Interviewee: E. Mohammed Rafique
Date of Interview: 21.12.2010
Time of Interview: 5:00 pm
Duration of interview: 64:05 min
Interviewer: Rituparna Bishnu
Mode of Interview: Telephonic
Rituparna Bishnu - Hello, Rafique.
E. Mohammed Rafique - Can you hear me?
Rituparna Bishnu - Yes, yes… I can hear you. Okay, Rafique, for the record if you please tell us the role in which you play in your organization? How long have you been in the position? And, how you have been involved in the development of NACP III?
E. Mohammed Rafique - How long I have been in this sector on HIV and how I have been involved in the development of NACP III - if I remember the question well.
Rituparna Bishnu - Yes.
E. Mohammed Rafique - I have been working since 1987 to be exact in the sector on HIV. what is called as venereologist. That is on STI and HIV. We saw the first case of HIV in India actually in 1986 when I was doing my post graduation in STI (Venereology). That was at Madras Medical College, and from then onwards I have been working only in this field of STI and HIV. For 17 years I was with the Tata group at Munnar and then I moved on to Transport Corporation of India Foundation (TCIF) and then to FHI where for a short while I worked under BMGF funding, that is, under Avahan funding. Here in FHI with the ‘Aastha Project’, we started the Project for sex workers at Kamathipura in Mumbai. And also we were guided by the capacity building team for FHI which was also funded by Avahan. Then after ten months I was selected by UNAIDS for helping out in the design of NACP III through an electronic forum called Solution Exchange. We helped in the design of NACP III, by getting the voices from the community to be heard by everyone in the discussion including the Planning Committee who are designing the NACP III. So, my work was to moderate the discussions on the thirteen themes on HIV based at the UNAIDS India office, where I was posted as the moderator and resource person for the AIDS Community in India which we started with the design of the NACP III actually. I formed a community and also saw to it that I bridge the community with the planning team for NACP III. So, this happened for about 5 months and we were doing the introductory phase of designing the NACP III when we were getting the feedback from mostly the civil society. So, the AIDS community, which was a virtual one and it, represented the civil society and we had e-discussions. In addition, the executive Committees on the various themes had their meetings which I attended and posted the summaries on the e-discussion forum. Thus for the first 5 months of the birth of the AIDS Community in India, we had discussions only on formulating NACP III.
Rituparna Bishnu – Thanks, Rafique. If I moved on, could you tell me what you think were the key changes between that happened between NACP II and NACP III?
E. Mohammed Rafique - There are three marked changes if you can compare NACP II design with that of NACP III design and programme implementation. Though both are talking about Targeted Intervention…
Rituparna Bishnu - Hello…
E. Mohammed Rafique - What was the question that you were asking? Okay, three main differences between NACP II and NACP III:
First was the amount of funding that went into prevention versus the amount of funding that went into treatment. This was not same, as there was a slight increase on the ratio for treatment. But the three main differences that I would like to stress here was NACP III looked at decentralisation at a more grass-root level. For in NACP II we had decentralisation up to the State AIDS Control Societies (SACS). But here in NACP III the design took it further to the District AIDS Control Societies (DACS) and form there further to the village level that is the Panchayat level. If you see most of the states have got the district AIDS Control Societies (DACS) set up and also they have got functional village committees at the Panchayat level. So, this decentralization is unique to NACP III.
Another strong point of NACP III was it listened to the voice of the communities and also the civil society organizations, thereby the design was modified to have a more community-based approach and thereby you had something like how do you do CBO management in terms of having a Targeted Intervention model. So, even if the main stage still remains in NACP III Target ed Intervention, we have got in NACP III so many interventions that are talked about or even done handing over to the particular CBO.This is special reference with communities CBOs of the high risk groups, those of sex workers, MSMs and IDUs use, mainly. Or here you will see that the programme has become of/by and for the CBO’s. This is the second major difference.
Third one is the one I highlighted earlier. So, we went deeper into treatment and we have got second line ARV and things like that, which also is a reflection of listening to HIV affected groups and various Key Population including People Living with HIV (PLHIV). And also we have got more stress on things like enabling and environment and a better business model doing things with health resources and more, how to work in resource constraint setting, how do we do the best. But all this should be done slowly on…I would say, third one was that we… I will come back to it later; I am missing the third one.
