目标宏伟高尚，投入资金也是慷慨的。但是，印度软件巨头对于预防艾滋病的捐款没有造成持续的影响力。
在一个湿热的下午，之前从事性工作行业的Fathima（化名）迎来了一批未受过教育的妇女——她们仍然在从事性交易并且需要预防艾滋病——进入在Pune的Mukta诊所。作为一个同伴教员，她的工作就是向她们传达有关安全的信息。但是这些来访者看到那些花枝招展的海报都是英文的时候，她们突然陷入迷惑，英文的文章就像一堵墙一样构成了障碍。
为何在为那些文盲来访者提供服务的诊所里大量使用英文？
答案是这和资金的来源有关。Pune诊所是一个拥有超过一百家NGO的网络机制中的一部分，这个网络机制在Avahan的保护之下，Avahan是印度最大的艾滋病预防行动计划。Avahan或者叫做"唤起行动"，是世界最大的慈善家——比尔·盖茨的创意。
在盖茨2002年11月访问印度的时候，他宣布了一个10年一亿元的行动计划，来遏制艾滋病在印度的传播。这成为了比尔-梅林达·盖茨基金会在这个领域里最大的投入计划。
计划安排在合适不过了。在抗击艾滋病方面，经过近20年零零碎碎的努力，印度正经历AIDS流行的侵袭。上百万的穷人由于缺乏关注，他们自身受到了可怕病毒的侵害。政府部门和非政府组织没有足够的资金来宣传或对感染者提供治疗。盖茨通过后来的将预算提升至258,000,000美元.
七年以后，回到Pune诊所，Fathima 为妇女们提供咨询、给予她们安全的保护并送她们回家。现在需要考虑的是未来的情况。一个坏消息是Avahan的帮助已经准备撤出，并且Fathima会失去收入。她不愿意再次从事性服务。45岁的她也无论如何在那个领域无法发展。
2003年，计划开始实施，Avahan设定了3各目标：遏制艾滋病在印度的传播、将这个计划从最初的六个地区扩展到整个国家来实施、发展一种政府可以采用和维持的运作模式让项目可以一直继续下去。过了五年多，Avahan没有达到其中的任何一个目标。毫无疑问，这个计划对艾滋病问题有所缓解，但是对于258,000,000的投入来说，这个计划所起到的作用显得太微小了。现在，Avahan即将离开，将这个项目交给了由政府运作的国家AIDS控制组织（NACO），而NASO并不愿意继承该项目的实施。对于一个缺乏预算的机构来说，不接手是个聪明的选择。如果NACO接受了这个计划，它会试着减少项目和同伴教员薪水上的开销。
五星行动计划
当盖茨基金会决定在印度开展工作时，就具有了明显的优势。它决定聘请商业领域最具智慧的人应用最合理的管理方式来运作它的项目。Avahan准备了邀请最好的老板以及在麦肯锡公司咨询调查的资金。招聘人员锁定了Ashok Alexander, 他曾经花了17年将印度的企业加入到全球竞争的行列。"他们给我了一个我不能拒绝的邀请，"Alexander坐在他新德里豪华的办公室里回答道，"我喜欢HIV/AIDS计划的挑战性，并且这个机会让我可以从事一些新的事情。"
很快这个15人组成的团队就到位了。他们中的10个人来自私人部门。团队成员处理艾滋病问题以及他们在麦肯锡咨询得出的问题。Alexander的办公室准备好了大量的数据，以及一张包含上百种颜色的点来区分整个国家疾病的地图。暗语：Avahan是"风险"、其AIDS预防项目是"公民特权"、性工作者是"消费者"。
经典的商业原则帮助Avahan大规模地在6各地区同时启动。但是由于缺乏公共健康经验也导致项目质量上打了一定折扣。Tejaswi Sevekari是一个叫Saheli的性工作者抵抗AIDS的组织的负责人(该组织在Pune) ,他记得在国际探路者（一个与Avahan合作的NGO）工作时发现的问题：数据的收集和报告完全是用英文并且没有图片。5年以后，仍旧是这样；这个项目没有完全放弃使用英文，尽管没有"消费者"能够理解这个语言。
Avahan以金字塔的形式运行，Alexander 以及他的团队成员监督超过100家NGO的工作运行情况。很多方面都体现出了他们经验的缺乏。当Avahan引进了一辆造型优美的移动车并用它带着诊所直接到妓院的时候，这个外表看起来高贵的交通工具引起了众人的怀疑。在Mukta诊所，Laxmi Mali医生说：性工作者们一开始以为这是警察或者是政府派来的车，所以他们拒绝了诊所提供的帮助。
相关资料连接
Ashok Alexander 访谈
http://business.in.com/showinterview.php?flag=p&id=1182
错误的出现
早期的失误可算作是轶事。而在2005年，一个内部评估显示了Avahan所作努力中的很大比例是浪费。Avahan的外展计划联系到了31,000各社群成员，但是只有其中的11,000人真正来过诊所。Avahan的负责者们认为不需要他们讲解过多，同伴教员已经完全了解了干预服务；但事实是他们并不了解。
Avahan对于扩大规模的追求也意味着它的确超越了不少。一开始在6各地区轰轰烈烈的开展工作，在南部为卡车司机开放了多达50个服务网点。但是，到2005年中期，只有12%的卡车司机了解了他们提供的服务。并且只有7%的司机在使用这些服务。这迫使Avahan将服务站点减少到20个。由于相同的原因，Avahan的6,000个性传播感染服务中心被减少到只有800个。
