[Reader-list] How Bill Gates Blew $258 million in India's HIV Corridor

Sanjay Kak kaksanjay at gmail.com
Tue Sep 1 15:54:58 IST 2009

Following in the footsteps of the Lancet magazine assesment of the Gates
Foundation's impact on HIV prevention (in short: not much) here is another
more journalistic review. Quite illuminating.


How Bill Gates Blew $258 million in India's HIV Corridor
Elizabeth Flock
Jun 5, 2009


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

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

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

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

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."

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