Rituparna Bishnu - You said that the deeper stress on the treatment with the ARV, the second line of treatment.
E. Mohammed Rafique - No I would not take treatment because if you see if you analyze the amount of fund that went, if you see the ratio between the prevention and treatment, in NACP II and NACP III there is hardly much difference. So, it remains the same, though funding for treatment per se if you compare remains largely increased. But funding for prevention also has increased that way. So, what we have to analyze is the ratio. So, if I remember right, it used to be 75%, 25% in NACP III, it came down to… the treatment must have increase to 30% to 40% and the ratio ratio between the prevention and treatment will in NACP III be 60:40 now, if I have got the figures right. But the third difference what I would like to stress is actually - first was decentralization, the second was…
Rituparna Bishnu - The community voice and the civil society involvement.
E. Mohammed Rafique - And the third would be, actually, we got representation of the… we also got into NACP III more into not duplicating what others were doing, just like Avahan is doing, do not duplicate and the government does not duplicate. And also what NRHM is doing and also like the health system strengthening and all that took place only in NACP III. We found that in NACP III much of the HIV response is being blocked at the grass root level because you cannot have a heavy rollout say in a PHC where there is no doctor attending. So, you had to have the infrastructure already in place. So, that is why the importance went into things like health system strengthening and in many general areas of health, and the tie ups, therefore, and the horizontal linkages or diagonal linkages that we made, between the various departments, and line ministries, of course, Health System Strengthening and Mainstreaming was unique to NACP III. That I would as put as number three. Others following I would mark as being number four and five.
Rituparna Bishnu - Do you think there was any change that took place between NACP II and NACP III in regard to the Truckers Programme, the Monitoring And Evaluation, the Advocacy and Management processes. ?
E. Mohammed Rafique - In the Truckers Programme what we did was we found out what are the best practices in Truckers Programme and that actually went to Avahan because I had before I joined FHI, worked for about six months when Avahan started the Truckers Programme. So, this was actually a take off from the DFID Healthy highways project and when that was stopped for some reason, Avahan took that up in a different way, namely more like a biz model.
What Avahan did was it took on the biggest volume, 80% of the volume of trucks we found was plying in 20% of the highways, namely the highways numbers 2 to 9 only. So, to put it another way in something like 20% of the highways mileage we could find out 80% of the volumes. So, in the Avahan sponsored project which we did in TCIF (Transport Corporation of India Foundation) we saw to it that we concentrated on 80% of the volume. This was the business model and also this Avahan model brought in a lot of thinking on sustainability, what happens after the project. If you see all the Avahan models that we created, the Avahan programmes, if you see they always have a lineage of sustainability, they had strong management system in place so much so that even people in those days I remember, they used to call it micro-management, but I would not call it that way because management you could get quality data and also the data in time which was more important and that led to some landmark studies being published in the British Medical Journal (BMJ) right from Avahan. Prabahat Jha’s study, the one from South India that was published, which talked about the HIV infection rates and prevalent rates. These are landmark studies that showed us where the response of the country was actually heading after about 4 or 5 years of Avahan. You could also tribute some of the response to the government programmes. These are the changes that Avahan brought in the response, that is, strong management systems and the business sustainability model. That has also now… because the government is in part taking over some of the Avahan programmes, it was rubbing off into the government NACP III and that was being reflected strongly in the mid-term evaluation of NACP III also.
What was the other part of your question?
Rituparna Bishnu - I just wanted some information if you could give like, what do you think… you were saying that there were many other key changes which happen between NACP II and NACP III? Do you think was there any change in the part of like the M&E process, the advocacy or the management processes between NACP II and NACP III?
E. Mohammed Rafique - I have already told about it.
Rituparna Bishnu - That is why I just wanted like… do you want to emphasize something else on these issues?
E. Mohammed Rafique - Management, if you see the key things are how we doing with the resources how we are managing with our own funding is that main thing, that is, we have made… NACP II was funded by World Bank, DFID and the consortium which were funders who are mainly World Bank, and DFID, or what we have, we had to attend during the design stage, that is why our government… up front told the bank and other funders that we do not require the funds and that the whole NACP III if I remember right, around 12,000 crores, would be a miniscule part of our national health budget. The government was brave enough to tell the funders that they could fund NACP III as part of NRHM. That gave it a strong ownership and at the same time government did not want to loose all the technical inputs that these bodies were giving, like the UN bodies, the funders were usually bringing in; they told them to be on the board to guide in the design stage, in the planning stage, in the review stage, in the mid-term review and also during all the meetings that they had during the rollout of NACP III where they critically reviewed the progress step-by-step, in every step of the NACP III implementation.
