By Dr. C. Rangarajan, Member of India's Parliament and Chairman, National Institute for Public Finance and Policy New Delhi,
February 27, 2009
Ladies and Gentlemen: Let me, at the outset, thank you for inviting me to give the keynote address in this very important event. I have had the honour to chair the session dedicated to the draft volume of this book at the International Conference on AIDS in Asia and the Pacific (ICAAP) in Colombo in August 2007. I recollect the discussions we had at that time, and am very glad to see the final version of the book that is being released today. It has taken some time to come to this stage, but I can see that the time has been well spent.
I would like to congratulate the editors, Dr. Mariam Claeson and Dr. Markus Haacker, and all the other authors who have brought their collective intellect to bear on the complex issue of HIV and AIDS in the South Asian region. I am sure this volume will be a reference text for researchers, academicians and policy makers in the years to come. It is also nearly a year since I presented the "Report of the Independent Commission on AIDS in Asia" to the UN Secretary-General Mr. Ban Ki-moon in New York last March. Some of you in this room had enriched our deliberations, and had also helped us in the peer-review of several of the chapters of the Report. I wish to take this opportunity to thank you for your valuable inputs into the work of the Commission.
The Commission had one simple purpose – to gather all the evidence that existed on the state of the HIV and AIDS epidemic in Asia, to reflect upon the possible future trajectory and to recommend measures with the eventual goal of halting and reversing the epidemic in Asia by 2015. This is the task we set before ourselves. In many ways, the book being released today also has the very same objectives. It addresses the problem of HIV and AIDS in the context of economic development in South Asia.
To do this, it uses various tools of analysis – epidemiological evidence, randomized intervention, macro-economic modeling, applied micro-economic household analysis, health systems approach and operations research. Each chapter, therefore, is an area of academic work in itself, with a vast literature on the respective subject. What is commendable is that rarely all these tools are brought together in any one book, especially in the field of HIV and AIDS.
Needless to say, the tools have their own limitations especially when applied in the context of developing countries. During the AIDS Commission hearings, I was told how we lack systematic epidemiological surveys and databases that would provide a more realistic picture of the epidemic. Even with sophisticated data gathering through sentinel surveillance, India had overestimated its HIV prevalence by nearly two times. The Commission heard how important it was to move from first generation sentinel surveillance to second generation bio-behavioural surveys especially in concentrated epidemics like the ones in the South Asian region.
On the basis of evidence that was presented before the Commission, however, there was little doubt that the drivers of the epidemic were sex work, drug use and men having sex with other men. Without the kind of work undertaken in the epidemiological chapter of this book, even this basic fact would have been hard to substantiate.
Better quality of data will only support this finding, and leave little doubt where prevention programs should be focused. Going from evidence to concrete example, the Commission was again presented with two intervention programs that seemed to have achieved some measure of success in sex work settings. One was the ‘100 percent Condom Use’ program started in Thailand in the early 1990s, and the other being the Sonagachhi program around the same time. They were two very different types of interventions – the first one being a top-down approach, and the latter a bottom-up empowerment approach. I have personally visited both the interventions in Bangkok and Kolkata, and have been impressed with their success. The socio-political contexts are also very different – would the ‘100% condom use’ program work in India and the Sonagachhi model work in Thailand? It is hard to say.
