Ashok Alexander, Director, Avahan-India AIDS Initiative, Bill and Melinda Gates Foundation

Earlier this year, I left a long career with McKinsey & Co for an offer I just could not refuse-to head Avahan ("call to action")-the India aids Initiative of the Bill and Melinda Gates Foundation. The India that I have seen with Avahan is very different from any I knew before. I have traveled to extraordinary places and met remarkable people. I have interviewed devdasi sex workers in Bagalkot, swapped jokes with truckers outside Vishakhapatnam, and looked at the world through the eyes of barely teenaged injecting drug users in Imphal.

These experiences have given me two learnings. The first is that there are two very different Indias, and tragically, these scarcely meet. The second is that sound business principles can be a key to tackling the HIV/AIDS epidemic in India.

First, there is the India that is shining. This was the India I had seen from my vantage point at McKinsey-the India of great it companies, skilled knowledge workers and heady economic growth. It is an India driven by business people confident in taking on the world. It is an India that is going places, an India of which we are all proud.

But there is another India that does not shine, indeed offers barely a flicker of light to the millions that live within it. This is the India which has some of the world's most devastating healthcare challenges, and a vastly inadequate public health system.

There have been some large health gains since independence, including the steep improvements in life expectancy, infant mortality and crude birth rate. India has established an impressive three-tiered system of public health infrastructure. Small pox and leprosy have been contained, and the polio campaign has been a success. Yet, all these mask wide disparities-between states, urban and rural areas, and above all between rich and poor. According to an NCAER study, the richest 20 per cent receive three times the share of public subsidies spent on the poorest quintile. The poorest 20 per cent have more than double the mortality rates, fertility rates and malnutrition rates compared to the richest 20 per cent. And for a state that promises universal healthcare, India has one of the lowest public health budgets in the world-at 0.7 per cent of GDP, it's about half that of Bangladesh.

One of the biggest failures is our failure to control communicable diseases, despite the availability of relatively low-cost solutions. These diseases kill over 2.5 million children below the age of five and an equal number of young adults every year.

But if there's a problem that has the potential to wreak widespread havoc in this fragile healthcare system, it is HIV/AIDS. Yet, there is only a poor understanding of this epidemic or the fact that it could become the major barrier to the country's economic development. HIV/AIDS is like the proverbial elephant surrounded by blind people-most sensing its presence, but grasping only a small aspect. Three elements make it particularly vexing.

• Multiple epidemics: India has some 4.6 million people currently living with HIV/AIDS, and six states are in a situation of generalised epidemic. The factors that contribute to the epidemic vary even from district to district.

• Dispersed risk-groups: Only about 5 per cent of commercial sex work in India happens in brothels. Moreover there is high mobility-of sex workers as well as clients-making small and dispersed high risk-groups difficult to isolate for intervention.

• Stigma, apathy and denial: Public awareness has risen. However, in most of India, the epidemic is characterised by stigma, apathy and denial-all of which act as barriers.
• Given the proportion of the challenge, the response so far has fallen short.

• Inadequate funds: That too much money is going towards addressing HIV/AIDS is a myth. India currently spends about 11 cents per capita to tackle the epidemic. In contrast, Uganda spent $1.80 and Thailand $0.55 per capita. We need at least a 10-fold increase.

• Gaps in existing programs: Too often, awareness efforts have ended up stigmatising risk-groups; there is inadequate attention to other infections (such as syphilis) which alter the HIV/AIDS risk; programme components are not well integrated; or the mechanisms to transfer best practices and scale up a good solution are missing.

• Capacity to implement: India has a large and vibrant NGO network, many focusing on HIV/AIDS. However, the influence of these implementing agencies is largely limited to a small local area or a particular high-risk group. There are few implementation agencies with a national or state-level programme.

Our plan features six linked strategic initiatives. At the core is a prevention programme focusing on the six highest prevalence states and the entire national highway system. This is supported by initiatives in communications, advocacy, knowledge building, impact measurement and capacity building.

Avahan seeks a scaled, yet precise, plan of action. In developing our strategy, we have borrowed ideas from the world of business. These include market segmentation to get a grip on the problem; achieving scale through standardising service delivery and appropriate partnerships; strategic alliances; and exact measurement of impact.

• Segmentation: Given the staggering numbers involved, we have carefully 'segmented the market'. We have defined our theatre as not six states, but some 80 key districts within these. We have zeroed in from over 7,000 km of national highway to 50 key trucker halts. And we are focusing initially on about 300,000 commercial sex workers most at risk.

• Standardisation for scale: India has one of the highest levels of sexually transmitted infection (STI). Treatment is often undependable. Avahan is creating a national franchise for STI services to bring the myriad healthcare providers under one brand that stands for reliable STI services.

• Partnerships for scale: The Indian Oil Corp (IOC) and the Transport Corporation of India (TCI) are key in implementing our national highway programme. IOC provides potential access to some 4,000 petrol pumps that serve as information and service points. TCI ensures access to thousands of trucks everyday, and involves truckers.

• Strategic alliances: We are creating coalitions. For example, IOC and TCI will work with Population Services International (condom distribution using a "social marketing" approach and franchised STI services) on the highway programme. In Andhra, two partners-Hindustan Latex FPPT with grassroots knowledge, and the International HIV/AIDS Alliance, with community involvement skills-bring complementary skills.

• Measuring impact: In the world of public health, impact has rarely ever been measured with corporate rigour. In HIV/AIDS, the gains from many prominent national programmes have never been well estimated. We, however, are commissioning an independent agency to give us a rigorous framework for monitoring and evaluation.

Business can be a powerful voice of advocacy in changing attitudes towards the epidemic. We are proud that some of the most respected leaders of Indian business have agreed, so far, to join our board and guide Avahan's efforts. After McKinsey, this is an altogether different challenge, but I feel I have a sound compass in my business training. I am convinced that the way forward is in creating the right set of unions-between business and social sectors; and between the India that shines and the one still in the shadows.