SELECTED ABSTRACTS IN 2012

Title: TB services for the High-Risk-Groups (HRGs) of HIV programs through Targeted Intervention (TI) –TB collaboration: good practices from South-East Asia

Author: Dr Sugata Mukhopadhyay

Background:  In Asia, HIV epidemic is mostly concentrated within HRGs (sex workers, IDUs, MSM/Transgender, migrants, prisoners). They are equally vulnerable to TB due to unhealthy and over-crowded living conditions, poor socio-economic status, lack of nutrition, sheer ignorance and poor infection control in overcrowded health facilities, especially within high TB burden and concentrated HIV epidemic settings. But TB case detection efforts and expanding services are still limited for those groups, who are already covered under HIV programs despite unmet TB case detection targets.

Methods: The 'Targeted Intervention' (TI) HIV Prevention projects of HRGs give platform for dissemination of key TB messages, TB case detection in HRGs and linkage development with local TB services through existing peer outreach programs. The STI clinics marked for HRGs perform regular TB screening among clinic attendees and referral. Selected peer Educators of TI projects function as community DOTS providers through training and motivation.

Results: In 2001, Sonagachi STI/HIV Project, Kolkata, India initiated TB case detection in sex workers and their clients with the assistance of City RNTCP Office and CARE West Bengal with encouraging results. In 2005, a pilot project of TI-TB collaboration in Allahabad by CARE India detected 33 TB cases in 18117 high risk population including 10 co-infected cases in 6 months. In 2004 -05, similar pilot project in Bangladesh, the attendees of a STI clinic which was earmarked for HRGs were also screened for TB and 135 TB cases detected  within an year. The success of Avahan project in TI-TB collaboration (2006-07) in India prompted emergence of TB/HIV schemes in RNTCP for the NGOs though this scheme has, so far shown grossly insufficient utilization rate.

Conclusion: The initiative needs good advocacy and support to mobilize optimum resources and facilitate strategies and guidelines to saturate HIV TI projects with TB services.

(Selected for poster presentation in 43rd World Lung Conference, Nov'12 in KL)

Title: Southern Health Improvement Samity efforts to serve the underprivileged and difficult-to-reach TB affected people of the islands of Sundarban

 

Authors: Dr Sugata Mukhopadhyay, Mr M.A. Wohab

Aim: The abstract describes contribution of SHIS, a premier NGO of West Bengal India and partner of India’s Revised Tuberculosis Control Program (RNTCP), to provide TB services to remote islands of Sundarban Delta region at the Southern most part of West Bengal, India as part of country’s ongoing efforts of Universal TB care.

Method:  Inhabitants of 54 islands of Sundarban have extremely limited civic amenities like electricity, education and healthcare. Boats and launches are only modes of commutation. Working in TB control since 1982, SHIS has so far covered 39 islands which are home to 2.56 million people. The unique mobile boat dispensary services of SHIS have been reaching marooned villages of the islands, spreading awareness through local folk singers, screening TB suspects through Sputum Microscopy and Chest X-ray as per RNTCP guidelines and providing DOTS to TB patients through local Community DOTS Providers. SHIS has developed a network of 943 of providers across Sundarban who, are mostly cured TB cases and received TB services from the initiative of SHIS.  

Results: From 2009 to 2011, SHIS have screened 46866 TB suspects and detected 6707 TB cases with around 58% NSP cases in the islands. NSP case detection rate 67%, 62% and 62% in 2009, 2010 and 2011 respectively. The cure rate of the NSP is 94% in 2009, 99% in 2010 and 94% in 2011. 

Conclusion:  SHIS already achieved 85% cure rate and will soon achieve 70% NSP CDR through sustained and more intensified mobile boat dispensary services for the underprivileged islanders of Sundarban

(Selected for oral presentation in 43rd World Lung Conference, Nov'12 in KL)

Title: Scaling up of sexual & reproductive health (SRH) services for the sex workers, with the sex workers, by the sex workers – an unique model of Durbar, sex workers’ organization of Kolkata, state of West Bengal, India (35)

Authors: Dr Sugata Mukhopadhyay, Dr Smarajit Jana, bharati Dey, Mrinal Kanti Dutta, Pintu Maity, Dr Protim Roy

Background: Durbar, a sex workers’ organization of Kolkata, West Bengal, India, is working for establishing socio-political and reproductive rights of sex workers. Durbar is pivotal to provide SRH services to sex workers and their clients which were initiated in 1992 in Kolkata through WHO-supported pilot project. Since then, SRH services have been scaled up through unique empowerment model across the state of West Bengal.

Methods: Durbar followed core principles of 3Rs (Reliance, Respect, Recognition), kept sex workers in forefront of SRH project management and leadership since inception and built their capacities on SRH. This helped sex workers to meticulously map and establish effective networks with other peripherally located sex workers across the state. SRH services were scaled up in Kolkata city through 12 SRH clinics which were established between 1992-95 to cover more than 5500 sex workers and clients.  By following same principles and strategies, by 2000, SRH services were expanded in 11 more districts of West Bengal with 27 SRH clinics that have been catering SRH services to local sex workers and clients.  A network of about 600 well-trained peer counsellors and 30 community nurses has been created from sex workers’ communities in Durbar’s SRH projects that further empowered sex workers through direct SRH service delivery to their own community. Evening SRH clinics have been established exclusively for male clients.

