Gender Responsive Budgeting and HIV/AIDS

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Gender Responsive Budgeting and HIV/AIDS Aasha
Kapur Mehta Professor of Economics Indian
Institute of Public Administration Indraprastha
Estate Ring Road, New Delhi aashakapurmehta_at_gmail
.com
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Gender Budgeting Purpose
The purpose of Gender Budgeting is to focus on
needed outcomes and reprioritise expenditure to
attain those outcomes. The challenge is to use
the Gender Budgeting as a means to get the
Gender-just allocations and outcomes in every
ministry and every sector.
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The Budget - Outcome Disconnect in the context of
HIV/AIDS

• Despite the huge success in placing gender and
  HIV/AIDS on national and international agendas
  there remains a sharp disconnect between funds
  allocated to HIV/AIDS and meeting immediate,
  real, grassroots micro needs.
• Ill health related shocks
• exacerbate the distress of those who are poor and
• drive the non-poor below the poverty line.
• Most Indians do not have insurance and borrow
  heavily or sell assets to cover expenses.

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The Problem Entry into Poverty due to Ill Health

• Any chronic or long duration illness can
• drive the non-poor below the poverty line.
• exacerbate distress of those who are poor
• The National Rural Health Mission notes
• 25 percent of Indians fall below the poverty line
  because of hospital expenses.
• Hospitalised Indians spend on an average 58
  percent of their total annual expenditure on the
  medical care.
• Most do not have insurance and borrow heavily or
  sell assets to cover expenses.

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The Immediate Cause and Context

• Immediate Cause Being Infected or Affected by
  for eg HIV/AIDS
• Context Planning Commission estimates that 27.5
  of Indias population (301.7 million people) were
  below the poverty line in 2004-05.
• Panel data 25 of those who are not poor enter
  poverty due to ill health, disasters and other
  factors.
• The number of persons infected with HIV/AIDS
  ranges from 5.7 million to 2.47 million depending
  on methodology, coverage and source.

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Identifying Consequences

• Three Cases
• of Persons who are
• HIV infected and affected

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Case 1 Woman on footpath Entry into Severe
Poverty, Deprivation and Desperation X and her
family are suffering the worst form of stark
poverty. Home is a 6 foot by 6 foot space, on a
footpath in Kurla in Mumbai under a makeshift
roof made of a plastic sheet. Her husband used
to work as a plumber. He earned Rs 3,000 per
month before he started falling ill. She sold
her jewellery for Rs.10,000 four years ago, when
her husband was very unwell. The doctor told
him to take medicine for six months. The
medicine costs Rs. 800 per month. They cannot
afford this, So he took it for four months and
then discontinued it. Source Aasha Kapur Mehta
and Sreoshi Gupta, UNIFEM and IIPA, 2006
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He is HIV positive. She looks after her husband
when he is unwell. Her husband is now taking ART
but suffers from fever, vomiting, diarrhoea and
weakness. There are days when he cannot get up.
When he is okay he can take own medicine. When
he is unwell she has to take leave to care for
him. He is sickly and often needs to have his
feet pressed or head pressed. She, so far, is
HIV negative. She has six children to feed. With
no income and nowhere to live they started living
on the footpath and she started working. The
Mumbai Municipal Corporation demolishes the tiny
space they live in every few months. Source
Aasha Kapur Mehta and Sreoshi Gupta, UNIFEM and
IIPA, 2006
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An NGO heard that they were going to commit
suicide so they they started helping the family
with basic rations, medication and educational
expenditure for children for a few months to be
tapered off once things stabilise. She has
started working as a part timer and cleans
floors and washes utensils and clothes. Earlier
she was able to work in 3 houses and earned
Rs.1500/-. Now she too is keeping unwell so she
works only in 2 homes and earns Rs 1200/-. They
have to visit the hospital for medication several
times each month and each visit is expensive.
They have to spend on x-rays and CD-4 tests, so
she had to borrow money from the houses where she
works. Source Aasha Kapur Mehta and Sreoshi
Gupta, UNIFEM and IIPA, 2006
10
Case 2 25 year old Maid
Z is a 25 year old woman with 2 daughters. She is
HIV positive. Her husband died of HIV/AIDS. She
works as a domestic servant and earns Rs 1800 per
month. She spends Rs 1500 on ARV medicine in the
of getting access to ARV from the govt hospital.
Her major worry is providing for her daughters
and what will happen to them after she dies.
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Focus Group Discussion with Commercial Sex
Workers in Mumbai

