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Integration and Convergence in the context of National AIDS Program Planning in Resource-constrained Settings.

Author(s) Nabeel M K1
Affiliation(s) 1Education, Research, and Evidence-informed Advocacy, Public Health Organizations, New Delhi, India, 2, , , ,
Country - ies of focus Global,India
Relevant to the conference tracks Health Systems
Summary Using the principles of public health ethics, particularly resource allocation ethics, this paper conducts a conceptual analysis of Integration and Convergence in the light of National AIDS Program Planning in Resource-constrained Settings. Sustaining and maximizing current achievements equitably in a resource constrained environment is indeed a challenge. Resorting to a fair and legitimate priority setting framework is the bare minimum that countries ought to do, without which the AIDS programs stand a serious risk of implosion. By undertaking an exercise of meaningful deliberative democracy, there are potential substantive benefits beyond procedural ones.
Background HIV is now referred to as a chronic manageable condition – a class of conditions under which diabetes and hypertension are included. With the advent of ART and other advances in treatment, care, and support, and with the increasing number of persons newly infected with HIV, the number of people requiring prolonged care and treatment continues to grow. Thus there is a clear need to continue investments in order to consolidate and sustain the successes so far, as well as ensure that the successes of the global and national efforts are equitably distributed. Convergence and Integration have been advocated as means to achieve the above two goals. The Planning Commission of India working group on AIDS has also made remarks on similar lines that “one of the critical challenges is to move towards more effective and efficient approaches through convergence and integration of programme components such as basic HIV services, comprehensive care, support and treatment with National Rural Health Mission (NRHM) and general health systems to the extent possible” (Planning Commission Working Group on AIDS, 2011). Apart from reducing the costs of interventions, convergence and integration have the potential to strengthen overall health systems as well (Shakarishvili, G et al, 2011; 2010).
Objectives The objective of this paper is to analyse India's National AIDS Program planning through a lens of integration and a prism of resource allocation. The National AIDS Control Organization (NACO) – now a separate department under the central ministry of health and family welfare in India – conducted a series of consultations with stakeholder groups for planning the next phase of the National AIDS Control Program (NACP). Different reviews of the current phase of NACP indicate success against the set benchmarks on several fronts. The program is on track and will achieve the targets set for most of the indicators (NACO E-Consultation, 2011). The fourth phase of the program (NACP-IV) is projected as the logical next step in India’s efforts to halt and reverse the epidemic, which is also in line with the Millennium Development Goals (MDG). It is envisaged to build on the different achievements of its predecessor - NACP-III – in order to reverse the epidemic through enhanced prevention as well as reinforced care, support, and treatment. However, NACP officials themselves have stressed the need for concerted attention in future for “consolidating the gains and ensuring quality and coverage”. (NACO E-Consultation, 2011) In addition, there have been concerns regarding the availability of resources in order to continue the existing beneficial interventions and to accelerate the achievements in alignment with the national goals and the Millennium Development Goals (MDG) to halt and reverse the HIV epidemic. Quoting the Planning Commission of India’s steering committee on Health, media reports talked about a proposal to ‘merge’ NACP with the National Rural Health Mission (NRHM) (Times of India, 2012). According to some members of the steering committee, it is about training the front line health workers similar to the Auxiliary Nurse Midwives (ANMs) in the  AIDS program. However, officials from the Ministry of Health and NACO publicly expressed their unhappiness and emphasized that the NACP deals with a specialized issue and a clientele different from that of ANMs. (Times of India, 2012) It appears prima facie that this proposal for a “merger” originates with the objective to streamline the health programs. This most recent media debate does not mention the proverbial ‘elephant in the room’ which are the resource constraints faced by the AIDS program.