Alexander的团队试图处理这些状况。例如，Avahan尝试着消除性工作者的恐惧（如她们对移动服务车的怀疑），Avahan聘请性工作者们来充当服务项目和社群之间的联络人。一个她们内部的人更有说服力。但是Avahan支付社群联络人工资的行为引起了争议，因为其它的NGO无法招募性工作者作为志愿者。
在2008年AIDS刊物上刊登的一系列评估都展示了评审团注重项目的效果和影响。由盖茨基金会支持的这些评估重于不同方法收集数据。一个设法确定Avahan是否在Karnataka地区的控制HIV上作了重要贡献的研究显示出：无法证明Avahan在其中扮演了重要的角色。
所有的钱都去了哪里？
Avahan使得印度应对艾滋病方面出现严重错误的关键是他们花费经费的方式。Avahan的运行费用昂贵，经费花费不停出现问题。在某地著名的安全套需要10分钱，那Avahan的经费花在了何处？这很难说，因为Avahan非常独立。Avahan每个月卖出5,000,000只安全套并且发出安全套10,000,000只。当被问到为何要在安全套上花费这么多时，Alexander笑道，说，"实际情况复杂得多。"进一步调查，Alexander立即说他不知道财务的事情，他也不能出示财务开销清单。
一块是路程的费用。Jonty Rajagopalan, Avahan 的项目官员从2006年到2008年说她每个月乘飞机从她在Hyderabad的基地到她在Andhra Pradesh和Tamil Nadu的所关注的地区。另一个块是薪水。Avahan每年的年薪总额是424,894美元，如果不包括总裁和项目运行官员，这个新水在全球的基金会中排第二。Avahan目标干预官员的薪水也是普通NACO官员薪水的3至4倍。
Avahan的营销方式也十分流行。Eldred Tellis是Sankalp的负责人，Sankalp是孟买的一家关注艾滋病的NGO，与Avahan一同工作，他说他曾经看到大量的资金投入制作纸质精美的印刷品，用于印刷项目的报告；而用在人身上的钱是很少的。小额信贷机构Basix的负责人Vijay Mahajan的评价是：Avahan有大量的资金和人才，但是产出的实际效果却很少。
一个不确定继承者
当知道要继承这个项目的时候，NACO派出了评估小组到4个国家去寻求资金支持。NACO的负责人Sujatha Rao说：评估得出的信息是NACO没有能力继续支持这个项目中的大部分内容。"我们告诉他们你们没有能力创造出大量的资产将其转交给政府来做吧"Rao说道。
但是Alexander不同意。"我们不会是永久的资助者，我们试图催化出新的，"他说。他相信艾滋病的流行无论有没有资金都会得到遏制。Avahan现在重新定位，关注孕妇和新生儿的健康。
UNAIDS 的顾问及Humsafer Trust的负责人Ashok Row Kavi认为Avahan的期望是不现实的。"他们希望艾滋病在5年内消失，要做到这一点的话，大量的人会死去。"
NACO的年度预算是225,000,000美元。目前没有花在Avahan上。Rao 只是没有找到足够的钱来继续这个项目。"我们永远不可能复制一个相同的运作模式，如果我们不能将这个项目维持下去，那么他们之前的努力就等于0了"她摇头说道。
当讨论到把这个大项目转交给政府时所遇到的困难时，Alexander说这样的转接会是很好的。Kavi不同意，他说关于NACO与盖茨基金会关于将项目转给政府的讨论已经遇到了障碍。资金需要落实但是他们还没想到办法。他仍然担心Avahan的有经验的管理者会因为工资的缩水而离开。一个装有空调的Avahan诊所的运行到是还没有遇到问题。
质量上最大的漏洞将要出现，这个漏洞将造成很大的伤害。Mukta诊所的顾问Hussain Makandar担心安全套的问题以及性工作者停止使用安全套的问题。
Alexander坚持认为项目中的1/10可以转交给政府而剩余的那些都要等到下五年才能缓慢的进行。"我们正在做一个过度的计划，我们并没有说'这个项目在这，我们走了'"。但是NACO以及Mukta的官员等人都对计划表表示迷惑。
最后的Avahan报告：
目标3：发展一个能够让政府继续实施的艾滋病预防模式。尚未实现。
目标2：在全国范围内扩展这个项目。Avahan的项目开展不超过6个地区。尚未实现。
目标1：遏制疾病的流行。官方的统计数据表明印度艾滋病患者从5,100,000下降到2,400,000。这只是统计上的变化，并没有健康上的提升。影响还未知。
回到巨大的印度的性服务领域，卖淫是一个在增长行业而安全套却是一个例外。"每个月都会有新的
面孔在妓院里出现，"Mali说，"20%的人现在被感染，和我们一开始做项目的时候一样。"
Why would a clinic serving illiterate visitors use more English than Indian languages?
