Third Draft 14 Oct. 2006
Mid-term Review Report on the National Response to HIV in Pakistan
Contents
Page
Executive Summary
1.Background and Introduction
1.1Overview of HIV/AIDS Situation and Response Analysis in Pakistan
1.2Review Methodology and Format
2.Progress against the Nine Priority Areas of the NSF
2.1The Nine Priorities of the NSF
2.2Expanded Response
2.3Key Populations Most at Risk
2.3.1Targeted Interventions – Intravenous Drug Users
2.3.2Targeted Interventions – Female Sex Workers
2.3.3Targeted Interventions – Male Sex Workers
2.3.4Other Target Groups
2.4Youth
2.5Surveillance and Research
2.6Sexually Transmitted Infections
2.7General Awareness
2.8Blood and Blood Product Safety
2.9Infection Control
2.10Care and Support
2.11Situation Summary
3.Institutional Arrangements
3.1Overall Institutional Arrangements
3.2Organisational Structure for Managing AIDS Control Programmes
3.3Staffing and Continuity
3.4Capacity Building
3.5Improving Coordination
3.7Management Information
3.8Management Contract
4.Commodities and Procurement
4.1Introduction
4.2Overall Spending
4.3Commodity Procurement
4.3.1The Budgetary Process
4.3.2Drugs and Medicines
4.3.3Screening Kits
4.3.4Consumables
4.4ARVs
4.5Condoms
4.6Procurement Issues
5.Stakeholder Analysis
5.1Participation and Coordination
5.2Building the Constituency to Scale Up the National Response
5.3Stakeholder Analysis
5.3.1The Nature of the Analysis
5.3.2The Issues
5.3.3The Stakeholders
5.3.4The Analysis
5.3.5Use of the Analysis
6.Issues and Challenges
6.1The Major Issues
6.12Susceptibility, Social Distance and Homophobia
6.3Target Populations and Coverage
6.4Bridging Populations
6.5Youth
6.6Implementation
6.7Quality of Care
6.8Communications
6.9Coordination
6.10Information
6.11Capacity Building
6.12Public-Private Partnerships
7.Recommendations
7.1Subject Headings
7.2Expanded Response
7.3Vulnerable, Target and Bridging Populations
7.4Women, Children and Youth
7.5Surveillance and Research
7.6STIs
7.7General Awareness
7.8Blood and Blood Product Safety
7.9Infection Control
7.10Care and Support
7.11Institutional Arrangements
7.12Commodities and Procurement
7.13 MIS
7.14The Four Main Strategies
7.15Determining Priorities
7.16Conclusion
Tables
Table 1 : Total National Response Expenditure compared with PC-1 Budget25
Table 2 : Expenditure on Drugs and Medicines compared with PC-1 Budget27
Table 3 : Expenditure on Screening Kits compared with PC-1 Budget28
Table 4 : Expenditure on Consumable compared with PC-1 Budget29
Table 5 : Stakeholders’ Power to Influence37
Table 6 : Stakeholder Position Map38
Table 7 : Stakeholder Knowledge39
Table 8 : Stakeholder Alliances40
Table 9 : Issues Identified and Recommended Resolution Strategies/Actions61
Charts
Chart 1 : Suggested Prototype Organisation Structure20
Chart 2: The Policy Process Framework34
1
Third Draft 14 Oct. 2006
Executive Summary
This mid-term review (MTR) report is based on the findings of the recently published 2006 update of the Situation and Response Analysis (SRA) that provided an overview of the HIV/AIDS epidemic in Pakistan, the progress of the national response and the gaps and constraints affecting it. This report assesses achievements since the 2000 SRAby reference to the nine priority areas and related goals set out in the National HIV/AIDS Strategic Framework (NSF) 2001-2006. It discusses the key areas where improvements are required in order to strengthen the national response, and makes recommendations that should be built into the NSF for 2007-2011.
Some encouraging progress has been made in gearing up the national response. Notable achievements have included the adoption of the NSF, a significant expansion in the number and scope of interventions, and the increase from less than 50 to over 350 participating NGOs.
