$258 Million for Condoms?

Q. Please tell me about how you started. Why did you decide to leave McKinsey and join Avahan?
A. They made me an offer I couldn’t refuse. I was 17 years at McKinsey but I liked the ambitious arch of this HIV/AIDS program. McKinsey and the Gates Foundation know each other quite well.  I joined at the end of 2002, and I officially started April 1, 2003.

Q. How did you build your team?
A. Most of the people came and found me and AVAHAN. People were all in good jobs, but they got excited about this ‘venture’, and it was exciting enough for them to go.  Alkesh Wadwani was a senior manager at McKinsey, and set his career aside to start with this venture. It was a chance at doing something new. There were two other McKinsey people. I have a team of 15. Ten are from the private sector, five are from technical backgrounds. For example, one has an MD in infectious diseases. From the private sector they are from consumer products, IT, and banking.

Q. When you started Avahan in 2003, where did you start first?
A. We wanted to do HIV/AIDS prevention, and be highly focused on the high-risk groups. This includes sex workers, truckers, and injecting drug users. These are the highest risk groups. In a large country, people often prevention with school children, etc, but we are more focused on those who are most vulnerable. This was our focus from the beginning. We looked at the situation and the context.  The first program was in 2003. Our first programs were launched simultaneously in many places. Mysore was one of the first, it was featured in the Wall Street Journal. There were no condoms there, and a lot of sex work was going on.  We started with such scale and speed, there was no first.  

Q. Avahan works in partnership with many NGOs across India. How do you find them?
A. We give different grants, identify organizations and ask for proposals. Sometimes, we pick the organization. In, Karnataka there was one large NGO so we didn’t create another—the University of Manitoba is there.  We started everywhere at once in six states to test the prevalence of HIV. The coverage was inadequate. The notion of coverage…the number of sex workers without reliable quality services. We said the fire is burning here so we went here.

Q. Can you explain your structure?
A. All our work is done through NGOs. It’s like a big pyramid.  We fund 20 large NGOs and 140 grassroot organizations through them. They set up the clinics. The programs are run by the NGOs. They deal with the local doctors, and refer sex workers to them. 280 some clinics. 650 sites. A site means we are working in a district for intervention. There are four-six towns within a district. A site may not have a clinic, but there is a referral arrangement there.  It’s really all about making sure people wear condoms.

Q. What is the total amount granted the Gates Foundation towards Avahan?
A. $258 million have been given total in the first five years.

Q. How can you spend $258 million on just condoms?
A. When I took the job I thought I would just be encouraging people to wear condoms. But it’s a little more complicated than that (laughs). It’s not a lack of awareness. If you meet a sex worker, she will educate you about how to use a condom. Yet it is often not used. Often the client doesn’t want to, or he is drunk, or whatever, so the crux is not just telling how to use a condom. Also, we are working on the issue of violence, beating up a sex worker.  $258 million…well, a lot is on condoms and telling people about it.  I can’t recall exactly how much.  10-20%, maybe, on monitoring, evaluation, but we use sex workers to do this as well so doesn’t cost as much.

Q. Can you be more specific about what is spent where? Treatment, vaccines, publications, etc?
A. Treatment? Nothing is spent on that.  Vaccines? The Gates Foundation is largest funders of vaccination in the world, but not through AVAHAN.  Publications? We will disseminate these nationally or globally. But we are not in a hurry to publish until it’s appropriate. We will be talking to different groups.  We gave NACO $23 million grant to strengthen capacity. This is part of the $258 million.

Q. Is funding a government program directly problematic? Does this give the foundation too much power?
A. No. The grant is part of the transition program. Our people work in NACO’s offices, working and spending time with NACO to pass on best practices.

Q. Can you put some numbers on how many people you’ve helped?
A. We work with 300,000 females sex workers: 220,000, plus 20,000 injectors. We work with six million men, and this includes 220,000 men who have sex with men, four million are in the truckers program on the All-India highway, and two million in the program are in identified hot spots.

Q. Avahan is now moving on from HIV/AIDS. Can you please explain how this is happening?
A.  Well, on March 1st,  the second phase of the programme began. The first phase was delivering through NGOs, through a private channel. We were not funding the government, but working closely with the government and in concert with them and the national program. We were following their framework, passing on what we were learning to them, and invited to a seat at the table. In the second phase, we will transfer to the government, 10 percent of the program is transferring to the government this year, and NACO (National AIDS Control Organization) will run things. We’re not saying ‘here’s the program and we’re off’. We are doing a transition program in the communities. Ultimately over the next five years they will take over. In five years we would hope the HIV/AIDS epidemic is contained enough that we will no longer have to be involved. We are not perpetual funders. We try to be catalytic.