• A focus group discussion with about 30 commercial
  sex workers who are part of the CCDT Roshni
  Project in Mumbai made it clear that the worst
  affected are the CSWs. Consequences include-
• Being thrown out of the brothel.
• Many of their sakhis getting admitted to crisis
  centers and some to the hospice at the terminal
  stage. There is no hope and the future bleak.
• No place to live, no place to rest, or bathe or
  use the toilet or wash clothes.
• Police do not allow them to stay on the road and
  often take them into custody.
• Source Aasha Kapur Mehta and Sreoshi Gupta 2006

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• The most frequent opportunistic infections
  suffered by CSWs are tuberculosis and diarrhoea.
  Fever is also frequent.
• If work is available and they are able to get
  customers, they work.
• If the work pays decently, they may eat, but on
  other days, they go to sleep hungry.
• When they reach the terminal stages, they are
  admitted to a hospice, where there is no charge
  for either stay or cremation.
• A major source of worry is the future of their
  children. Long term rehabilitation options that
  can enable a safe future for their children are
  vital sources of support.
• Source Aasha Kapur Mehta and Sreoshi Gupta 2006

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Consequences of being infected or affected by
HIV/AIDS

• Shock and anger on discovering HIV status.
• Fear.
• Stigma.
• Loss of work/Inability to work
• Financial problems
• Frequent opportunistic infections,
• Financial burden increases due to medical costs.
• Children drop out of school due to financial
  problems.

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Consequences of being infected or affected by
HIV/AIDS

• Reduced access to food and nutrition.
• The wife has to start working due to Majburi and
  she becomes responsible for supporting the
  family.
• Increase in debt.
• Selling of assets, mortgaging of property,
  selling of jewellery etc
• Need for care medical, emotional, physical,
  financial, nutritional, spiritual
• Early marriage of children is common if a parent
  is HIV positive.
• Additional..

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Caregivers and Gender

• Out of 2,376 PLWHA interviewed in one study,
• 29 (683 persons) reported that they needed care
• Women accounted for 70 percent of the 882 persons
  reported to be caregivers
• 20.7 percent of women caregivers were HIV
  positive
• Source NCAER Socio Economic Impact of HIV and
  AIDS, 2006

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HIV/AIDS and Care Needs

• Care covers a range of services and activities
  which include physical, clinical, emotional,
  financial, nutritional and other dimensions.
• Care is primarily provided by
• the medical care system,
• at home, where the primary burden of care giving
  falls on women, though care givers may also
  include the elderly, children and men.
• Source Aasha Kapur Mehta and Sreoshi Gupta,
  UNIFEM and IIPA, 2005

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Physical Care can include bathing the patient,
taking him to the toilet, turning bedridden
patients to avoid bedsores, providing water
feeding the patient, cleaning, washing
bedclothes, dishes, utensils, etc. Emotional
care is an important component of care due to
depression and stigma. Medical Care involves
provision of medication at the hospital and care
during hospitalisation. Source Aasha Kapur Mehta
and Sreoshi Gupta, UNIFEM and IIPA, 2005
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Nutritional care is extremely important for an
HIV positive person. Households that are below
the poverty line cannot afford good nutrition.
Information regarding cheap sources of nutritious
food is often not known. Financial Care When
opportunistic infections become frequent, the
person is no longer able to work, so income
decreases very suddenly. Or when status is
discovered, you may lose your job. Medical bills
go up. Assets, however meagre are sold in
distress and the family is left shelter less.
Source Aasha Kapur Mehta and Sreoshi Gupta,
UNIFEM and IIPA, 2005
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• Assuming that there is a cure, family members run
  from one doctor to another whether herbal,
  ayurvedic or allopathic.
• When all sources of funds are exhausted the wife,
  who has never worked outside the home before,
  often takes casual work such as sweeping and
  swabbing floors in order to earn some money to
  feed the children.
• Spiritual Care needs can be provided by yoga
  experts and many people need and benefit from
  this.
• Source Aasha Kapur Mehta and Sreoshi Gupta,
  UNIFEM and IIPA, 2005

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Identifying Solutions Meeting Needs