So, this was, I think, a good win-win situation for both the funders because now funders could, without bias, look more into how the programme is being rolled out, and they could also criticize freely and in a more democratic process, because they were not tied up with looking into fund utlization.
Rituparna Bishnu - Yes, and what do you think actually contributed to the changes which happened between NACP II and NACP III? What are the factors or what was the impetus to this changes?
E. Mohammed Rafique - The programme was really like mind-boggling because India is a country which is one billion population, then if you look at the prevalent rates the estimates, they all show the effectiveness on how… you cannot discredit NACP II but NACP III, by its very scale, has to be appreciated. And, of course, the work done in NACP II is now reflecting in the prevalence rates, you can also counter argue this thing… which brings us to M&E. So, you can see on the Monitoring and Evaluation that is the point I have not talked about, if you see the three main tools that we are using at national wide survey. One is the prevalence rate, the second is the BSS that we do, (Behaviour Surveillance Survey) and third one is the estimate that we are taking of the total PLHIV, estimates done annually by UNAIDS and others. In addition in NACP III we followed UNAIDS principle of , three ones, namely:
One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work
of all partners.
• One National AIDS Coordinating Authority, with a broad based multi-sector mandate.
• One agreed country level Monitoring and Evaluation System..
So, under that what happened was… and especially the estimates, when we began NACP III, we brought in the number of surveillance centres more than double, we were somewhere 600 to 800 in NACP II, we brought it to 1200 and 1500 or so. So, with these number of surveillance centres being increased and also the use of data that we used in NFHS (National Family Health Survey), the later ones that were rolled out, that has the estimate of the ante-natal survey which was so large a data covering the entire nation. Taking the ante natal HIV prevalence as a proxy for the general population and using updated software like spectrum for retrospective trend calculation of the prevalence rate, you could get a better estimate – we still get guess estimates but we could get a far better estimates and it turned out to be a lower one, almost a reversal of the figures – for from 5.2 million we came down to 2.5 million within a gap of one year just by using these large data from NFHS and also by doubling the number of surveillance centres for the high risk groups. Now, in NACP III we brought down the estimates, or the number of PLHIV also, and the estimated number of PLHIV, that is. Only how this has happened – whether it is the enabling environment, whether it is the better access, the better increase in health system strengthening and the more availability of ARV, we do not know. There has been substantial increase in the number of PLHIV who have been accessing ARV. This is if we are talking on terms of the uptake of treatment. if we are going to the treatment angle and we are seeing what has been achieved there. So, even now the ratio stands at, if I remember right, the ratio stands at something like 25% or something of the number of PLHIVs identified to the number of PLHIVs accessing treatment. So, you could say that some of them are not eligible for treatment as per the regiment standards, and that is why it is only still 25%. But this has to be compared with other places in the world in other developing countries to know where exactly India stands; and I do not have any information on this. I think, these are the many difference and also the treatment that I talked about. What is the other question?
Rituparna Bishnu - You have mentioned the changes which happen between NACP II and NACP III, it was just to know what contributed, what factors contributed to this change and what was the impetus to this change?
E. Mohammed Rafique - when we completed NACP II we did a review of NACP II and when we examined what has happened, we found the government and all the planners could not afford to be complacent because where we found that the infection rates were in control there were pockets of high incidence. So, if we see the review at the beginning stages of NACP III, during the estimates, where UNAIDS made the estimates public, you will see that the slides talked about the HIV infection in the six states, namely four in the South and also the, two North Eastern states was coming down. However, the pockets of high incidence in North India and this always was in any health issue, the northern states, that is, Bihar, Madhya Pradesh, Uttar Pradesh, Rajasthan the so called Bimaru states, has always been where we lost the battle; like in polio we had lost the battle. In all other health programmes also, it was in these states in the Indo-Gangetic plain that we lost. Now we have also Jharkhand and Chhattisgarh in this group because of the division of their former states. I would prefer not to call it ’Bimaru ‘but I prefer to call it Indo-Gangetic plain. Even historic wars have been lost here as also the health wars.