Results:  Durbar’s SRH services currently cover over 20,000 sex workers and 60,000 clients in the state. In 2010-11, Durbar provided STI/RTI treatment to 12701 sex workers and 5506 clients, distributed 3424827 condoms and around 50,000 OCPs, screened 22098 persons for syphilis, referred and followed up around 900 women for ANC and referred 21 women for infertility to hospitals.

Conclusions:  Durbar model is a unique example of scaling up of SRH services for the sex workers, with the sex workers, by the sex workers.

(Selected for poster presentation in International AIDS Conference 2012)

Title: Total Control of Epidemic (TCE) Program of Humana People to People - A Community Driven Response to the Fight Against AIDS

Authors: Ib Hansen, Sugata Mukhopadhyay, Marie Lichtenberg

Background:  The Total Control of Epidemic (TCE) Program of Humana People to People aims to reduce spread of HIV and its impact by systematically engaging individuals and communities to take control of their own risk factors, while increasing access to prevention, treatment and support services. Implemented in close partnership with respective Ministries of Health and National AIDS Councils across Sub-Saharan Africa and Asia TCE has made major impact in HIV control. 

Method: TCE model works through two primary strategies:

a)      Individual HIV Counselling to Prevent New Infections: Every person in target areas was provided with counselling for behaviour change and was assisted to develop individual risk reduction plan by multiple follow-up sessions of Field Officers of Humana People to People. Home-based testing consistent with country guidelines was conducted as an integrated part of the process.

b)      Community Mobilization to Change Social Norms: To change social norms across the full range of HIV related issues (stigma, discrimination etc.), community-wide mobilization was carried out with local leaders, activists, PLHIV to project them as role models for others along with intensified promotion of existing services.

Results: Since the first TCE pilot in Zimbabwe in 2000, 11 million people were covered in 12 countries. 28 million individual HIV counselling sessions were delivered. As a result, 2 million people were tested for HIV and got results. Over 500,000 women attended PMTCT services. In Blantyre, Malawi, 4 times increase of PMTCT utilization within 3 years and in Ehlanzeni District, South Africa, 6 times increase of PMTCT utilization within 4 years after TCE implementation were observed.  More than 600,000 community activists were trained and engaged in community mobilization activities.  

Conclusion: With average cost of U$ 2/person/year, TCE model represents cost effective community-based interventions for HIV control and care with proven results, that might be replicated across the most HIV affected countries.

(Selected for oral presentation in International AIDS Conference 2012)

 

Public health system of India – an overview (focusing mainly on rural health system)

National Rural Health Mission (NRHM) is the unique initiative of Govt. of India which encompasses all the National Health and Disease Control Programs (except AIDS and Non-Communicable Disease control programs) to provide operational synergy and additional financial, administrative and technical support to those programs. One of the key objectives of NRHM is to strengthen the primary healthcare services at the rural set ups and its referral linkages and decentralization of responsibilities of healthcare management upto the village level.

Village Health and Sanitation Committee (VHSC): A village around 1000 population has a Village Health & Sanitation Committee. The members of the committee are selected from the local villagers like community leaders, teachers, healthcare providers, community health workers and members of the local governance body named Panchayeti Raj Institution (PRI). VHSC is responsible to develop annual health action plan of the village, its implementation & monitoring and overall decision making on the health situation of the village. The committee receives funding support from NRHM on annual basis.

Community Health Workers:  Generally, a village with 1000 population should have the following community health workers:

ASHA (Accredited Social Health Activist) worker: Eligible female volunteer of the village is selected by VHSC of the village to be trained and function as ASHA Worker who is primarily responsible for door-to-door visit, health education, basic health services and linking the community people with the existing public health system through referrals and follow up. There should 1 ASHA worker for 1000 population as per the NRHM norm. NRHM has so far introduced nearly 1 million ASHA workers in the rural health system of India.

 AWW (Anganwadi Worker): AWW works at AWC as health cum education volunteers (Anganwadi Centre) which is the most peripheral rural unit of the Ministry of Women & Child Development under the scheme of Integrated Child Development Service (ICDS) scheme. The key role of AWW is to provide free nutritional supplementation to the children below 6 years and pregnant/lactating mothers, immunization services, ANC & PNC, referral services health education to the women and non-formal preschool education to children below 5 years. There should be 1 AWW per 1000 population. Today in India, about 2 million aanganwadi workers are reaching out to a population of 70 million women, children and sick people, helping them become and stay healthy.

Traditional Birth Attendant (TBA): They are traditional birth attendants in the villages who assist women to deliver at home. Govt. of India has decided to train theis cadre of community health workers to ensure positive outcome of deliveries conducted at home.

Sub-district/block level health services:  India has 640[1] administrative districts within its 28 states and 7 Union Territories and each district is divided into administrative divisions and divisions into several administrative blocks.