The answer lies in where that money comes from. The Pune clinic is part of a network one hundred-plus non-governmental organisations (NGOs) working under the umbrella of Avahan, India's largest HIV prevention initiative. Avahan, or "call to action," is a brain child of the world's largest philanthropist: Bill Gates.
Gates had announced the 10-year, $100-million initiative to stop the spread of HIV/AIDS in India during his much heralded visit to the country in November 2002. This was to be the largest of its kind for the Bill & Melinda Gates Foundation.
The timing couldn't have been more appropriate. After nearly two decades of piecemeal efforts to counter HIV, India was hurtling towards an AIDS epidemic. Millions of poor people exposed themselves to the dreaded virus due to a lack of awareness. Government agencies and NGOs didn't have the money to preach safety or treat the infected. Gates showed his seriousness by later raising the budget to $258 million.
Seven years later, back at the Pune clinic, Fathima has counselled the women, given them the sheaths of safety and sent them back. It is time to worry about the future. The bad news is Avahan is ready to pack and go; and Fathima is set to lose her income. She doesn't want to slip back into prostitution. At the age of 45, she doesn't have much of a career there anyway.
When it started on the ground in 2003, Avahan set for itself three goals: Arrest the spread of HIV/AIDS in India, expand the programme from the initial six states to across the nation, and develop a model that the government can adopt and sustain so that the project could be passed on to it. More than five years later, Avahan hasn't achieved any of these goals. Doubtless, the initiative has made a dent into the HIV/AIDS problem, but the impact is marginal for a bill of $258 million. And now Avahan is leaving, handing over the reins to the government-run National AIDS Control Organisation (NACO), which doesn't want to inherit it. It is too expensive for the budget-starved establishment that is as nimble as a sloth. If NACO takes over, it will try to prune the costs of the programme. Salaries for peer educators will go.
