How Bill Gates Blew $258 million in India's HIV Corridor
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.
Image: Vikas Khot
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.