1)      Sub Health Centre or Sub Centre: For 5000 population of the block (5 – 6 villages), there is a sub-centre (SC)[2] which is manned by a Multi Purpose Worker/MPW – female or ANM or Auxiliary Nurse Midwife plus a Multi Purpose Worker/MPW – male. In the public sector, a Sub-health Centre is the most peripheral and first contact point between the primary health care system and the community. A Sub-centre provides interface with the community at the grass-root level, providing all the primary health care services. Of particular importance are the packages of services such as immunization, antenatal, natal and postnatal care, prevention of malnutrition and common childhood diseases, family planning services and counseling. They also provide elementary drugs for minor ailments such as ARI (Acute Respiratory Tract Infection), diarrhea, fever, worm infestation etc. and carryout community needs assessment. Besides the above, the government implements several national health and family welfare programs which again are delivered through these frontline workers like ANM and MPW.

2)      Primary Health Centre (PHC): For every 30,000 – 40,000 population[3] there is one PHC, which acts as a referral point of 4- 5 SCs (30 – 40 villages) and manned by 1-2 Medical Officers and 14/15 para-medical staff like Staff Nurses, Lady Health Visitors, Health Educators, Health Supervisors etc. It has facilities of basic institutional care including delivery with 4 – 6 beds, basic laboratory services and ambulance for referral services. PHCs are the end-point of primary health care.

3)      Community Health Centre or Community Care Centre (CHC/CCC): This is the referral point for 4 PHCs with specialized services, covering a catchment area of 100,000 population (100 villages). The specialized services include emergency medical/surgical/obstetric care, ambulance services for referral, institutional care (30 beds) and laboratory services. CHCs are the starting point of secondary healthcare.

4)      Sub-District/Sub-Divisional hospitals: These are 51 – 100 bedded hospitals to be located in the divisional headquarter of the district.

District health services: Every district is expected to have a district hospital linked with the public hospitals/health centres down below the district such as Sub-district/Sub-divisional hospitals, Community Health Centres, Primary Health Centers and Sub-centres. As per the information available, 609 districts in the country at present are having about 615 district hospitals. However, some of the medical college hospitals or a sub-divisional hospital is found to serve as a district hospital where a district hospital as such (particularly the newly created district has not been established. Few districts have also more than one district hospital. These hospitals are 100 – 200 bedded and generally equipped with specialist health and laboratory services. The District Hospitals are actually the end-point of secondary health care.

Tertiary healthcare: The tertiary healthcare referral points are located above district level namely State Hospitals, Regional Medical Centres, Medical Colleges and National level Medical Institutions.

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[1] http://en.wikipedia.org/wiki/List_of_districts_of_India

[2] In hilly and difficult-to-reach area there is one SC for every 30,000 population

[3] In hilly and difficult-to-reach area there is one PHC for every 20,000 population

An unique hot-spot for commercial sex work

Yesterday I visited a Targeted Intervention Project of FSWs after four long years and got a shock of my life after seeing one of the hot-spots of the project in Delhi.

The place is located in one of the filthiest garbage-dumping areas of Delhi with a canal passing by that carries black turry water mixed with all types of biological wastes of the world. We crossed that area in a complete adventurous mode through the mud and garbage and along the edge of the canal with every chance to slip and fall down into the dirty water of the canal. The hot-spot is located at the back portion of garbage area which is actually a large deserted jungle area with almost no visible human movement inside. The FSWs and clients somehow manage to sneak into that area through the heaps of garbage and mud from late morning till evening.

The FSWs generally carry a large plastic sheet with them. The sheet is spread in the convenient location between the bushes and trees for the sexual act. The only witnesses of their activities are some moving stray dog inside the jungle.

We found thousands of used condoms lying almost in all the places between the trees denoting safe sex practice by the FSWs and their clients. The cops have absolutely no idea about these activities as we were reported, so the women who hail mostly from East Delhi and UP don't have to remain worried for administrative vigilance and legal hassles. But there is chance of snake-bite, as I know jungles of Delhi like this have big poisonous snakes (mostly Cobra). When I asked about it, the women agreed, but thankfully, there is no case of snake-bite till now.

The jungle is equally filled with litter that is often brought by gushing wind from the near-by garbage spot. I just failed to understand how those clients (I saw quite a few of them, moving silently in the jungle, mostly young men in their early twenties. The FSWs looked relatively older, in their mid thirties/early forties) grow desire to have sex inside that filthy place with litter lying all-around. Some of the men, I saw were also boozing in the jungle as if they had a picnic over there.

It was truly a queer experience. I visited many hot spots including dingy lanes of Sonagachi, exotic big brothels of Indonesia, massage parlors/night clubs of Thailand and Bali, chaotic GB Road of Delhi, open field brothel of Durgapur, West Bengal, cruising points of MSWs and street-walkers in various places. But this one that I visited yesterday was unique in the sense that the place is damn difficult to reach, and in true sense, with all due respects to those sex workers and their clients, only animals can do sex in those places, not humans.

I gave a big thank to the outreach worker of the project who is responsible for that particular hot-spot, a girl, doing her graduation, who is tremendously enthusiastic and devoted in her work. She has engaged the FSWs strongly with the project activities. She also ensures condoms that have been supplied uninterruptedly to the FSWs by the project are being properly and adequately utilized by them.

We already saw their extensive usage in the jungle through the used ones scattering almost in every nook and corner of the place.