And there again we have HIV also and history repeated itself that was for polio. While we made some decline of a prevalence rates in the South, that is, in Tamil Nadu, Andhra Pradesh, Maharashtra and Karnataka. Though Andhra are a little bit late than Tamil Nadu and Maharashtra in the decline, we saw pockets of high infection rates in some of the states like UP and Bihar, as well as in some of the other Northern states. So, this was what NACP III tried to look at and, therefore, we said, we should broaden the surveillance centres because if you are going to have one or two surveillance centres spread out in one district for something like 600 odd districts in India it is not going to work. or say for 800 districts in India if you are having only 600 or 800 centres, it is only one per district and it is not going to reflect the actual sero prevalence rates in the country and therefore, we must be able to get also these pockets where these high infection rates are occurring, namely, the isolated pockets in the Northern states, we must be able to get those figures also. That is why the monitoring had to be brought in. And the stress went on the estimates. Also we realize that what has been achieved in the southern states in NACP III could not be just what we call an equivalent achievement to over time in the Northern states because the factors that led to achievement in the southern states was basically, the southern states were more literate like Kerala and other states has a high literacy rate. Also, structures are better. There is also more empowerment of women; if you see Kerala and some of the southern states. So, what worked there did not work in northern states and so actually we have to start again from the scratch in the northern states when we were trying to transfer the programme. That is why NACP III had a little bit of a… I would call a lag phase or where we lost time there in NACP III, and that is the difficulty we are finding in rolling out NACP III. We designed NACP III with the successes in the south. We found in the mid-term review that the successes in the south did not lead to successes in the north.
Rituparna Bishnu - And Rafique, what was the role that Avahan played in the development of NACP III?
E. Mohammed Rafique - Avahan had its model for truckers, had its model for sex workers and IDU. if you look at the various programmes that Avahan did, IDU was the Orchid project in the North East; so, Avahan was managing that. If you look at Maharashtra, they had the Aastha project. Maharashtra is the one for Aastha Project in Mumbai. Maharashtra, they had the Pathfinder I. If you look at Andhra, Avahan had the HLFPPT, the coastal area totally and centred in Hyderabad. And also in Karnataka we had the one which KHPT was organizing. I forgot the name of the name of the programme but KHPT was in charge of it, Karnataka Health Promotion Trust, and in Tamil Nadu of course BMGF tied up with APAC and the others. So, the plus point about BMGF was not only it looked at what were the gaps in the government programme and took on those geographic and thematic gaps, also in those gaps it saw to it that it worked in the business model which I was talking about, only on the highest volumes and looked upon replicating those BMGF business models and the replication would be done by those actually implementing the model after BMGF withdrew from the programme after the project was over.
So, that was the model that BMGF did. So, BMGF, wherever it had managed to work along with NACP III, it had a business model for NACP III. However, NACP III comparatively is a very large programme and it is very difficult to affect changes in all parts of it. So suddenly one cannot change NACP III from what has been the plan for 4 or 5 years ago and make it a business model today. It is a very large programme. Avahan by having 5 or 6 comparatively smaller in scale programmes than in NACP III, go ahead with creating sustainability model, changing it along with the lessons they learned immediately they put a feedback into the model. So, these are the differences between NACP III and Avahan models.
So, Avahan had the advantages and also concentrated on the highest volumes and the effectiveness of the programmes was very good, because they looked at delivering quality with the minimum inputs. Namely, if I put my 1 rupee into the programme where would I put it, they thought a lot before they put it. So, if I take Mumbai I would put it only in the sex workers project, so ‘Aastha Project’. Pathfinders are doing 80% of the work in the districts, so let’s put it on Pathfinders. Thus, at time of planning before they funded the programmes and I think these choices they made before funding, were crucial. However, if you compare that with NACP III, NACP III cannot afford to make choices, they have to cover everyone in the country, being the government so they were left with doing what they would not have done if they were Avahan. So, you could not actually look at the effectiveness with that formula of how much money spent by how many people covered, as you cannot apply this to NACP III.