• -Provide Accurate information regarding HIV/AIDS
  symptoms, opportunistic illness, exposure,
  prevention, medication, adherence, monitoring and
  testing and reduce the possibility of incorrect
  diagnosis,and drug resistance.
• -Allocate Funds on priority to ensure universal
  access to pre and post test counselling, medical
  care, treatment and antireterovirals,.
• - Ensure continuity of access to ARV.
• -Provide access to monitoring CD-4 counts.
• Source Based on Aasha Kapur Mehta and Sreoshi
  Gupta, UNIFEM and IIPA, 2006

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Identifying Solutions Meeting Needs

• -Involve Representatives of Positive Peoples
  Networks when PLWHA are started on ARV, so that
  they can patiently explain the importance of
  regularity in taking medicines, adherence and of
  drinking boiled water etc to avoid diarrhoea.
• Determine standards with respect to the ARV
  drugs.
• Provide universal access to clean drinking water
  and sanitation
• Provide information about the importance of
  nutrition.
• Source Based on Aasha Kapur Mehta and Sreoshi
  Gupta, UNIFEM and IIPA, 2006

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Identifying Solutions Meeting Needs

• -Meet Training and infrastructure needs of health
  care providers
• -Provide District hospitals with an ambulance and
  functional x-ray, sonography, ECG and CD-4
  machines that are maintained and available for 24
  hours each day.
• -Enable behavioural and attitudinal change of
  Health Care Providers.
• Support Caregivers by giving them Basic knowledge
  and skills about care and how to administer it.
• Provide Community Care Homes and Hospices.
• Source Based on Aasha Kapur Mehta and Sreoshi
  Gupta, UNIFEM and IIPA, 2006

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Identifying Solutions Meeting Needs

• When immunity declines, the person cannot
  tolerate diarrhoea causing pathogens. Especially
  in slums, diarrhoea/other stomach related
  problems are frequent (as is TB) as water is
• not available
• not safe
• people dont understand the importance of boiling
  water
• common bathrooms facilities are available at a
  distance and these are dirty.
• Hygienically prepared food and clean water are
  very crucial.
• Source Based on Aasha Kapur Mehta and Sreoshi
  Gupta, UNIFEM and IIPA, 2006

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Identifying Solutions Meeting Needs
Provide skills, skilled work and links with
employment or IGPs as this is critical for
dealing with financial deprivation due to loss of
income plus expenditure There is an urgent need
to provide access to social safety nets and link
the poor with employment generating projects,
networks and support groups. Additional. Source
Based on Aasha Kapur Mehta and Sreoshi Gupta,
UNIFEM and IIPA, 2006
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The Macro Micro Disconnect

• Funds are available for HIV/AIDS
• Domestic public and private funds.
• Bilateral and multilateral funds
• The Global Fund
• Brinda Karat notes that the allocation for the
  National AIDS Control Programme is Rs 720 crore
  in budget 2007-08, while the allocation for all
  the national disease control programmes taken
  together is only Rs 884 crore.
• And yet, despite several sources of funds, many
  of those who are HIV affected, do not have access
  to basic treatment and drugs.

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What can Stakeholders (Govts, UN, others) Do?
Correct the Macro-Micro Disconnect

• Use gender budgeting to increase and reprioritise
  expenditure on health so as to reduce the burden
  of ill-health and care especially for women and
  the poor.
• ii) Recognise the invisible work done by women,
  the care economy as this saves the exchequer
  considerable expenditure on public provisioning
  for care?

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What can Stakeholders Do? Re-prioritise
Expenditure to meet Needs/Get Desired Outcomes

• Relieve the work load on care givers (who are
  primarily women) by strengthening Primary Health
  Centres and Public Hospitals to ensure
• Reliable and quality Medical Care
• 24 hour functional Diagnostic Testing facilities.
• Ambulances to link PHCs to Hospitals.
• effective drugs through revised schedules
• Provide community care homes and hospices to
  reduce the burden on Home based care givers.
• Source Based on Aasha Kapur Mehta and Sreoshi
  Gupta, UNIFEM and IIPA, 2006

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What can Stakeholders Do? Re-prioritise
Expenditure to meet Needs/Get Desired Outcomes
(contd)

• Ensure universal access to preventive and
  curative treatment and care.
• Make special provisions for women patients in
  PHCs and public hospitals.
• Ensure access to safe water in the home for all.
• Ensure access to toilet facilities both in the
  home and in public places.
• Provide schemes to assist with income-earning
  for those who are ill and their families.
• Provide for the children of positive persons.
• Source Based on Aasha Kapur Mehta and Sreoshi
  Gupta, UNIFEM and IIPA, 2006