India is gradually overcoming the challenges of HIV with gradual decline of prevalence in many places of the country. The gallant efforts to confine the HIV transmission within the population of so called ‘high risk groups’ through the Targeted Intervention (TI) approaches under the National AIDS Control Program of the country has been showing the good results now.

Sugata M

TB case notification - a remarkable step of Govt. of India

Notification of TB cases is a remarkable decision of Govt. of India and how RNTCP develops the notification system in the coming years is something very interesting to observe.

Presently TB cases outside RNTCP are being reported mainly from the following two sources:

1)      Non-RNTCP govt/public sectors (Public-Public Partnership initiative):  Those sectors have their own health services like Defense, Railways, Para-Military, Mines, Education etc. Some of these sectors are already reporting TB cases detected by them to RNTCP wherever linkages between these sectors and RNTCP have been developed.

The current policy decision of TB case notification is expected to scale up and strengthen those public-public partnership linkages as TB case notification from non-RNTCP public sector should be comparatively an easier job than the same from non-govt. private sector.

2)      Non-govt. sector (Public-Private Mix/PPM initiative): RNTCP is currently linked to Non-govt. sectors through 3 Global Fund supported projects as below:

·         Project Axshya/GFATM Round 9 Civil Society project: Linking chiefly unqualified rural practitioners with RNTCP in 374 districts of 23 states

·         IMA PPM project/RCC project: Linking the qualified private practitioners who are IMA members with RNTCP in 15 states and 1 UT

·         CBCI-CARD project/RCC project: Linking Catholic healthcare facilities with RNTCP in 19 states

·         Besides, there are NGO/Private Practitioners’ Schemes of RNTCP that have been engaging Private Doctors and NGOs with RNTCP on individual basis.

But these linkages are not enough as the non-govt. and private sectors providing health services to the people of the country including TB management and care are so vast. It is estimated that about 45% of the TB cases are treated in the private sector.

 There is an urgent need to expand the PPM (Public-Private Mix) initiative of RNTCP much beyond the above-mentioned projects and on-going NGO/PP schemes to achieve the two main objectives:

1)      To standardize the TB treatment across the country

2)      To enhance TB case reporting from all healthcare providers

The policy decision of making TB a notifiable disease should help in achieving the two objectives, provided the policy will be rolled out with proper strategy and approach with clear and simple operational protocol in place that will be accepted by all stakeholders and implementable.

The role of Civil Society will be immense to help RNTCP to achieve its notification objectives. Other than advocacy, Civil Societies can function as an effective interphase between the National Program and private sector to enable and roll out the notification process.

Currently, the National Program is still finding ways to sustain the communication with private sectors as mere one/two time sensitization of the private providers has been found to be grossly insufficient to engage them with RNTCP. The private practitioners should be kept under constant communication and followed up, where the Civil Societies can play a meaningful role, definitely with some kind of external funding assistance or incentives.

Prioritization of the private practitioners according to the volume of TB cases been provided services by them should be an important strategy that RNTCP may consider in coming future to initiate the process of notification.

At the same time the national program should take proper attention and care of sensitive issues like maintaining confidentiality of the TB patients including their HIV status during the notification process.

Let me wholeheartedly congratulate Central TB Division and Govt. of India for taking such strategic and timely decision, especially at a time when the national program has taken the decision to achieve the targets of Universal Access of TB care in the country.

From: Dr Sugata Mukhopadhyay

World TB Day

Shrayan Mukhopadhyay

World TB Day is on 24th March. TB is a disease that kills many people in India. TB is curable but people still die due to lack of proper information and treatment. TB can be prevented if detected early. If a person has cough and if it continues for more than 2 weeks, the person is likely to have TB. He should visit the nearest hospital and take services from DOTS program. He should not delay because the bacteria can damage the lungs badly. World TB Day thus signifies the day when peple should stay fit and fine and cured from TB. It is also the day where various TB organizations and hospitals make the general public aware about symptoms and signs of TB. And if affected by TB they make people aware of the treatment and prevention of the disease. This is how the World TB Day is celebrated.

(Shrayan is a lad of 15 years, studying in tenth standard in Amity International School, Saket, New Delhi)

Making Family Planning Work in Afghanistan

Aftab Ahmed Awan, Pakistan

Afghanistan is a country ravaged by decades of war, internal conflict and strife. It is only in the last few years that a democratically elected government has been able to bring some semblance of stability in the different part of the country, though the situation still remains highly volatile.  The country is getting a lot of support from international community for the rebuilding of the infrastructure and systems which have been almost wiped out by continuous war like situation.

Though Afghanistan is going through a phase of rebuilding and restructuring, yet she still faces huge challenges in providing essential services to its citizens. These difficulties are caused by factors such as geographical remoteness, civil instability, the over-centralization of government, a lack of infrastructure such as transportation systems, and a lack of government resources, among others[1].

All the above mentioned problems have severely hampered the development process which almost stood still form many years in the past and started afresh only recently. The effects are manifest in the population statistics which are a real cause of concern for the development planners in Afghanistan. Using estimates derived from a number of recent surveys, the UN estimates the current Total Fertility Rate (TFR) at 6.6 children per woman and the U.S. Census Bureau estimates 5.7. Not only do these TFRs, as high as they are, represent quite a decline from the past, but the onset of decline has been quite recent. The real question now is: what about the country's demographic future? The UN has quantified the effect of such high TFRs in its constant-fertility projection. If the TFR remains at 6.6, by 2050 the country's population would reach 111 million and be growing at 3.6 percent per year, a rate that would double a population in 19 years[2].