Rituparna Bishnu - Right Rafique, during when the NACP III was being developed like it was in the design phase in around 2005 to 2007 or it was in the early implementation phase when it was writing the guidelines and all. Did you see any involvement of Avahan or what was the involvement of Avahan during this process it was involved in the working groups or in the writing of the guidelines. How were they involved with the NACP III development?
E. Mohammed Rafique - Yes they were involved because we had representatives from all the funders and in the working groups. I remember those days they were working out from the UNO
DC office, the planning committee and the executive committee meetings in the targeted intervention group in which I was also a member. Ashok Alexander was also a member in the TI group, and he was there in every meeting of the targeted intervention groups, which was the most important group for NACP III. There were thirteen working groups of course, but the main important was targeted intervention and I remember attending all the meetings on targeted intervention, IEC and gender. These are the ones that I attended, while my Research Associate attended some others. Now that we got, what are the notes and we summarized them. We posted them on the AIDS community and asked for comments, we had extensive discussions on the summaries of the working group, we give the feedback of these discussions, with which we went back to the working groups. I was a scribe for the TI group that is I took down the notes for the targeted intervention committee meetings. So, this way we were able to bridge… provide… it was a virtual bridge but it was just like good enough for those who are the civil society organization through a electronically linked e-forum, and in the end of the discussion we have more than thousand, two hundred members.
E. Mohammed Rafique - We started with something like 10 or 15 members on day one.
Rituparna Bishnu - okay that is a great number.
E. Mohammed Rafique - so within five months we have gone to a thousand and two hundred; and it is not that we talked all the discussions after five months. There are so many as and when the working group committee members and planning team wanted something, clarification or inputs, we would put special queries on the network. It went on for two, three years during the mid term review also. There were queries on NACP III, on each and every theme on HIV. Of course the AIDS community would discuss. The Red Ribbon express, I remember was restarted just because of queries on the AIDS committee. It was one of the suggestions and I remember the IEC Director in NACO said, “Okay, okay. We will run the Red Ribbon Express.” He gave this response in the AIDS committee.
Rituparna Bishnu - Right... And, Rafique, who were the main partners, who had a major influence in the development of NACP III. The partners who had played a role?
E. Mohammed Rafique - If you see they had the planning team based in the UNODC office which was the, you know, was the work space actually for them. And you see there were thirteen working groups. These working groups was led by the head of the working group,
Rituparna Bishnu - It is okay.
E. Mohammed Rafique - The head of the working group , provide inputs and the scribe jots down every point that was discussed and gives inputs of what was not discussed by the team and what civil society felt was important. Know what is left out of the discussion is more important. So the thirteen working groups would meet, they would review NACP II, what was NACP II, what was the gap in NACP II, what has to be filled in, what civil society organisations, funding agencies, the others who are expert in the field, academic institutions and other experts who felt, that in a particular field what therefore could be done better by NACP III and how it could be done? All this would be put together and circulated to all the experts by email, as well as to those who are members of the working group. And each working group if I remember had something like 25 members.
The working group members are people like you had for the TI group, representatives from MSM, IDU and for MSM, the best one in MSM, that person would be there. Somebody, you know who would represent the biggest organisation in South Asia for MSM. So, it was something like this for each person was handpicked. So, we could get the inputs and if that input was not coming from that particular representative, then we always had the electronic forum; and we could always pick up the telephone and call people and get the inputs. This was one of the uniqueness in designing in NACP III itself. We got lot of inputs from the e-forum and that shows the input from the virtual AIDS Community of Solution Exchange and that also shows the variety and richness of members of the AIDS Community at that time. Now if I retrospectively look back after 3,or 4 years, back to June of 2005 from now where we are in 2010, five years of NACP free designing have been over. So, now if I look back, I can still say that it was the participation of the civil society both online and offline that made it a democratic and participatory process.
Rituparna Bishnu - The best of the effort was being made?
E. Mohammed Rafique - Yes, yes and the thing was the inclusiveness, we got so many responses, suggestions, ideas, few more people suggested for inclusion in the working groups, and we included them in the working group. And we kept the numbers-the biggest was the targeted intervention group of 25. The rest was about 15 or 10 people.
Rituparna Bishnu - And Rafique what role did actors like the Wold Bank, the UNAIDS, the other funding agencies play in this scenario?
