Bharathi Ghanashyam, India: May 2011
The theme of this article is based on the question, ‘Is the Global Fund adequately supporting services for women and children in your country?’ Perhaps a more apposite query would be this: ‘Is your country doing enough to convince the Global Fund to adequately support services for women and children in your country?’
By its very mandate, the Global Fund’s model is based on concepts of country ownership and performance-based funding. People implement their own programmes in-country, based on their priorities. The Global Fund provides financing on the condition that verifiable results are achieved. This in effect means that it is not the Global Fund, but the countries themselves, who have to decide funding priorities.
Having established this, it is important to say here that there is compelling evidence to suggest that women and children in India need special and focussed attention with regard to all three diseases – HIV, TB and malaria. The situation with malaria in particular, is shrouded in mystery; data is not easily available, and spokespersons not forthcoming. But there is a strong likelihood that it could be just as severe as HIV and TB. In its World Malaria Report 2008, the World Health Organisation (WHO) estimated that there were 10.6 million cases of malaria and 15,000 deaths from the disease in India during 2006 [1]. A good proportion of these are likely to be women and children.
There is certainly evidence to confirm the vulnerability of this demographic with regard to HIV and TB. Dr SoumyaSwaminathan (Coordinator, Research Special Programme for Research and Training in Tropical Diseases, World Health Organisation) reported recently in The Hindu [2], “in 2009, India had the highest number of TB cases in the world (approximately 2 million new patients), suggesting that the prevalence in children is also likely to be high. Tuberculosis is the third major killer of women aged 15-44 years, accounting for approximately 700,000 deaths a year globally and causing illness in millions more.”
Swamithan also points out the additional challenges that women with TB face. TB is more common during and immediately after pregnancy, possibly due to changes in the immune system during this time. This not only poses a risk to the life of the woman, but also increases the chances of death in newborn babies. Babies born to women with TB are underweight, and at high risk of developing the disease themselves, due to close contact with their mother. TB can also cause infertility and chronic infections of the reproductive system.
Linkages between HIV and TB challenge women and children more acutely than men. According to Dr Swaminathan, a study in Pune found that TB increased the probability of death for HIV-infected pregnant women and their infants. Further, HIV-positive women with TB during pregnancy have a higher risk of transmitting HIV to their babies, compared to women without TB.
It is also accepted that women suffer more stigma and isolation when they are infected or affected by HIV or TB. For example, children are often pulled out of school to help care for their sick parents. In addition, among the beneficiaries of the CHAHA programme implemented by the India HIV/AIDS Alliance, it was found that women head 38% of CHAHA households, and 8% of children in the programme are orphans.
Therefore the situation requires consideration at several levels, especially around prevention, accurate diagnosis (in the case of TB), treatment, care and support. Partial responses are inadequate, and this is a reality that has been accepted and documented across the world. More importantly, it has been demonstrated through successful interventions.
James Robertson, Country Director, India HIVAIDS Alliance, says, “The additional resources provided by the Global Fund have helped ensure that priorities not adequately funded by the national budget get sufficient support to show impact. For example, the Prevention of Parent to Child Transmission (PPTCT) programme was initially scaled up in India with a Round 2 grant and expanded with subsequent funding. This funding was essential, as it has enabled the government to take ownership of this vital service. The Round 6 funding for children and families affected by AIDS has helped provide data and experience to support efforts to include expanded programming for these groups in India’s new national HIV strategy.”
Andreas Tamberg, Fund Portfolio Manager, The Global Fund, says, “The overarching goal of the Global Fund’s partnership model is to create an enabling environment to support countries to develop and implement effective, evidence-based programmes to respond to AIDS, tuberculosis and malaria. This partnership is based on a core set of shared principles and a collective responsibility for delivering on international targets on health through achievement of the Global Fund’s vision – a world free of the burden of AIDS, tuberculosis and malaria.” In this light, it becomes important for concerned countries to take joint responsibility with the Global Fund to create and sustain the enabling environment that can achieve the desired impact.
Several respondents thought that the priorities of the National AIDS Control Organisation (NACO) towards women and children left a lot to be desired. One person, wishing to remain anonymous, says, “There is considerable uncertainty about whether women’s and children’s needs must be addressed by NACO or the Ministry of Women and Child Development. But in the community we feel that HIV is a complex issue. Aanganwadi workers and Accredited Social Health Activists (ASHAs) cannot address the needs related to People Living with HIV (PLHIV) and Children Living with HIV (CLHIV), as they are not trained for this. They can inadvertently cause situations that can lead to stigma and exclusion. Therefore this task has to be held by NACO, which has to build in and seek support for these activities within its programmes.” Traditionally, the National AIDS Control Programme (NACP) has not given much importance to care and support, whereas evidence proves that this is the one area that can dramatically improve the lives of PLHIV.
Diagnosing and treating TB in children is challenging. Risk of progression from infection to disease is increased among children (particularly up to four years old), HIV-infected and malnourished. These are also the groups that pose the greatest diagnostic challenges because of difficulties obtaining sputum samples, and the paucibacillary nature of disease (involving few bacilli).
As stated in ‘Pathways to better diagnostics for Tuberculosis’, a blueprint for the development of TB diagnostics by the New Diagnostics Working Group of the Stop -TB Partnership, “Increasing the speed, effectiveness and accuracy of diagnostic tests is central to the goal of rolling back the global tuberculosis epidemic that afflicts nearly a third of the world’s population.” This situation certainly merits greater attention from the Global Fund. Partner countries, particularly India, should take these issues seriously when prioritising areas for funding.
Country Coordinating Mechanisms (CCMs) are the nucleus of the Global Fund’s country-level programmes and performance. Several respondents felt commented on limited civil society representation on CCMs. For one, “A very small number of members of the CCM comprise civil society. Corporate members exist in name only as they often do not participate in meetings. In this scenario, whatever the government decides works, and while the government might mean well, the absence of voices from a wide range of stakeholders results in important priorities getting missed out.”
The figures are out there. Women and children need support at several levels and they need it fast. Returning to the theme of this article, perhaps it should be, ‘Is your country doing enough to convince the Global Fund to adequately support services for women and children in your country?’
This is a question to ponder over, and seek answers.
SOURCES:
[1] The Hindu 17th June 2010: www.hindu.com/2010/06/17/stories/2010061754161100.htm
[2] The Hindu 14th April 2010: www.thehindu.com/health/medicine-and-research/article1694675.ece
