The Dance of Dependence

The latest amendment to the law introduced critical changes in how organizations could accept foreign money. Among other things, receiving funds only in an account in the State Bank of India branch in New Delhi became mandatory. Non-governmental organizations (NGOs) were barred from transferring foreign grants to other NGOs in India, and a lower ceiling on administrative expenses was prescribed. The government could also suspend the use of funds merely on a reason to suspect misdoing. NGOs across the country, many of whom had their licenses expiring that year, were given time until December 31, 2021, to align themselves with these new regulations.

These new rules were a huge setback for NGOs, volunteer groups, and other associations and sent them scrambling into the lengthy process of renewing licenses. While the public and private healthcare infrastructure creaked and groaned under overwhelming cases, much of the population depended on such organizations to provide medical relief. According to a report in The Hindu, the uncertainty of violating the provisions of the FCRA prevented many large donors from donating critically necessary equipment, such as oxygen production plants and concentrators for hospitals and charities, adding stress to an already burdened health infrastructure. In India, more prominent NGOs such as CRY work with a network of smaller NGOs through sub-granting. SOUL, working with the education of tribal children in the Sunderbans, is one such NGO, but under the new FCRA rules, the more prominent NGOs it relies on are now restricted from sharing funds with them for carrying out their work, and SOUL fears being shut down. Such organizations are unable to raise money independently and are dependent on their larger networks. According to experts, one of the most significant consequences of this move will be the reduction of such grassroots-level work.

Earlier in May, Amitabh Kant, then CEO of NITI Aayog, had emailed NGOs registered at their Darpan portal, appealing to them to join hands with the government in this crisis. Later, in an article for the Indian Express, he wrote, "Civil society, and voluntary and non-governmental organizations constitute the backbone of collective articulation of citizen interest in a democracy. As facilitators, mediators, and advocates of this interest, they have put people before everything else during this pandemic crisis." and went on to iterate the importance of their work.

Non-governmental organizations, if taken literally, would include the entire private sector, which would be misleading. Aside from not being under government control, three significant factors define what is commonly referred to as an NGO. For starters, they are registered as societies and public trusts, making their donors eligible for tax relief. Second, they primarily work in the 'development' sector, where their activities can range from promoting education, providing healthcare and housing, or carrying out relief work to advocacy and research. Finally, they are generally non-profit and do not generate their own funds, instead relying on external agencies and donors.

NGOs in India have evolved significantly from their ancestors; understanding them as they are now requires tracing some of that past.

This change was not wholly organic and took place against the backdrop of the global economic crisis of the 70s and 80s. As countries, especially developing countries, underwent a wave of privatization in response to the recession, India, too, experienced a neoliberal transition of its institutions around this time. While these ideas were a part of existing discourse in the government anyway, much of this was accelerated by the conditions of the Structural Adjustment Programs (SAPs) led by the International Monetary Fund (IMF) and the World Bank, under which India accepted money to help it deal with the economic breakdown. India negotiated terms with these institutions and after much deliberation, accepted them.

In simple terms, the SAPs required the state to cut back its involvement in critical sectors and open them up to the free market. This included healthcare too. The National Health Policy of 1983 had already echoed this view by mandating a plan of “...[reducing] government expenditure” and “[encouraging] investment by nongovernmental agencies in establishing curative centers and by offering organized logistical, financial and technical support to voluntary agencies actIve in the health field.”

A decade later, The World Bank, in their 1993 report, prescribed a policy that reinforced those ideas.

It is hard to say with any certainty exactly how many NGOs are there in India as there is no single, complete database of this information. NGO Darpan has 1,54,099 self-registered organisations. In a 1992 report, The Ford Foundation stated that there were about 100,000 NGOs registered with the government as private societies. One-eighth of them, or around 18,000, are development organisations, "ranging in size from such well-established groups as SEWA, which now counts 50,000 members across India, to two or three people working as activists in a village or an urban slum." A CBI census of NGOs arrived at a minimum of 31 lakh NGOs and other government reports contain different figures.

AIDS has claimed approximately 40 million lives worldwide since its discovery in 1981. It is an epidemic that has spread in several ways around the world, often impacting communities that are already socially and politically marginalized. The Western reaction to the epidemic was strong, and bolstered by the need of the hour, research was accelerated and antiretroviral therapy (ART) was introduced in 1996 at the International AIDS Conference in Vancouver, Canada – reported to reduce AIDS-related deaths by between 60% and 80%. AIDS was transformed from a horrific death sentence to a manageable disease in the West in under 20 years.