E. Mohammed Rafique - UNAIDS was mainly in a facilitating role. the conduct of the-this thing, all the working group committee meetings, the process was conducted, all the voices were heard, they had people from NACO, the Government, who with the representatives of UNAIDS led the process, and jointly facilitated all the recommended group meetings, and looked through the draft, and worked on the executive summaries and meeting reports. This was reviewed by the UNAIDS and other funders. Funding agencies headed by the bank, the revenue committee which looked into all this and the planning team had to put up everything to this review committee. It was a very open, transparent, democratic process. We saw through it, the voices from the grass root level was not only heard, but also listened to, and included if it is fair enough, or valid enough.
Rituparna Bishnu - And were there any specific reports or studies that was particularly influential during the development of NACP III?
E. Mohammed Rafique - Well we looked at various studies, for each high risk group, success stories, best practices, and lessons learnt that were strictly looked at, where Avahan has done and published various success stories and by the representation of Avahan, people in the TI working group, these examples are largely now the standard operating procedures in NACP III.
So, one of the advantages of NACP III was the discussions on the lessons learned where we fail was one of the most open discussion that we had. These practices in NACP II did not work, which is why we have to change them. The way we are going to change failures because these are the things that we ought to make it work. These discussions helped us to open our eyes to some of the failures. For sometimes we lose contact at the ground level and not know what works on the ground. This helped the planners know what worked and what did not work on the ground. Even the mid-term review on a large scale helped find out lessons learnt. If you remember right after the review of NACP III, we found out that so many NGOs of NACP II was not being translated into the ground because of the, I would have said complacency but from arrangement lack of some of the NGOs. So there was a whole review of the NGO in NACP III under the government, if I remember right about 600 NGOs or something like that number were changed. Out of a total of say 800 or 900 NGOs, those were the NGOs being changed. So, you know, how important it is to act on what we are failing at least.
These type of changes could only happen in NACP III, because you had a type of mechanism where you had a system where you could get information, like MIS and you can cross check the NGOs and implementing agencies. And the evaluations system is strong now. And also we also have a strong leadership in NACP III. Sujatha Rao as a person, the CCM committee had strong views and sometimes it also led to being criticized for having rolling out very strong but at some places it was advantageous where if I see taking decisions of black listing or not funding such a large number of NGOs. These were the plus points. The same strength in NACO leadership led to-if you look at it very unbiased, if you look at the technical review panel reports of the global fund, they have all come down little bit heavily on, especially around 6 and 7 those days till after NACP III started rolling out. On NACO’s not allowing the civil society to participate in the global fund, not allowing the decisions to be taken collectively that has been even voiced by the technical review panel. GFATM has come back to NACO saying that the CCM process should be conducted and the norms of global fund-it cut both ways you know, it needed strong leadership when you want to deal with complacent NGOs. And you need a little bit of your facilitating leadership when you deal with mechanisms like CCM. This is where the learnings take us.
Rituparna Bishnu - Great... Great... And Rafique would you describe Avahan as an important partner during the development of NACP III?
E. Mohammed Rafique - Yes because the model put up by Avahan, the success stories that was published. One of the strong points of Avahan was documentation, publications that they brought out. It comes out from a strong management system that they produced. I think that model is what NACP III can learn from. I know it is difficult; the scale at which NACP III is operating is so large compared to Avahan. Raising and holding the bar at that scale would have its own hurdles but if it can be done we would have a programme that is close to the ideal programme.
Rituparna Bishnu - And do you think this perception of Avahan as an important partner has changed over time or do you have the same notion?
E. Mohammed Rafique - See, Avahan has played its role I think in HIV. They came in and they demonstrated the models amongst high risk groups and so on. Then, they passed on to other areas which they felt like vaccines, neglected diseases and health system strengthening, health sector reforms and things like that, which they want to make changes and show what can be done there, what can be done effectively. The same resources or with lesser resources if you can do it. So I think it is up to NACP III or NACP IV that we are talking now to look at the success stories. If Avahan is phasing out from HIV then we must look at other success stories from the HIV . There are other models which are also coming up which is strong community model like the AIDS Competent Process (ACP) is one. And that has now been done effectively in countries, mostly in Africa and Thailand and some Asian countries. In India in about 900 villages in Karnataka, in Tamil Nadu, a couple of districts in the North East-Nagaland and Mizoram being the highest number of districts that have done the AIDS Competence Process. So, I think as we go on into NACP IV then the model will be moving more towards the sustainable model in which Community is owning the response and taking forward the response. So right from government offered facilities there will be more of a NGO facilitative role and more of a community ownership role and we will also be seeing the linkages across different health programmes. It has cross linkages with NRHM and other development programmes. Some more sustainability will be there. These all started in NACP III, but we have a long way to go.