Keeping in view the scarce resources and not so good economic condition, the Afghan government needs to strengthen the family planning and population planning programs in the country in order to check the alarming trends in population increase. However this a challenge as there are many obstacles in way of population planning programs because of typical socio-cultural and traditional tribal set up in Afghanistan. These challenges can only be overcome by bringing together all stakeholders on single platform.

Afghanistan can learn a lot from the other Muslims countries of Asia like Iran, Indonesia and Malaysia who have highly successful FP programs and have succeeded in overcoming the challenges caused by traditional and conservative interpretation of religion. In all these countries governments  initiated dialogues with religious scholars and convince them to look for reinterpretation of religion in the light of the changing requirements of modern times. Regular interaction of Afghan religious scholars with religious scholars of the above mentioned countries can be a right step in this direction. This interaction can be very helpful Afghan religious scholars and would help in overcoming the resistance which is mostly caused by narrow and traditional interpretation.

NGOs are also an important stakeholder and can play a very important role increasing effectiveness and efficiency of the family planning programs in the country due to their unique advantages. In all South Asian countries and similarly in neighboring countries of Pakistan, Bangladesh, Nepal and India, NGOs have emerged as alternate providers of public services, particularly within poor and rural communities.

Many lessons can be learnt from the neighboring country of Pakistan, which has successfully involved NGOs in the family programs to enhance the reach, quality and effectiveness of the service delivery. Pakistan is also similar to Afghanistan in many respects as both countries share similar socio-cultural background, traditions and the recent history of conflict. Though Pakistan has an area slightly bigger that Afghanistan and contains a population nearly six times the size Afghan population yet the challenges faced by both the countries are very similar. Many Pakistanis do not have access to government services, due different factors including geographical remoteness, lack of resources, lack of capacity in public sector and an ongoing conflict situation in northern areas of Pakistan. So the role of NGOs has increased manifold which have stepped up to fill the gap. NGOs have emerged as alternate providers of public services, particularly within poor, rural and hard to reach communities. The role of NGOs in provision of family planning services is even more prominent as NGOs have been involved in the family planning program since the beginning.

In Pakistan the early programs on family planning were started in late 1950s and early 60s. Provision of family planning services was started through setting up of FPAP which today in one of the largest organizations working in the sector of family planning[3]. NGOs have played a pioneering role in establishing family planning in all countries of South Asia and in setting the reproductive health agenda. NGOs have provided important clinical services, including contraceptive surgery. Apart from service delivery, there has been a considerable role for NGOs and CBOs in advocacy, BCC and community mobilization, where they have advantages. They have also been used as agents of information and advocacy to support the national program.  Some other roles of NGOs also include: ensuring quality of services being delivered, community mobilization, social Marketing and facilitators of Family planning education, training and linkages development.  

NGOs and civil society organizations have many advantages over the public and private sector which can contribute in enhancing effectiveness, efficiency and reach of the FP program. The foremost advantage which the NGOs and CSOs enjoy is their capacity to work at the grassroots level at very low costs. Since most of the NGOs have strong community linkages and presence, therefore they find it much easier to work at the community level and to overcome barriers and resistance which is often faced by public or private sector. Moreover, they often operate without a lot of overheads which keeps their cost very low which is a very important factor in resource constraint situations.

The slightly informal structure of NGOs gives them a flexibility which the public sector often lacks and which is of utmost importance in socially and culturally sensitive programs. They can adopt and review their program according to the changing ground realities. They do not have to go through the bureaucratic channels to review and redesign their program to meet the needs of community. This reduces the time required for taking necessary decisions and for taking prompt actions when required. Since most of the NGOs have to report back to donors and government and go through the rigorous audits conducted by donors and governments, they have to maintain high levels of transparency and accountability which is another argument for employing NGOs in FP programs. Of course, there have been studies and researches which prove that NGOs have proved more effective in implementing FP program because of higher quality of services, high rates of success, better outcomes, presence of more female workers and their capacity to scale up when pilots have proved successful[4].

However this does not mean that there are no disadvantages or challenges while working with NGO. There are several challenges which should be considered before going ahead with the decision. It is a common issue that most CSOs and NGOs have limited resources and sustainability problems, and do not have the capacity to locally raise funds for themselves. There exists a certain amount of distrust for NGOs among stakeholders due to the religious and cultural norms and they are often seen as working on foreign agenda which leads to unfavorable working environment for NGOs. NGO have also been criticized for their heavy reliance upon donors and sustainability issues of the projects. NGOs have also suffered in recent times because of the shifting trends of donor funding and lack of focus on FP. In the last decade or so the funding for FP program has declined considerably which has adversely affected the effectiveness or FP program and has resulted in stagnant indicators like unmet need and CPR.

