How Bill Gates Blew $258 million in India's HIV Corridor
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Image: Vikas Khot
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ON THE EDGE: It's difficult to persuade customers to use condoms in Mumbai's Kamathipura, Asia's largest red light district, where HIV is rampant.
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n 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.
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