Rituparna Bishnu - Right... And, Rafique, in your opinion, how did NACO and SACS perceive Avahan inn the development of NACP III?
E. Mohammed Rafique - Well, NACO was very, very open in NACP III. They had the representatives in every working group committee. Also, the planning committee members-were also senior members who had worked in NACP II before. It is not that they were passive viewers to the development of NACP III but they were wholly involved and participated wholly, because they knew at the end of the day that it was going to be their own programme. So, the best input that we got from NACO was in getting tie up with other ministries like supposing if NACP looked into say what programme will work for tribal people to reduce HIV among them? Then we had to work with the tribal development ministry. And then for communication you work with ministries that were involved in the print and electronic media. These were the linkages that NACO could bring in. They had those members also comment into the working group and comment upon the feasibility of strategies that was being discussed or being developed. I think NACO’s role was crucial for development of NACPIII because otherwise at the end of it if you do not get inputs and you develop a strategy which is not going to have the concurrence of other ministries.
And that is going to be the key difference and key working point between NACP II and NACP III. And it will not take off then. You see more of it in NACP IV but to take what we started in NACP III into logical conclusion.
Rituparna Bishnu - Right... And, Rafique, what do you think, you have said that there were many contributions which Avahan has made into the field of HIV and AIDS in India. If I just ask you to mention three top most important contributions what would they be?
E. Mohammed Rafique - The contribution was this. One would be the strong management system and the MIS that they have developed, the programmes mainly based on prevention strategies which had COGS and other collection formats . They based strategies on strong scientific evidence which would reduce STI and thereby reduce HIV, through the prevention programme that Avahan looked at.
I was involved in actually collecting the database of all the Avahan partner programmes in the country and collating it into one big database. We did it successfully though it took us three months to do it. All the Avahan partners, meant collating database right from Excel to Access. We managed to put all these different databases into one format. However, unfortunately, though it was NACO that initially wanted this collated database, was silent about it after the work was completed as Sujatha Rao had left. So, the database that we assimilated was I think not used. You had a system where you know, thanks to the Avahan format the same variables-of course the partners had very different ways of introducing differences even if you give them the same format. So we spent most of our time writing programs to transfer data from the different variable to where it would have been if the difference was not introduced by the partner. Since the data involved was large we collated this with some amount of hard work and so it took us three months. We could do it at the end. We had something like say a partner coming out with five lakhs records. One record means one person comes with an STI . This translates for six partners to something like thirty hundred thousand records which is a wealth of data on STI itself. Also gives you other info like numbers tested for HIV, what was the HIV rate and condom usage. We have all of this in one main database. So, these are the strong systems we are using in Avahan. The data is there... Even in NACP III we have the data. There is another lag time between the state submitting it and it really being available online. Most of it is not being updated online. But the major hindrances are that you are still little bit not open about it. We are saying that this needs to be kept confidential. Very few people have an access to the entire database.
Rituparna Bishnu - And, Rafique, in your opinion were all the learning’s which was generated by Avahan fully incorporated into NACP III?
E. Mohammed Rafique - There were some things that could not be incorporated. We could not publish most of the success stories but some of the things like the business model and the Link worker and CBO model. These were things that were included by NACP III but they have not actually become the great success. When we included it we thought these were great ideas, as they did work in NACP II, or in other players, or in other areas where the models worked. I think you know we are struggling with NACP III even in the midterm reviews we did not get very satisfying reports from the models that we had followed. Right now, we are going back to our drawing boards and trying to redesign the link worker model. Especially in the North Eastern areas they have started this.
Rituparna Bishnu - And, Rafique, how frequently did you interact with the Avahan team?
E. Mohammed Rafique - During NACP III design?
Rituparna Bishnu - Yes.
E. Mohammed Rafique - Well, I had access to Ashok Alexander, as well as, to Alkesh and others on the Avahan team, who were also in the working group. We had their mobile numbers and we had to call them up and take what is Avahan stand point in NACP III and all that.