Despite the above mentioned disadvantages and drawbacks, NGO remain the most important stakeholders in FP and population planning programs. No FP program can succeed without active and meaningful participation and support of NGOs in Afghanistan or for that matter anywhere else. This fact has been proven time and again through many studies. Learning from the experience of Paksitan with similar challenges and factors can be very helpful for the success of FP program in Afghanistan. This can be done through exchange visits, brining technical expertise from region or through involving NGOs from other countries of the region for capacity building of NGOs and civil society organizations in Afghanistan. 

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[1] (Evaluating NGO Service Delivery in South Asia: Lessons for Afghanistan: Laura Antuono, Chris Meeks Melissa Kay Miller, Jean Rene Watchou, Robert M. La Follette School of Public Affairs University of Wisconsin-Madison, 2006)

[2] http://www.prb.org/Articles/2009/afghanistan.aspx

[3] http://www.icomp.org.my/new/uploads/fpconsultation/Pakistan.pdf

[4] Evaluating NGO Service Delivery in South Asia: Lessons for Afghanistan; Laura Antuono, Chris Meeks, Melissa Kay Miller, Jean Rene Watchou, Prepared for Workshop in Public Affairs, International Issues Public Affairs, 2006

Fund to fight key diseases running low

RICHARD FEACHEM, SAN FRANCISCO, USA

 A study just published in the Lancet, a British medical journal, found that malaria killed 1.2 million people in 2010. That is nearly double the World Health Organization’s official estimate.

 Compounding this tragic news is that the Global Fund to Fight AIDS, Tuberculosis and Malaria — the largest and arguably the most effective financier of malaria control — is running out of money. It has suspended new grants until 2014 — grants that would have provided millions of families with protective bed nets, life-saving medicines and vital health-care services.

 Unless we make a concerted and immediate effort to support the Global Fund, the tremendous gains it has made in the past decade will be lost. The United States should convene an emergency donor meeting to address the Global Fund’s resource gaps and ensure that it can operate at full capacity.

 Ten years ago, HIV/AIDS, tuberculosis and malaria were crushing burdens on development, killing over 6 million people a year and draining billions of dollars from the global economy. In the developing world, HIV was a death sentence. Only about 50,000 Africans were on anti-retroviral treatment. After five decades of spotty results, aid was still primarily directed by Western technocrats with little accountability for results.

 The Global Fund was created in 2002 to change all of this. It had two fundamental goals: to mobilize massive new resources against HIV/AIDS, tuberculosis and malaria, and to shatter old development-assistance models by being transparent, accountable and demand-driven. On both, the Global Fund has been an unambiguous success.

To date, the Global Fund has disbursed $15 billion to programs in 150 countries. These grants have provided 230 million insecticide-treated bed nets and 170 million antimalarial treatments. While the new data have counted adult malaria deaths, increasing the total number of deaths reported, it also shows that these investments have saved more than half a million lives. Taking everything into account, malaria deaths actually decreased, from 1.8 million in 2004 to 1.2 million in 2010.

 Global Fund investments have also provided antiretroviral treatment for 3.3 million people living with HIV/AIDS. Nearly half of all people currently on AIDS treatment in low- and middle-income countries depend in some way on the Global Fund to stay alive.

   Further, its grants have let health officials treat 8.6 million cases of tuberculosis, saving more than 4 million lives. Thanks in large part to these efforts, the number of tuberculosis deaths has reached lowest point in 10 years.

   Through all of this, the Global Fund has remained true to its founding principles. Grant recipients — not donors — lead the process of identifying and addressing national health challenges. Civil-society groups, public officials and the private sector are equal partners in developing sound proposals and implementing effective programs. Scores of sensitive documents are published online, including extensive and detailed financial information.

 This is why the Global Fund’s model has been consistently validated by diverse organizations. Just last month, Publish What You Fund, a project of the nonprofit Global Campaign for Aid Transparency, ranked the Global Fund second among 58 donors surveyed for its commitment to transparency. And last year, the Global Fund earned top marks in the Department for International Development’s aid review for its “excellent track record for delivering results” that provided, “very good value to the … taxpayer.”

 The news of malaria’s revised death toll, and the striking downward trend in annual deaths, show that we need the Global Fund now more than ever. Yet instead of planning to end malaria, we are praying that our families and friends survive the next rainy season.

 Instead of creating the AIDS-free generation that President Obama envisions, we face scenarios in which millions now on treatment may be left for dead. Instead of modeling the elimination of tuberculosis, we are worrying about the rising tide of drug resistance.

   It is time for governments to take an honest look at their foreign-aid programs. They would be hard-pressed to find a better return on investment than what we have seen from the Global Fund. After 10 years, the Global Fund has unequivocally proven to be responsive, innovative and highly effective in its approach to aid. The United States should convene an emergency donor conference to mobilize new resources for the Global Fund. This is an investment we must continue to make.

 

Richard Feachem M.D.  is director of the Global Health Group at the University of California at San Francisco and formerly the founding executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. This article of his ran in the Provincial Journal and Richard is kind enough to allow this article to be posted in the Universal Health Blog.

Is Polio really gone from India?

Congrats India for remaining without reporting of any confirmed polio cases for one long year. This is indeed a mammoth achievement in the history of polio eradication in India.