A Five-Star Initiative
When it started on the ground in 2003, Avahan set for itself three goals: Arrest the spread of HIV/AIDS in India, expand the programme from the initial six states to across the nation, and develop a model that the government can adopt and sustain so that the project could be passed on to it. More than five years later, Avahan hasn't achieved any of these goals. Doubtless, the initiative has made a dent into the HIV/AIDS problem, but the impact is marginal for a bill of $258 million. And now Avahan is leaving, handing over the reins to the government-run National AIDS Control Organisation (NACO), which doesn't want to inherit it. It is too expensive for the budget-starved establishment that is as nimble as a sloth. If NACO takes over, it will try to prune the costs of the programme. Salaries for peer educators will go.
A Five-Star Initiative
When Gates Foundation got down to work in India, the priority was clear. It decided to hire the best minds in business to run its initiatives using sound principles of management. Avahan was ready to spend what it takes to get the best bosses and started its search at McKinsey, the consulting powerhouse. The recruiters zeroed in on Ashok Alexander, who had spent 17 years turning Indian businesses into global challengers. "They made me an offer I couldn't refuse," Alexander recalls, sitting at his plush office in New Delhi. "I liked the ambitious arch of the HIV/AIDS programme and it was a chance for me to do something new."
Soon, the 15-member team was in place. Ten of them had come from a private-sector background. The team members tackled HIV/AIDS much as they would a problem at McKinsey. Alexander's office is papered with data and maps containing hundreds of coloured dots plotting the disease across the country. The argot is sheer B-school: Avahan is a "venture," its HIV/AIDS prevention programme a "franchise," the sex worker the "consumer."
The classical business principles helped Avahan start on a big scale in six states simultaneously. But the lack of public health experience also led to a compromise on quality. Tejaswi Sevekari, director at Saheli, a sex workers' collective for HIV/AIDS in Pune, remembers observing the kinks during her stint at Pathfinder International, an NGO that works with Avahan. Data collection and reporting were entirely in English and had no pictures. Five years later, the scene is the same; the project hasn't fully given up on English though no "consumer" understands the language.
Avahan operated in a pyramid, with Alexander and his team overseeing the work of more than 100 NGOs. The lack of practical experience at the top manifested itself in different ways. When Avahan introduced sleek mobile vans to bring clinics directly to the brothels, the expensive-looking vehicles were sometimes met with intense suspicion. At the Mukta clinic, Dr. Laxmi Mali says sex workers initially thought the van was from the police or the government. They refused help.
| Related |
False Moves
The early missteps are largely anecdotal. But in 2005, an internal evaluation showed a big portion of Avahan's efforts had gone to waste. As many as 31,000 community members had been contacted by Avahan's outreach programme, but only 11,000 actually visited the clinics. The Avahan executives had assumed the peer educators would already know what the prevention services were without explanation; the reality was they didn't.
Avahan's craving for scale also meant it overshot quite a bit. It started with a bang in six states, with 50 sites for truckers in the south. But by mid-2005, only 12 percent of truck drivers were even aware of their services, and only 7 percent took advantage of them. This forced Avahan to reduce the sites to 20. For similar reasons, Avahan's 6,000 sexually transmitted infection (STI) centers were brought down to just 800.
Alexander's team tried to fix the glitches. For example, Avahan tried to allay the fears of sex workers (such as those who had met the mobile van with suspicion) by hiring them to act as intermediaries between the programme and communities. An insider could be more persuasive. Good idea, but Avahan's decision to pay them a salary has come in for criticism, because other NGOs can't recruit sex workers as volunteers.
A series of evaluations published in the AIDS Journal in 2008 show that the jury is still out on the programme's impact. The evaluations, funded by the Gates Foundation, were mostly on the methods of data collection. One study, which sought to determine whether Avahan was responsible for the decline in HIV prevalence in Karnataka, failed to prove that it played a key role.
Where Has All the Money Gone?