Rituparna Bishnu - What were the various modes of communication though which you had received information about Avahan?
E. Mohammed Rafique - One was in all the weekly review meetings, executive committees meeting, working group committee meetings, I could meet Ashok. Others were deputed for other working groups. And if I did not meet them, and if I thought that a particular point was coming from a particular Avahan model, I could always pick up the phone and ask for more information. There was access. It was not that there was no access. There are emails from Ashok Alexander published on the AIDS community in India. During the design of the NACP III when issues about Avahan’s stand on particular strategies was being raised he did respond immediately on them.
Rituparna Bishnu - And are you aware of any Avahan publications which have taken place during that time?
E. Mohammed Rafique - After the design, say a year after the design of NACP III and when NACP III was just about to be rolled out we had the Lancet study. Later one after two or three years Avahan tied up with Prabhat Jha and other authors which the Britsh Medical Journal (BMJ) published. It was the one on the prevalence rates. I think there is significant contribution from Avahan also. Then there was a particular one which I remember it was about Avahan shifting out of HIV. There was one publication on that. It was in one of the top two journals.
Rituparna Bishnu – Okay. And if I would ask you to suggest how can Avahan be more effective in engaging with NACO and other stakeholders?
E. Mohammed Rafique - There is a lot learned by NACO from Avahan than by Avahan from NACO, I would say. There Avahan has shown how do you choose the most strategic population, more strategic intervention, put their money in and get the key results, the most effective results. That is what Avahan strategy is all about. However, what NACO would want from Avahan is, how would Avahan teach me how to roll out a programme for the entire country? It cannot afford to be strategic. So, that is a gap that NACO expected and which I think Avahan can try to meet. But you know, Avahan being built on a business model, you are looking at a contradiction.
Rituparna Bishnu - I think that is a great suggestion.
E. Mohammed Rafique - But no, it indirectly has a contradiction in that. So, that is something that Avahan will go back to its drawing boards and say no we are a business model and we come from a business thinking and therefore we talk more about resource management. Though we are not for profits, we will see how effectively our resources are being used.
Rituparna Bishnu - And, Rafique, I think I have come to my last question. If I would ask you what has been the influence of Avahan in India other than HIV-AIDS? What would you say?
E. Mohammed Rafique - Well, HIV was a good entry point for Avahan and Avahan did to be very fair, did very well in that and also set the quality standards I would say. Avahan made for you not programmes in HIV, but new modes and standards to execute them. So people will actually try to achieve those kind of benchmarks. And now BMGF in India which is Avahan is moving on to other health sectors, also the expectations in those sectors will be similar, because people are looking at what has happened in HIV, I have always said that your reputation precedes you. You reach that place where you are making a fresh entry but your reputation is already there. Therefore, expectations also go up. People expect that the same standards you set up in HIV also comes in the other sectors.
Rituparna Bishnu - And do you think that Avahan has had any influence outside of India?
E. Mohammed Rafique - Well, BMGF has programmes outside of India and therefore what Avahan is the only Indian name for a small fraction of that whole organisation. Not a small fraction, a pretty large fraction because India programmes are very big and Bill Gates himself has said that most of the members in his company are from India and this is a way of paying back for what they have done for the development of the Microsoft brand of software.
Rituparna Bishnu - And, Rafique that is all from my side. Would you like to add something else which I could not cover through the questions? Would you like to say anything else?
E. Mohammed Rafique - You will be sharing it with me?
Rituparna Bishnu - The transcriptions?
E. Mohammed Rafique - The areas which you want clarification, then you can highlight .
Rituparna Bishnu - Sure... Sure… Sure... I said now the areas which you want to say which you could not say through the interview?
E. Mohammed Rafique - I got my third point that was what I was bugged about when I was talking...
Rituparna Bishnu - Okay that is great. We will surely get back to you if there are any clarifications that we need and thanks Rafique for talking, and, Dr. Singh really apologises for her being off the interview.
E. Mohammed Rafique - No, I do learn a lot because these help me to reflect back and think on the process, we keep going at this break-neck speed every time and we do not talk and pause and do.
Rituparna Bishnu - Anyways thanks Rafique. Thank you so much.
E. Mohammed Rafique - Bye... Bye...
Rituparna Bishnu - Bye...
