Control
Organisation (NACO), which doesn't want to inherit it. It is too expensive
for the budget-starved establishment that is as nimble as a sloth. If NACO
takes over, it will try to prune the costs of the programme. Salaries for
peer educators will go.
A Five-Star Initiative
When Gates Foundation got down to work in India, the priority was clear. It
decided to hire the best minds in business to run its initiatives using sound
principles of management. Avahan was ready to spend what it takes to get the
best bosses and started its search at McKinsey, the consulting powerhouse.
The recruiters zeroed in on Ashok Alexander, who had spent 17 years turning
Indian businesses into global challengers. "They made me an offer I couldn't
refuse," Alexander recalls, sitting at his plush office in New Delhi.
"I liked the ambitious arch of the HIV/AIDS programme and it was a chance
for me to do something new."
Soon, the 15-member team was in place. Ten
of them had come from a private-sector background. The team members tackled
HIV/AIDS much as they would a problem at McKinsey. Alexander's office is papered
with data and maps containing hundreds of coloured dots plotting the disease
across the country. The argot is sheer B-school: Avahan is a "venture,"
its HIV/AIDS prevention programme a "franchise," the sex worker
the "consumer."
The classical business principles helped Avahan
start on a big scale in six states simultaneously. But the lack of public
health experience also led to a compromise on quality. Tejaswi Sevekari, director
at Saheli, a sex workers' collective for HIV/AIDS in Pune, remembers observing
the kinks during her stint at Pathfinder International, an NGO that works
with Avahan. Data collection and reporting were entirely in English and had
no pictures. Five years later, the scene is the same; the project hasn't fully
given up on English though no "consumer" understands the language.
Avahan operated in a pyramid, with Alexander
and his team overseeing the work of more than 100 NGOs. The lack of practical
experience at the top manifested itself in different ways. When Avahan introduced
sleek mobile vans to bring clinics directly to the brothels, the expensive-looking
vehicles were sometimes met with intense suspicion. At the Mukta clinic, Dr.
Laxmi Mali says sex workers initially thought the van was from the police
or the government. They refused help.
False Moves
The early missteps are largely anecdotal. But in 2005, an internal evaluation
showed a big portion of Avahan's efforts had gone to waste. As many as 31,000
community members had been contacted by Avahan's outreach programme, but only
11,000 actually visited the clinics. The Avahan executives had assumed the
peer educators would already know what the prevention services were without
explanation; the reality was they didn't.
Avahan's craving for scale also meant it overshot
quite a bit. It started with a bang in six states, with 50 sites for truckers
in the south. But by mid-2005, only 12 percent of truck drivers were even
aware of their services, and only 7 percent took advantage of them. This forced
Avahan to reduce the sites to 20. For similar reasons, Avahan's 6,000 sexually
transmitted infection (STI) centers were brought down to just 800.
Alexander's team tried to fix the glitches.
For example, Avahan tried to allay the fears of sex workers (such as those
who had met the mobile van with suspicion) by hiring them to act as intermediaries
between the programme and communities. An insider could be more persuasive.
Good idea, but Avahan's decision to pay them a salary has come in for criticism,
because other NGOs can't recruit sex workers as volunteers.
A series of evaluations published in the AIDS
Journal in 2008 show that the jury is still out on the programme's impact.
The evaluations, funded by the Gates Foundation, were mostly on the methods
of data collection. One study, which sought to determine whether Avahan was
responsible for the decline in HIV prevalence in Karnataka, failed to prove
that it played a key role.
Where Has All the Money Gone?
At the core of Avahan's failure to make a serious difference to India's fight
against AIDS is the way it spent money. It was an expensive operation, never
tired of throwing money at the problem. In a country where a branded condom
sells for just 10 cents, what did Avahan spend on? It's difficult to say because
Avahan's finances are largely opaque. Avahan's outlets sell five million condoms
a month and distribute another 10 million. Asked how so much could be spent
on condoms, Alexander laughs, saying, "It's a bit more complicated than
that." Probed further, Alexander says he doesn't know the financials
off-hand, nor can he give them later.
Travel would have been one drain. Jonty Rajagopalan,
Avahan programme officer from 2006 to 2008, says she would take flights every
month from her base in Hyderabad to her focus areas in Andhra Pradesh and
Tamil Nadu, instead of being based in a focus area. Another large chunk: salaries.
Alexander's annual package is $424,894, the second-highest in the foundation
globally, not including the presidents and operating officers. Avahan's targeting
intervention (TI) officers are also paid three or four times what a typical
NACO TI officer is paid.
Avahan's marketing was done in style too.
Eldred Tellis, head of Sankalp, an HIV/AIDS-focussed Mumbai NGO that has worked
with Avahan, says he has seen a lot of money go into fancy publications on
high-quality paper, reporting the programme's work. Very little went to the
people on the ground. Vijay Mahajan, chairman, Basix, a microfinance institution,
comments on Avahan: "There is too much money and too many really smart
people with too little coming out."
An Uncertain Torchbearer
Knowing that it would have to inherit the project, NACO sent out evaluation
teams to sites in four states to get some clarity on costs. NACO's head, Dr.
Sujatha Rao, says the evaluation threw up one clear message: Large parts of
the programme are not sustainable by NACO. "We told them you can't create
a huge number of assets and then just leave and expect the government to take
over everything," says Rao.
But Alexander disagrees. "We are not
perpetual funders. We try to be catalytic," he says, ebulliently confident
that the HIV/AIDS epidemic will soon be contained, with or without the foundation.
Either way, it will have to be - Avahan is now repositioning, focussing on
maternal and newborn health.
Ashok Row Kavi, consultant for UNAIDS and chairman of Humsafar Trust for gay
and transgender health, says Avahan's expectations were unrealistic. "They
wanted HIV to disappear in five years. For that to happen, a lot of people
would have to die."
NACO's annual budget is Rs. 1,100 crore ($225
million), none of it spent on Avahan currently. Rao just can't find enough
money to continue the project. "We can never offer a replicable model.
And if we are unable to sustain the programme, all of their effort will be
for naught," she says, shaking her head.
When probed about the difficulties of handing over the massive programme to
the government, Alexander says the transfer is going just fine. Kavi differs;
he says that the transfer discussions between NACO and Gates Foundation are
"running into a brick wall right now. Costs need to be brought down,
but they can't figure out how." He also fears Avahan's now-experienced
MBA-graduate TIs, facing shrinking salaries, will depart. The question of
running air-conditioned clinics like Avahan doesn't even arise.
The biggest hole in quality will arise where
it can hurt most. Hussain Makandar, HIV counsellor at the Mukta clinic, is
worried about condoms; the ones from Avahan lubricate; the ones from NACO
break and the sex workers stop using them.
Alexander insists that only a 10th of the project will transfer to the government
this year and the rest will happen slowly over the next five. "We're
doing a transition programme. We're not saying, 'here's the programme, and
we're off.'" But NACO and Mukta officials, among others, are confused
over the timeframe.
So, the final report card on Avahan:
Goal 3: Develop a model for HIV prevention
that can be implemented by the government sustainably. NACO's resounding vote:
Not achieved.
Goal 2: Expand the programme nationwide. Avahan
could not go beyond the six states it started with. Not achieved.
Goal 1: Arrest the spread of the disease.
The number of Indians living with HIV/AIDS has been officially corrected from
5.1 million to 2.4 million. This was a statistical change, not an improvement
in health. Impact not known.
Back in the great Indian sex bazaar, prostitution
is a growth industry and condom an exception. "New faces keep coming
in every month (to the brothels)," says Dr. Mali. "Twenty percent
of the people we now see are infected, the same as when we started."