Despite the progress, the response is not yet well coordinated and lacks the multi-sector dimension. Most importantly, the coverage of key populations is still well below that needed to contain the epidemic. There has been promise but little headway with in-school initiatives and too little done as yet to address the risks that street children face. There has been an increase in HIV-related research in the past two years but operational research has not received the level of attention required. Very little progress has been made on the management of sexually transmitted infections (STIs), which is worrisome in view of the close linkage between the transmission of STIs and HIV. Very little progress too has been made in raising awareness of HIV infection among the general population; and, worse still, is the fact that the focus is inappropriate and messages are often inaccurate. Blood and blood product safety has improved but gaps remain in terms of the application of the law and the quality of blood bank services. Modest advances have been made in improving care and support for PLHIVs but they remain difficult to access; so more needs to be done to generate a demand- instead of supply-led response. In summary, despite the progress, little or no headway has been made in some of the nine priority areas of the NSF and, most significant of all, the HIV epidemic entered a concentrated phase three years ago and the speed and severity of the epidemic is now outpacing the response.
Urgent steps are therefore required to respond to the changed and evolving situation. One of the factors that have inhibited the national response has been the failure up to now to achieve a multi-sector approach to the national and provincial programmes. This is in part due to the pervasive view of HIV/AIDS as a health issue rather than a societal matter. To achieve a truly multi-sector approach, as envisaged in the NSF, calls for stronger leadership with changes in institutional arrangements that will encourage and facilitate better coordination across all sectors.
As part of the institutional changes, the structures of the National HIV/AIDS Control Programme (NACP) and the Provincial HIV/AIDS Control Programmes (PACPs) should be reorganised to better reflect their roles and responsibilities and be coupled with much greater delegation of responsibility and improved management systems. Of paramount importance to strengthening programme management and efficiency is the need to design and introduce a comprehensive management information system that integrates improved commodity procurement, storage and supply procedures, accounting and financial management systems, and systems for monitoring and managing activities and results of interventions. Standardised throughout NACP and PACPs, an integrated and uniform system would allow the ready comparison, transfer and consolidation of information.
To assist in the process of gaining consensus to institutional changes and securing the commitment to a truly multi-sector approach, a stakeholder analysis should be undertaken. This report sets out a first, quick attempt at this analysis, but this needs to be reworked and refined by NACP and PACPs, with the involvement of key stakeholders.
Five key issues underlay the gaps in and constraints to the national response: (a) the prevailing reluctance to accept that there is a danger of a generalised epidemic; (b) the perception – and indeed the reality – that that the response is health sector led, which dilutes the multi-sector dimension and support that is crucial to success; (c) insufficient human resources of the right skills mix and appropriate capacity building in technical and managerial areas; (d) cultural and other restrictions on focusing on sexual transmission of HIV and on the promotion of condom use for STI and HIV prevention; and (e) inadequate condom social marketing among key and bridging populations that is crucial to preventing the spread of HIV.
Sexual behaviour is a subject that most people find difficult to discuss, and this difficulty compromises the ability to inform people of HIV/STI risk and prevention. Yet understanding and changing behaviour is at the heart of the battle against HIV. Yet again this emphasises the importance of effective HIV communications that deliver the right messages.
Coverage of HIV prevention services remains low, both in terms of numbers and the types of target groups reached. As well intensifying existing interventions for target groups, more attention is required to street youth, men on the move, men who have sex with men, and bridging populations. And efforts for HIV prevention need to be scaled up urgently.
Based on the need to scale up interventions and resolve the gaps and constraints identified in the SRA, this report sets out an extensive list of recommendations. To implement these recommendations will require numerous actions that, collectively, form four main strategies:
- Create the enabling environment;
- Strengthen the institutional framework;
- Build the right capacity; and
- Scale up programme delivery.
The recommendations, and the four strategies for implementing them, should be incorporated in the revised NSF. However, it is important that the NSF is not simply a wish list but is a policy document that will provide clear guidance on actions and priorities. To this end, the report provides guidance on prioritisation, which is determined by: (a) the critical path; (b) interdependence; (c) the urgency determined by the swift action needed to prevent a further spread of HIV; and (d) the availability of resources for implementation.
The most important finding of the MTR is that Pakistan is in a stage of a concentrated epidemic, with prevalence among IDUs near or above ten percent in at least five cities, and risk behaviours and vulnerability factors existing that favour the spread of infection. This, therefore, should provide the focus for determining priorities in the NSF.