India’s success should not be doubted because of the strong AFP (Acute Flaccid Paralysis) surveillance system that the country has been able to establish for years. It is very unlikely to miss a single AFP or polio case now due to a surveillance network that each and every public health professional of India should feel proud of.

But ‘no polio case for a year’ doesn’t indicate we, as a country has acquired the much-awaited ‘polio-free’ status.  A couple of more years with no polio cases will definitely justify our eligibility for the polio-free certification. But the next two years, will definitely demand the highest level politico-administrative commitment and the maximum operational level hard-work to ensure the polio virus no more exits in the environment of the country.

One of the most important aspects of the final phase of polio eradication should be making all-round efforts to strengthen Routine Immunization coverage, especially in the traditional polio-reservoirs of the country like UP and Bihar together with high quality supplementary immunization rounds (Pulse Polio).

Getting over the polio-fatigue is one of the most challenging jobs at the field operation; especially to keep the front line workers on their toes in each and every future Pulse Polio round is really tough in a war spanning for more than 18 years.  The motivational communication should categorically include high level appreciation to push the polio virus in the corner followed by the ardent appeal to erase it from every nook and corner of the country in the next couple of years.

 I strongly feel the frontline workers should be also given a much better remuneration now to extract the best possible services from them in the ground during the final assault against polio.

Cross-border surveillance and immunization should be collaborated with the neighbouring countries. This is one of the key areas that must be given all due importance and attention. There are instances where polio hit back an already polio-free country being exported from the neighbours.

Continuing advocacy with the neighbouring nations for concomitantly maintaining high quality immunization activities within their territories is equally critical to prevent any polio spillage across the borders that might put water to all the eradication initiative and achievements made so far.

If we can’t take precautions from all possible angles the victory over polio might be further delayed.

After all it is also the matter of survival for the virus so winning never remains an easy process.

Sugata M, Universal Health

WHO's updated policy for TB/HIV Collaboration

This important new policy emphasizes the need to maximise the delivery
of a range of medical and preventive interventions that are simplified, practical,
streamlined interventions that save lives:

Routine HIV testing for TB patients, people with symptoms of TB (TB suspects), and their sexual partners or family members; The use of a simple clinical algorithm for TB screening for PLHIV   that relies on the absence or presence of 4 symptoms: current cough, weight loss, fever and night sweats, to identify people living with HIV eligible for at least 6 months of isoniazid preventive therapy (IPT) or for further diagnostic investigations for TB. Provision of co-trimoxazole, a cost-effective medicine to prevent against lung or other infections for all TB patients who are infected with HIV; Starting all TB patients with HIV on ART as soon as possible (and within the first 2 weeks of starting anti-TB treatment) regardless of immune system measurements; HIV prevention in TB patients: Evidence-based methods to prevent the acquisition of HIV for TB patients, their families and communities Infection control in PLHIV From: Universal Health

HIV-Hunger Cycle: Give them enough food to prevent AIDS

By Sugata M

‘Do you like to stop AIDS? Give them enough and enough food’

Let me tell you a story. This is a story of a woman who got HIV from her husband.

There are so many stories of poor women who were infected by the husband. What is sospecial about it?

From that aspect my story will sound a pretty ordinary one. But to me it is not onlyshocking but can give us a hard lesson of life.

Let’sgo into the story.

“Sandhya (name changed) was in her early thirties, living with her husband and twochildren in one of the medium sized cities in South India.Her husband was working in private sector and having a good income. They had a happy life.

Butthings were not the same. Sandhya’s husband suddenly fell ill and the ailments,in course of time got turned into a chronic one. The man who had a robust health previously underwent very rapid loss of weight, swollen glands in the body and not easily curable fever and loose motion. The physician finally got the HIV test done which came to be reactive.

Unfortunatelyhe died irrespective of attempts from the doctors and Sandhya with her two kidswere forced to shift to her in-laws house.

In the mean time Sandhya also had gone through HIV testing and found to be positive. And the things got worse. Her in-laws threw her and her two smallkids out of the house. They thought Sandhya is woman of immoral character andactually passed the virus to her husband to cause his premature death.

Sandhyawas literally came into the roads. She did neither find support from her parents,relatives nor find a job. Nobody likes to put a HIv infected into the job.

When hunger became intolerable with the two small innocent children to feed with Sandhya had taken the boldest decision of her life. She became a prostitute.”

So the crux of the story is, if you are hungry, your off springs are hungry but at  the same time denied all sources of food what best you can do to survive? Forget the so called ‘morality’ of life and jump into anything that can generate source of living for the survival.

I told the story to one of my good friends who is a strong feminist. Her reaction was, “I would have definitely committed suicide with my children before gettingmyself into such dehumanizing act.” I was simply surprised the way she responded.

But in reality how many hungry people kill themselves when humiliation goes beyond tolerance? Rather, most of them put all their attempts together to survive against all odds. After all, living is loving.

Sandhya did not do anything different. She tried to provide food to her children’s hungry mouth and dreamt of better future for them. Please don’t look at Sandhya’s story through the lens of morality.

My issue is not related to morality or sex work. It is insecurity of food that makes people vulnerable to HIV. Sandhya is one of such vulnerable women but throughout the globe there are millions of people who do not have enough food for them or their children. AIDS is constantly knocking at their doors.