Methodology The analysis in this paper is based on the Modified Accountability for Reasonableness Framework. Whereas ethics can guide policy makers and program planners on “what ought to be done”, economic analysis and research evidence can substantially help in setting the priorities in a resource constrained environment. Scientific and research evidence informs us of the effectiveness of particular interventions in order to guide resource allocation decisions and economics tries to find out the efficiency of interventions from a population-health point of view. (Gibson J et al, 2005). While there has been concerted efforts to incorporate evidence and economics into the priority setting process, decision makers often feel a gap in ensuring the ethics  of decision making are addressed. (Gibson J et al, 2005). It is in this context that a framework like the Accountability for Reasonableness (A4R) becomes handy for decision makers to ensure a fair and legitimate process in priority setting (Daniels N, 2000). The A4R framework has demonstrated the potential benefits of ethical considerations to deal with the “how” part in the decision making process of allocating scarce resources. The further addition of a fifth condition of empowerment to the original four conditions further strengthens the framework (Gibson J et al, 2005). This addition is an important step in respecting autonomy by virtue of citizens and groups who are empowered to participate in the process.
Results The results of the analysis is described under the following five conditions of the A4R+E framework: Condition 1: Relevance
As per the Relevance condition, the decisions need to be made on the basis of reasons that ‘fair-minded’ stakeholders can agree upon as criteria for decision making. The reasoning must comprise evidence, principles, and values.Condition 2: PublicityThis condition stipulates that the decisions along with the rationale for decisions should be transparent and publicly accessible. Condition 3: Revision and Appeals
As per this condition, NACP-IV planning process must have built-in opportunities to revisit and revise decisions in light of further evidence or arguments and there should be a mechanism for challenge and dispute resolution.Condition 4: Enforcement
As per this condition "enforcement" is necessary to ensure that the above three process-oriented conditions are met.Condition 5: Empowerment
According to this condition, there must be “efforts to optimize effective opportunities for participation in priority setting and to minimize power differences in the decision making context”.Further, the following also needs to be kept in mind based on the results of conceptual research on Convergence and Integration. Convergence and Integration have different meanings – former being more of a programmatic high level consideration and the latter as a grass-roots level service delivery consideration. Yet, these two terms have traditionally been used synonymously to broadly refer to the concepts discussed in the above two paragraphs. However, the term ‘Merger’ is relatively new in this context and connotes a more radical approach where one entity will lose its identity once the process of merger is completed. In the context of health care organizations, mergers have raised difficult ethical issues from the perspective of clients and patients, and service providers (Shaw D, 2003). Even though mostly in the context of hospitals, there have been instances where the mergers achieved neither cost-reduction nor quality-improvement (Weil T, 2010). Thus, mergers, especially those done in haste, have the potential to harm the program and its beneficiaries. Even in the case of integration of HIV related services with general health systems, there are cautions against blanket integration as opposed to carefully planned integration of select interventions.
Conclusion The analysis in this paper reveals that issues related to resource allocation have not been acknowledged and addressed adequately in the planning process of NACP-IV. As a result, the planning process, even though participatory in nature, did not have a resource allocation framework to adhere to. Neither was it able to consult the stakeholders with possible options and rationales for decision making in the context of shrinking resources. In addition, the concepts of integration and convergence have not been dealt with in detail leaving room for speculations and misinterpretations as mergers. It does not seem to be a problem exclusive to India that resource allocation within and between sectors related to health gets inadequate if not neglected attention. Critiquing the report of the Commission on Social Determinants of Health, Bayoumi in 2009 has stated that the Commission missed an opportunity by being “largely silent” on the issue of resource allocation. However, the Commission’s report did in fact show skepticism towards the current trends of health care reform which gives a very narrow focus on economic efficiency; as opposed to a broader attention to priority measures (Bayoumi A, 2009). It is still not too late for India to adopt a framework like the modified version of the Accountability for Reasonableness framework with empowerment as an additional condition (Gibson J et al, 2005). Certainly, this framework cannot stand in isolation but must form a broader frame on which evidence and economic analysis form superimposing rubrics for decision making (Gibson J et al, 2006). For this to happen, first there should be an explicit acknowledgement of the ‘elephant in the room’, rather than silence about resource constraints. Sustaining and maximizing the current achievements equitably in a resource constrained environment is indeed a challenge. Resorting to a fair and legitimate priority setting framework is the bare minimum that India ought to do, without which the AIDS program stands a serious risk of implosion. By undertaking an exercise of meaningful deliberative democracy, there are potential substantive benefits apart from procedural ones (Gutmann A, 1997).

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