"It is easy to hold to ideals when implementing a project in 20 villages. Implement it in 20 states and you will quickly learn what's possible and what's not!"
When I worked in the Gujarat state government I would repeat these words, half joking but half serious. These sentiments echo a reality familiar to India's government bureaucrats, at least the best of them. Scale is hard, and in this densely populated and complex country, it is the constant challenge.
The HIV epidemic in India has tested our government, civil society and those communities most affected. At times, government policies have been inadequate, and advocates have found purpose in pushing for change. Often what is feasible is something between the current, imperfect policy and ambitious demands for something better. Real policy change typically requires evidence of potential impact. How does civil society in all its fragmentation create a body of data to demonstrate that a certain approach can work and then guide policy change to improve implementation of HIV interventions?
Among the Global Fund's many contributions has been how its support has helped civil society build the skills necessary to develop evidence to convince policy makers to act. The Fund's support is designed to fill gaps in a country's response to AIDS, tuberculosis or malaria. Interventions are expected to be aligned with national priorities and be focused on performance through quality data and systems. For civil society partners, this approach can help generate information needed to drive policy change.
Few development donors are willing to invest at scale, especially in civil society partners. A Global Fund grant can give a civil society organisation an opportunity to design interventions they believe in and the funding to implement them at scale. Sometimes a strategy proves insufficient as we learned in an earlier Global Fund-supported programme, CHAHA. Our organisation, India HIV/AIDS Alliance, developed a child-centred care and support programme for families and communities affected by AIDS.
CHAHA initially included supplementary support in nutrition, education and income generation. While the programme showed excellent results, some of the components were not sustainable. We adapted the model to increase the capacity of government services beyond HIV to serve the needs of those affected. It was not the approach we'd used at first but the outcome taught us excellent lessons. Keeping policy makers involved in the process is crucially important to demonstrate that something is possible at scale.
CHAHA showed us how important it is to have the courage to change course. It helped shape our next Global Fund grant, Pehchan, a programme that builds the capacity of community-based organisations (CBOs) to provide HIV prevention programming for 453,000 men who have sex with men (MSM), transgenders and hijras in 17 Indian states.
Governance and oversight structures built into Pehchan have ensured a robust dialogue between government and CBOs. Today, CBOs share data with state government and collaborate to ensure the sustainability of both the CBOs and the HIV prevention interventions they implement for sexual minority communities. The programme has built connections between government and these marginalized populations of a nature that far exceeds what we ever expected. This transformation, a dance between policy and implementation practice, has been moved by many forces and catalysed by the Global Fund.