Liberalization and HIV in Kerala

The HIV/AIDS epidemic is a good illustration of the well-established link between poverty and ill health; job insecurity can indirectly affect people’s susceptibility to diseases and infections such as HIV. Working and living conditions can put people at a higher risk for disease and infection: poverty-driven sex work and migration are acknowledged socioeconomic risk factors for HIV. It is also likely that the availability of food and access to health services influence susceptibility to disease as well as the ability to cope with ill health. Without good nutrition and health care, people with HIV succumb to AIDS more quickly.

In this context, this paper by Sandhya Srinivasan and Mini Sukumar explores the following questions: Has structural adjustment in India, implemented since 1991, increased job insecurity and loss of livelihood in the state of Kerala? Did structural adjustment put some groups at higher risk of HIV? Did policy decisions reduce people’s access to care, especially through the public health system? If so, what institutional pressures led to these changes, and how were they received?

Kerala was chosen as a case study because its excellent health indicators are acknowledged to be at least partly due to the state’s commitment to public services. However, structural adjustment programmes (SAPs) have been linked to worsening living conditions and health status, thus SAPs at the national level will have effects at the state level. Second, Kerala is a state of migrants, and migration has often been identified as a risk factor for HIV infection. The state’s reported low HIV prevalence, despite this risk factor, merited further investigation.

The Kerala model, based on public commitment to social services, survived frequent changes of state government and flourished despite the low priority given by the national government to these issues. However, several overlapping trends have combined to create what appears to be a crisis. Some of these pre-date the introduction of structural adjustment, but have accelerated since its implementation in 1991.

Since the 1980s, the state of Kerala started having difficulties paying for its social support schemes through the revenues it generated. This contributed to the decline of the extensive public health care system, forcing people to turn to the growing and unregulated private health sector. Studies indicate that household expenditure on health care has increased drastically with liberalization, sometimes forcing families into debt.

SAPs at the national level are also believed to have affected the livelihoods of various sections of the population, leaving people impoverished and in debt, and forced to work in highly exploitative conditions. Their situation is exacerbated by the Kerala government’s apparent reluctance to take action against violations of labour laws. These conditions and the resulting sharp drop in income could be pushing women into the sex trade, thereby increasing their risk of contracting HIV. Some groups may be forced to migrate to other states in search of work, which also puts them at a higher risk. While earlier official figures show that HIV prevalence has remained at a low level in Kerala, recent figures suggest a significant increase.

The Kerala AIDS programme is independent of the health care infrastructure, with separate funding and the involvement of NGOs for implementation. Yet many components of the programme will have to be implemented through the public health system. However, the public services are inadequate, while the private services—to which people with HIV are often forced to turn—are irrational, discriminatory and expensive. There are no policies implemented to protect the rights of people with HIV.

India is facing a growing AIDS crisis but, so far, Kerala does not seem to have been as affected as other states. However, if the latest official estimates suggesting that HIV prevalence may be a growing problem in Kerala are correct, the deteriorating support system, further weakened by the consequences of the national SAP, may be unable to tackle the crisis as it affects Kerala.