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When the Concept of Sustainability Rings Hollow

June 16, 2011

By Jeremiah Norris – Senior Fellow, Hudson Institute

In March 2011, USAID/India completed an evaluation of a five-year HIV/AIDS effort, called the Samastha Project, initiated in 2006, that it had funded through a Cooperative Agreement with the University of Manitoba, Canada at a cost of $22 million.   This is about 20% of USAID/India’s annual HIV portfolio.

The Samastha Project “was designed to be gap-filling” in Karnataka State. That is, while it would be difficult to consistently quantify and attribute impact to the Project alone, its inputs have strengthen the government system and complemented that of other donors, such as the Bill and Melinda Gates Foundation.

The evaluators reached these key conclusions of the five year effort:

  1. “Samastha has met the project objectives, met and surpassed most original targets and indicators, and been highly effective;
  1. Clinical services (testing and treatment centers and hospital-based care) will continue after Semastha ends, but it is very likely that the quality of services will be adversely affected without Semastha inputs;
  2. equally—or more seriously, without Semastha’s outreach workers, community mobilization to access and use services will cease;
  3. and, the Integrated Positive Prevention and Care Centers and drop-in centers servicing positive people will no longer have adequate resources to assist PLHIV with treatment adherence support and related benefits.”

In terms of comparison with national statistics, the evaluators found impressive gains in relation to TB and HIV cross-referrals. Coverage of HIV testing among an estimated annual incidence of 55,000 newly detected TB patients in one area increased from 50% in 2008 to 82% in 2010. This was against the national average of 65% in that same year. And, the Project significantly increased coverage of care for children affected by HIV and AIDS to about 54.5% of the estimated 33,000 children in one state. This is about ten times the national coverage which is estimated at around 6.7%

Curiously, though, when it comes to reporting on ART, the evaluators said:  “there was a three fold increase in the numbers of people put on ART”, but they don’t quantify any numerical figure on which this statement is based.

There can be no doubt that India has a serious problem with HIV/AIDS.  Yet, given that it is one of the BRIC countries (Brazil, Russia, India, China); a member of the G20; one of the 12 or 13 largest economies in the world; a state with an intercontinental nuclear launch capability; a booming multi-billion dollar medical tourist industry; a middle class larger than the entire population of the United States; and is the main supplier of ARV therapies to the developing world—did it really need USAID’s scarce development resources?  And could not USAID locate a contractor in the United States to conduct the Semasthra project rather than to use our tax dollars to support one in Canada?

Lastly, USAID has been promoting the concept of ‘sustainability’ for years now.  It is difficult to find common ground with the evaluators when they state that Semasthra has “met the project objectives and surpassed most original targets [while at the same time finding] that it is very likely that the quality of services will be adversely affected” when USAID ceases to fund this project after 2011.

HIV/AIDS prevention, care and treatment is a life-long intervention for patients. There is no indication in the evaluation that the Government of India will now step in to replace USAID’s “gap-filling” approach to combating this disease. Nor, do the evaluators comment on how the positive aspects of the Samastha Project will be sustained after USAID leaves.

This leaves HIV/AIDS patients out on a tenuous limb of sustainability.

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