Q. What will Avahan do now?
A. We will move into something else—the burden of disease and bad health conditions in India. We will take the lessons learned from scaling up this. We may move into maternal and newborn health. There are challenges there like immunization. Right now, it’s just a gleam in our eyes.  For the problems in maternal and newborn health, solutions exist. No noble prize is needed. One needs to know how to scale up.  We are working with colleagues in Seattle to see if we can devise a strategy for India.  Avahan is the program for HIV/AIDS, the next one may have a new name. We are just making plans. We will build a project and see if it can go large scale. See if we can transfer. Not going to wait five years to start the next one.  Funding for HIV/AIDS has peaked now. Now we are transferring to the government.  In health, though, lots of people are spending money. Ours is a drop in the ocean.

Q. Has Avahan’s efforts been evaluated? Are those evaluations external?
A. We have our own evaluation advisory group. It is convened by WHO, and national and international health experts. Two independent reviews have been done, but not complete, not out yet.  Six universities have done research projects on us.  At the top is the advisory group, like a secretariat, conducting an orchestra, appointed by the foundation.  It is made up of the world’s experts.

Q. But if the evaluations aren’t external, where is the accountability?
A. They are not there to rubberstamp what we are trying to do. Most are respected experts, and they aren’t getting paid. They are volunteering their time for Gates Foundation.  A tech advisory board advises on different parts of the HIV prevention.  There is a big gap for every NGO globally on the aspect of evaluation. Asking, what came out of what we did? Must look if the biological prevalence has been brought down.

Q. Have you drawn lessons from your time at McKinsey?
A. We draw lessons from business. The business model is highly relevant in HIV and public health. Large part of our success depends on that. I think the big missing element in public health is that. The core of management is applied, principles of data, measuring, analysis. Training people in management—that needs to be done in public health. What I learned from business I use everyday. Not from McKinsey.  We use classical business principles, like how do you segment the market.  For example: the sex worker as the consumer. People say there are five or six million sex workers.  We are working with 300,000, this is market segmentation.  You have a disproportionate effect if we look at the frequency of the sex act, etc.

Q. How do you work with the sex worker?
A.  The way we work is this. NGOs recruit sex workers, and part time they work for our program, and part time they do their work. 8000 women do this. Many of those women don’t know how to read or write, but they are a sales force. Sex workers devise the tools to maintain this data

Q. Have you ever scrapped what you were doing and started over?
A. We have changed course plenty of times but not fundamentally. For example, we changed the truckers programs. There are actually relatively few sites with truckers.
We had started with 50 sites for intervention, but we whittled that down to 20. We’ve changed the STI program. Initially it was a franchise, with 6000 STI centers all over India, but the distribution of STIs is not even. We had 6000 sites, brought that down to 800. We changed the money to spend on demand creation

Q. How has the response been to Avahan’s work in India?
A.  I think the response has been good. When we started it was more challenging. The national response was there was a fair amount of denial, but things have changed. The government of India recognizes our contribution. We pass on what we learn, but also take from other good programs. We are not the first in the field.

Q. Can you talk a little about the controversy over numbers in 2002? Bill Gates quoted numbers for the level of HIV/AIDS that were later found to be exaggerated?
A. The problem in 2002 was with the global fund. I don’t know too much about that, but groups felt that the India numbers were exaggerated. We had no part in this. We haven’t put out estimates.

Q. The HIV/AIDS figures have historically been disputed in India. Is there a recognized figure now?
A. Yes, in the summer of 2007 there was a correction in figures. There was a change in methodology from household to sample survey. The only time we had contributed to the estimation was in 2007, we agree with those figures.

Q. Has there been any angst expressed from NGOs or those in the public health field toward Avahan?
A. We are transparent about selection processes. There has been some anxiety and angst from NGOs but not many. We have an independent panel.

Q. This is the Gates Foundation’s biggest grant in India. What’s the next largest? Does some go to vaccination?
A. Aside from AVAHAN, the second biggest grant is Sure Start with PATH, $25 million. After that our grants are smaller.  We are not doing anything in vaccination.  Vaccination is a small amount in India, a small part of research is done here.

Q. So do you spend time on PATH and other Gates Foundation initiatives in India?
A. Well, I head the Gates Foundation in India. But 90 percent of my time is spent on AVAHAN.