Experts say there is enough food in the world to feed everyone. But where has all those food gone?

Morethan 800 million people on earth know what is like to go to bed hungry. Around 200 million children under 5 yrs are underweight only because there is notenough food for them. One child dies every five seconds from hunger and relatedcause. 35% of the total population is malnourished in several countries locatedin East, Central and Southern Africa. In India which produces enough food for its people there are still incidences of death from hunger, selling of children out of sheer poverty and food insecurity.

If you analyze carefully whole of the food insecurity business you will find ademoralizing picture existing all corners of the globe.

Food insecurity, most of the time is man made and inevitably leads to disruption of human integrity thus generating numerous marginalized, hard-to-reach populationallover the world, left with hunger and humiliation. Never-ending war of DR Congo, political violence of Haiti, socio-political instability in Somalia, Sudan, Uganda, civil conflict and illegal drug trade of Colombia, war that devastated health system of Ivory coast, restless Chechnya, war that tore apart Iraq and Afghanistan, power game and proxy war by the ‘World Powers’ – the listis long but number of people denied access to food through these unending pathological processes is countless. The human community is further fragmented by social and domestic violence, terrorism, communalism, racism, castism, gender inequity and troubled childhood thus enhancing pace of hunger. Hunger is the natural triggering mechanism of dehumanizing events like human trafficking, prostitution, crime, drugs, child labor and migration pushing millions ofhopeless people into vacuum of AIDS. On the other hand, those already infectedby HIV are constantly refrained from producing and utilizing food, being victimized by disability, denial and discrimination. And the cycle goes on incessantly to make the virus stronger and deadlier.

This is Hunger-HIV cycle gradually taking shape of ultimate destroyer and silently preparing ground to make final assault in the form of AIDS. No other disease has taken so much of resources, attention and concern because AIDS has jolted the root of humanity and exposed the darker side of human civilization. Hungry,vulnerable people also remain miles away from critical information vital for living. HIV can be easily renamed as ‘Hunger and Ignorance led Vulnerability’.

Sandhya’story is a perfect example of Hunger-HIV cycle.

Breaking Hunger-HIV cycle is probably the toughest challenge in front of us. I strongly believe that it is neither condom, ARV drugs, microbicide nor vaccine butuninterrupted supply of food with sufficient quantity to the needy and hungrypeople of the world that can really make the true difference in reversing the pandemic of AIDS and many other communicable diseases.

Are our powerful global leaders sufficiently prepared and equipped to bring necessary changes in the food production, distribution and utilization processes and patterns? It needs concrete political commitment atinternational, national, state, district and sub district levels.

When billions of dollars are being spent for space research, weapon technology, nuclear plants and sophisticated biological inventions countless hopeless people are dying simply because of lack of accessibility, availability andaffordability to food – the basic vital source of human existence. Do our respected leaders feel the contrast?

The world has basically two groups of people: One who earns more and the other who earns less or does not earn. The first groups sometimes make money in trillions and billions. The second group, many a times can not even earn in terms of at wo digit number. Can the leaders of the world make a balance between the two absolutely polarized money earning patterns?

Iam not politician. I am not a public leader. I am just a physician who is practicing public health and epidemiology. Whatever I have documented so far is my deliberation from the perspective of public health and, over and above from the point of humanity.

(Published in Concern Worldwide 2009 Writing Competition)

Self-regulatory boards (SRBs) – an innovative and effective anti-trafficking initiative of DMSC, sex workers organization of West Bengal, India

D. Chowdhury, B. Dey, S. Jana, S. Mukhopadhyay, R. Steen

Issues: Involving community and development partners - in combating trafficking and enabling survivors of trafficking to lead a healthy life - is an ideal approach but to translate it into action is a challenge. Durbar Mahila Samanwaya Committee (DMSC), a sex workers’ organization, from Kolkata, India, made this possible by ensuring participatory democracy in practice.

Description: DMSC to formalize its fight against trafficking launched Self Regulatory Board (SRB) in 1997 - as an innovative anti trafficking approach in sex work. The primary objective of SRB is to regulate new entry into sex work. 60% of the SRB members are from sex workers community and 40% representative from Social Welfare Department of Government of West Bengal, doctors, lawyers administrators and members of civil society organizations. Any new entrants to the sex work set ups are brought before SRBs who clarify their age, motives and process of entry. Girls below 18 yrs and unwilling entries identified through medical examination and counseling and not allowed to join sex work and are sent back home or rehabilitation centers.

Lessons learned: There are 33 SRBs operating presently. Eight are in Kolkata and 25 in other districts. 558 girls (84% below 18 yrs) were rescued during 1996-2007 and 497 sent back homes and 61 to rehabilitation centers. Number of minors in sex work decreased from 25% to 0.7% and mean age of sex workers increased from 22 yrs to 28 yrs in Sonagachi as compared between 1992 and 2001.

Next steps: Durbar’s SRB program of community-led anti-trafficking approach should be adopted and integrated with TI programs in sex work set ups in line with community based and community centric approaches of the third phase of National AIDS control Program of India.

AIDS 2008 - XVII International AIDS Conference (selected for poster presentation), Abstract no. THPE1084