At the core of Avahan's failure to make a serious difference to India's fight against AIDS is the way it spent money. It was an expensive operation, never tired of throwing money at the problem. In a country where a branded condom sells for just 10 cents, what did Avahan spend on? It's difficult to say because Avahan's finances are largely opaque. Avahan's outlets sell five million condoms a month and distribute another 10 million. Asked how so much could be spent on condoms, Alexander laughs, saying, "It's a bit more complicated than that." Probed further, Alexander says he doesn't know the financials off-hand, nor can he give them later.
Travel would have been one drain. Jonty Rajagopalan, Avahan programme officer from 2006 to 2008, says she would take flights every month from her base in Hyderabad to her focus areas in Andhra Pradesh and Tamil Nadu, instead of being based in a focus area. Another large chunk: salaries. Alexander's annual package is $424,894, the second-highest in the foundation globally, not including the presidents and operating officers. Avahan's targeting intervention (TI) officers are also paid three or four times what a typical NACO TI officer is paid.
Avahan's marketing was done in style too. Eldred Tellis, head of Sankalp, an HIV/AIDS-focussed Mumbai NGO that has worked with Avahan, says he has seen a lot of money go into fancy publications on high-quality paper, reporting the programme's work. Very little went to the people on the ground. Vijay Mahajan, chairman, Basix, a microfinance institution, comments on Avahan: "There is too much money and too many really smart people with too little coming out."
An Uncertain Torchbearer
Knowing that it would have to inherit the project, NACO sent out evaluation teams to sites in four states to get some clarity on costs. NACO's head, Dr. Sujatha Rao, says the evaluation threw up one clear message: Large parts of the programme are not sustainable by NACO. "We told them you can't create a huge number of assets and then just leave and expect the government to take over everything," says Rao.
But Alexander disagrees. "We are not perpetual funders. We try to be catalytic," he says, ebulliently confident that the HIV/AIDS epidemic will soon be contained, with or without the foundation. Either way, it will have to be — Avahan is now repositioning, focussing on maternal and newborn health.
Ashok Row Kavi, consultant for UNAIDS and chairman of Humsafar Trust for gay and transgender health, says Avahan's expectations were unrealistic. "They wanted HIV to disappear in five years. For that to happen, a lot of people would have to die."
NACO's annual budget is Rs. 1,100 crore ($225 million), none of it spent on Avahan currently. Rao just can't find enough money to continue the project. "We can never offer a replicable model. And if we are unable to sustain the programme, all of their effort will be for naught," she says, shaking her head.
When probed about the difficulties of handing over the massive programme to the government, Alexander says the transfer is going just fine. Kavi differs; he says that the transfer discussions between NACO and Gates Foundation are "running into a brick wall right now. Costs need to be brought down, but they can't figure out how." He also fears Avahan's now-experienced MBA-graduate TIs, facing shrinking salaries, will depart. The question of running air-conditioned clinics like Avahan doesn't even arise.
The biggest hole in quality will arise where it can hurt most. Hussain Makandar, HIV counsellor at the Mukta clinic, is worried about condoms; the ones from Avahan lubricate; the ones from NACO break and the sex workers stop using them.
Alexander insists that only a 10th of the project will transfer to the government this year and the rest will happen slowly over the next five. "We're doing a transition programme. We're not saying, 'here's the programme, and we're off.'" But NACO and Mukta officials, among others, are confused over the timeframe.
So, the final report card on Avahan:
Goal 3: Develop a model for HIV prevention that can be implemented by the government sustainably. NACO's resounding vote: Not achieved.
Goal 2: Expand the programme nationwide. Avahan could not go beyond the six states it started with. Not achieved.
Goal 1: Arrest the spread of the disease. The number of Indians living with HIV/AIDS has been officially corrected from 5.1 million to 2.4 million. This was a statistical change, not an improvement in health. Impact not known.
Back in the great Indian sex bazaar, prostitution is a growth industry and condom an exception. "New faces keep coming in every month (to the brothels)," says Dr. Mali. "Twenty percent of the people we now see are infected, the same as when we started."
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