But the wider question is how to translate the so-called ‘boutique’ interventions into broad-based national or even international programs. The socio-economic dimensions become relevant when we look at the impact of HIV and AIDS on economies and households. They are the two ends of the macro-micro spectrum. Academic work on the economic impact of AIDS has progressed much more rapidly in Africa than in Asia for obvious reasons. No country in Asia has a prevalence rate anywhere close to Southern African countries. Also, the two epidemics are fundamentally different. Yet, the techniques that were used until recently to estimate the impact on economic growth or household income were essentially the same. Coupled with little or no data on the population or income distribution of HIV in Asian countries, earlier projections have not had any degree of accuracy. The challenge has been to incorporate parameters in the formal model structure which will take into account the economic loss to particular population groups – those that are infected and affected by HIV. The next step is to estimate the total welfare loss to the individuals or households on the one hand and the economy and society on the other. The chapters in Part II of the book try to do precisely that. The figures of welfare loss for both the economy and the household seem to be on the higher side, but these papers have pushed the envelope further in analyzing a complex health issue which is intertwined with the issues of stigma and discrimination. If anything, we economists still have some distance to go before we can say with any degree of certainty that we know how to value in economic terms personal sentiments and social discrimination and the connections between the two. The alternative is to stick to the straight and narrow path of evaluating pure monetary loss in terms of man-days lost and private expenditure on health. Following this direct method, the Commission estimated that as per current trends of the epidemic in Asia, the foregone income at the household level annually is about US$ 2 billion. This can be halved to US$ 1 billion per year by 2020 if a full and comprehensive prevention program is undertaken. The program should be able to increase condom use in high-risk sexual contact to about 80 percent, integrate oral substitution and provide clean syringes to IDUs, as well as provide near universal coverage of ART. The cost of this comprehensive program was worked out to be anywhere between 50 cents to one dollar per capita, depending on the state of the country’s epidemic. Moreover, the cost of the prevention part comes to only about 20 percent of the total expenditure. In fact, the Commission found that for countries with expanding epidemics like the ones in South Asia, one dollar spent on appropriate prevention could save upto 8 dollars in long-term treatment costs. Therefore, the design and implementation of a national prevention strategy should actually be accorded the highest priority as far as HIV and AIDS policy is concerned. However, one incontrovertible evidence is that households that are affected by HIV and AIDS do suffer economically. This is mainly due to the additional burden of health expenditure. This results in several adverse consequences – neglect of health condition, indebtedness, additional burden on women and children’s education. The extreme case is that of the AIDS orphans, for whom very little has been done until now in Asia. This is the greatest risk to development posed by HIV and AIDS in this country and this region. Even if we take the latest estimates, over three million people are infected with HIV in South Asia. This is not a small number. There are three million lives and several millions more who are directly or indirectly affected by the epidemic. This provides enough justification for strong and effective government intervention.
As the two chapters in Part III of the book show, the economic impact of HIV and AIDS would be even greater without government intervention. But even with government spending resources on providing ART, there are substantial private costs. Given that healthcare is a sector where private provision plays a significant role, the issue is how to effectively leverage the private sector in the strategy to combat HIV and AIDS, without losing sight of the main objective of mitigating the impact of the epidemic for the affected individuals. With the fall in the cost of first line ART, it has been possible to provide universal access through government financing. However, without a sustained decline in the cost of second line ARTs, the long term fiscal burden would be very high. This is already the case in Thailand where more than 75 percent of the AIDS expenditure is tied to treatment, leaving little room for prevention programs. As Indrani had suggested in one of the Commission’s meetings, a sustainable policy of second-line access has to build an element of cost-sharing into it. This can also work as a long-term insurance policy guaranteeing public delivery of second-line ART when it will be needed. More work on this line needs to be undertaken to give options to policy makers and enable them to take a strategic view on HIV and AIDS treatment over the long term. The AIDS Commission in its Report has observed that impact mitigation is one of the three pillars of an effective AIDS response – the other two being prevention and treatment. However, it found little evidence of an effective national strategy or even examples of successful impact mitigation programs in any Asian country. Going forward, international organizations like the World Bank should start thinking on what would be a sustainable policy which can provide adequate economic security to persons affected by HIV and AIDS. That would be an effective way to mitigate the risk to economic development posed by the epidemic in this region. Ladies and Gentlemen, I would like to end with the risk posed by the ongoing crisis in the developed economies and its implications for HIV and AIDS. The last decade has been good as far as resources mobilized for HIV and AIDS is concerned. The downturn in the global economy may weaken the ability to raise adequate resources.
Calls for diversion of funds from AIDS to other health challenges and issues like climate change will grow louder. In this context, the multilateral agencies have a very significant role to play. They have to bridge the funding gap if the governments cannot increase their own resources in a significant way.
HIV and AIDS policy on the other hand will have to ensure that the money is spent on the right kinds of interventions which have the highest impact. Times of crisis are also times of opportunity. It is important that all of us grasp this opportunity to make HIV and AIDS programs more effective and efficient, using the tools of epidemiological and economic analysis presented in this volume. Most importantly, this has to be done in an environment that would protect human rights of the most vulnerable sections – especially sex workers and men who have sex with men.
There is one particular theme that is common to both this book and the Report of the AIDS Commission, and that is: “We can win the fight against HIV and AIDS”. Thank you. |
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