I dare say I know more sex workers than anyone in India. I am friends with men who have risky sex with other men (MSMs) in six states. The transgenders of Chennai adopted me as a brother. I know the best places truckers stop along the highways. The last decade I have been exposed to communities and people on the fringes. How did this happen?
Ten years ago I received an offer I couldn’t refuse. The Bill & Melinda Gates Foundation asked me if I would start an India office and a programme to help stem the growth of HIV in India. India’s epidemic most affects the vulnerable groups named above. The idea was to bring prevention services to these groups.
I was ensconced in a comfortable career with McKinsey and Company. My job was to help businesses compete more strongly. I knew little about HIV and less about public health. But the chance to have an impact on this scale excited me. As I stepped into a new life, the question I was asked most frequently was: why? We named our programme ‘Avahan’, or call to action. Avahan is today probably the largest, most rapidly scaled donor-funded HIV prevention programme ever. It works in six states in the south, west and the north-east. At its height, Avahan provided prevention services in over 80 districts; distributing 13 million condoms monthly to some 200,000 sex workers, MSMs, and injection drug users. Avahan has become a partner and key contributor to India’s national HIV programme. India has a vigorous national programme and infections are declining in almost every state.
Avahan took me to an India I never knew. I visited small towns from Imphal to Mysore. I encountered the grinding poverty that forces a woman to sell herself for a paltry R50. I also discovered courage and leadership in these most marginalised and desperate communities.
Scaling up, we applied simple business principles — segmenting the sex work market, managing logistics, measuring results. We learned a lot. I believe these learnings are universal and can indicate ways to impact in areas of public health and development, which goes beyond HIV.
The first lesson is that scale is everything. When we started, many public health experts thought that the scaling up of HIV prevention is impossible. The most fundamental reason was that the consumer — the sex worker — was hidden and mobile. There was little data. Massive stigma made the prevention service delivery difficult. We demonstrated that there are several routes to scale. The most important is creating an active and aware consumer who excitedly demands your product. A few weeks from starting out, I sat with 20 sex workers on the mud floor of a dark hut in the outskirts of Visakhapatnam. “HIV will kill you if you don’t use condoms. You’ll be dead within 10 years,” I said earnestly. They looked at each other. One, Kollama, said quietly: “Why don’t you tell us something we don’t know? Ten years is a lifetime. Tell us how to find a life without violence.”
McKinsey hadn’t prepared me for this. The consumer didn’t want the HIV prevention product. She wanted another ‘product’ — a life free from violence. It dawned on to me that the two were associated. Violence often related to sex without a condom. If we tackled violence, we’d boost safe sex.
But how could we solve a pervasive social problem? Despairing, we put the question to the community. The answer came in the form of Crisis Response Teams. If a sex worker was picked up by police to be abused at the local thana, she uses her mobile phone. Some 15 shouting, militant sex workers would show up quickly, accompanied by a local lawyer or media person who worked pro-bono. The police would back down, even apologise.
Our programme soon came to be known as the Violence Reduction Programme. Sex workers flocked to our community centre to join the local group. In the process they also received instructions on safe sex. Crisis teams mushroomed, and consequently ‘Avahan’ scaled rapidly, reaching over 600 towns in six states in a little over two years.
Over 15,000 community groups across Avahan manage violence. Each had established systems of self-governance, including performance appraisal; that good corporates can learn from. They elect office-bearers democratically. They are linked through taluk, district and even state level networks. These groups look for sustainability that will last long after the donor is gone.
This was our second learning. The consumer had to be king — or rather the queen, in our context. If the community is at the centre, scale will follow. Many public health programmes ignore this. Programmes deliver products assuming the consumer wants them. Elegant solutions are created in air-conditioned offices. Thinking on scale is absent. Pilots are created in the futile hope that someone else will scale things up.
Beyond HIV, the third learning was that business thinking and public health know-how can be married to achieve the rapid scale-up of needed solutions. Are business people out there who want to make a social difference listening?
The mantra of scale through the community at the centre is universal. In Bihar, we are testing if breast feeding or tackling malnutrition can be scaled the same way Avahan changed my life, and set it on a different trajectory. Last week I announced that I would soon leave Avahan and the Gates Foundation, to pursue other dreams. Again I am asked: why?
But why not?
Ashok Alexander is the outgoing country director of the Bill & Melinda Gates Foundation
The views expressed by the author are personal