The ART treatments were efficient but expensive, and it would take another decade before they became generally accessible in low- and middle-income nations. At this time, help was difficult to come by because the issue appeared to be under control in North America. It doesn't, however, imply that it wasn't still widespread in other regions of the world, such as Africa and Latin America. The United Nations established UNAIDS in 1996 to coordinate the worldwide effort to battle AIDS, and it published a report in 1998 that showed the scope of the issue. It emphasized the need for more financing and the introduction of comprehensive programmes that addressed the disease's multifaceted difficulties, including mortality, stigmatization of those affected by it, and the diseases' economic and political repercussions.

The last argument is what really drove action towards the diseases. It was claimed that HIV/AIDS may obstruct democratic processes by impeding socioeconomic advancement and escalating the competition for resources. As potential recruits for terrorist and rebel organisations, AIDS orphans were also suggested to be a source of societal instability. And so it came to be that the alarm was raised again. According to a paper published by Copenhagen Consensus, a think-tank in Denmark, HIV/AIDS was ranked as the number one economic priority in terms of its cost-benefit analysis. When the Gates Foundation entered the arena towards the close of the millennium, AIDS became the biggest focus for the next decade and more.

In India, AIDS was first identified in 1986. With the ensuing panic about the disease across the ocean in Africa, the government also set itself to work to assess and contain the situation at home. An original report by the UN estimated the infection rate to be 0.9 percent, or 5.7 million people, across India. This survey was done by employing hundreds of monitoring sites to test the blood of expectant mothers and high-risk groups including injecting drug users and sex-workers over four months each year. It is easy to see why this number would be skewed, is it not? The sample that was surveyed did not fully reflect the general population. This was confirmed in another survey in 2007 when another population-based survey tested blood samples from 102,000 individuals for HIV in the general public rather than just certain categories. It revealed that number to be 0.36 percent (out of the 1.1 billion population). India's HIV caseload had been significantly overstated.

This does not imply that the sickness is not significant. Every life lost is important. But greater attention than ever before was paid to the exceptional help provided to AIDS and the disease-specific programmes that it inspired. The AIDS epidemic was the easiest topic to get funding for 20 years ago if you wanted to organize a medical conference. Numerous studies have examined how researchers and non-governmental organizations (NGOs) moved through the AIDS-focused environment, choosing to take on work merely because it was the only option to ensure financial security.

The health systems in nations that offer high-quality healthcare to all of their citizens are effectively regulated by the government and supported by taxes and social insurance payments. These nations do not divide their populations according to employment status or income to receive health benefits, and their healthcare providers have cultivated a strong culture of ethics. Furthermore, these nations ensure that healthcare is maintained as a public benefit rather than subjecting it to market vagaries.

Healthcare is a fundamental human right that should be accessible to all individuals, regardless of their socio-economic status. States with a greater presence of the private sector in their healthcare systems tend to have higher healthcare costs and poorer health outcomes. In contrast, states with a stronger public healthcare sector have lower healthcare costs and better health outcomes. This is because the private sector is driven by profit, whereas the public sector is focused on providing necessary care to the community.

When healthcare is privatized, private companies often rely on funding from private donors in addition to government funding. This funding can come from a variety of sources, including individuals, foundations, and corporations.

However, the allocation of this private funding is not always based on objective criteria. Private donors may choose to fund specific types of healthcare services or research based on their own personal beliefs or interests. This can lead to a distorted allocation of resources within the private healthcare sector, where certain services or research areas are overfunded while others are underfunded.

Furthermore, private funding can also affect access to healthcare. Private donors may choose to fund services or research that is only available to certain groups of people, such as those who can afford to pay for care or those who live in a certain geographic area. This can create unequal access to healthcare within the private sector, with some individuals having access to a wider range of services and treatments than others.

Governments preach about providing universal access to healthcare, but their actions and policies reflect a fragmented and selective approach that results in extreme impoverishment and access to healthcare imbalances. If this is to change, healthcare must be made into a public benefit and separated from the market. There is no reason India should be any different from the other nations headed this way. In reality, certain states, like Mizoram, Sikkim, Goa, Pondicherry, and the Andaman Islands, are already on that path and spend more than Rs. 4000 per person on healthcare in their budgets. They do so because they lack a strong private sector and have an effective primary healthcare system. We must demand change and work toward removing healthcare from the market's grasp and turning it into a public good.