The challenges posed by the complexity and scale of the issues that have to be addressed will call for strong leadership and commitment to the four principal strategies for moving the national response forward.
1.Background and Introduction
1.1Overview of HIV/AIDS Situation and Response Analysis in Pakistan
This report is based on the findings of the recently published 2006 update of the Situation and Response Analysis (SRA). The SRA provides an overview of the HIV/AIDS epidemic in Pakistan and the progress of the national response and the gaps and constraints affecting it.
The SRA shows that Pakistan now has a concentrated HIV epidemic and that urgent action is required to avert the spread of the epidemic into the bridging population. As we look into the future from the current situation, therefore, we must necessarily focus on the issues that have hampered – and could continue to hamper - containment of the epidemic. Nevertheless, it is right to recognise the considerable individual and collective efforts of the National HIV/AIDS Control Programme (NACP), the Provincial HIV/AIDS Control Programmes (PACPs) and implementing partners who have worked hard, have recorded many achievements and have laid a solid foundation for further progress.
Since the 2000 SRA, significant progress has been made in gearing up the national response. Notable achievements have included:
- Development and introduction of the National HIV/AIDS Strategic Framework (NSF) that guides the response to HIV;
- The significant expansion in the number and scope of interventions. Prior to 2003, only injecting drug users (IDUs) were reached whereas, by September 2006, there were 19 projects through NACP, PACPs and non-government organisations (NGOs) working with various groups, including youth, and several about to be awarded;
- Condom promotion is now an integral element of service delivery for key populations most at risk;
- Under Global Fund support, 16 voluntary counselling and testing (VCT) centres became operational in April 2005 and five antiretroviral (ARV) Centres of Excellence have since been established;
- The significant increase from less than 50 to over 350 participating NGOs with 32 interventions and the strengthening of the NGO community through the formation of the Pakistan National AIDS Consortium (PNAC);
- More multi-sector involvement not only within the public sector but also with civil groups;
- Progress in establishing a National Network of person(s) living with HIV (PLHIV);
- Enactment of blood transfusion laws to help prevent transmission of HIV;
- The production of protocols and operational guidelines;
- A mass media campaign to raise awareness and the expanded use of electronic media;
- Design of the National Monitoring and Evaluation (M&E) Framework that has just been finalised and is expected to become operational in the near future;
- Replacement of the former surveillance system with the integrated behavioural and biological surveillance (IBBS);
- Preparation of legislation dealing with human rights aspects of HIV/AIDS and the draft National HIV and AIDS Policy (NHAP), to be presented to the Cabinet for approval later this year;
- Decentralisation and provincial autonomy; and
- More than US$71 million of financial resources have been mobilised to support the national response.
Disapppointingly for those who have worked to deliver activities to support the national response and despite the achievements listed above, the epidemic has moved into a concentrated phase that poses even greater challenges for the immediate future.
This report therefore necessarily concentrates on the gaps in and constraints to the national response in order help formulate policies and implementation strategies for effective action to contain the spread of the HIV epidemic.
1.2Review Methodology and Format
The mid-term review was conducted through the efforts of eight specialists responsible for various factors of the response including HIV/AIDS, governance, social development, economics, communication, and procurement and commodities. Their work resulted in the SRA report and this MTR report.
Based on the gaps and constraints identified in the SRA, this report makes recommendations for changes to be considered for and included in the NSF 2007-2011 and the subsequent Programme Implementation Plan (PIP).
The findings and main recommendations set out in this report were presented and discussed at a series of workshops held in Karachi, Lahore and Islamabad. This helped not only to build acceptance of the recommendations but also to ensure a consensus on action priorities.
Since the preparation of the SRA, the final draft NHAP has been produced. Although there may be some slight changes before the policy document is finalised and approved, for purposes of this report we assume that the policies set out in that final draft are definitive.
In this report, the progress of the national response is assessed with respect to the priority arrears and related goals of the current NSF and is presented in chapter 2.
The SRA concluded by listing five major issues which are holding back an effective national response and to which the more important gaps and constraints apply. Tackling the five issues calls for strong leadership that is able to engage the attention of non-health sector policy makers, civil leaders and the general population and to convince them of the real threats that HIV/AIDS poses and the actions required. Combined with leadership is the issue of achieving a true multi-sector response through suitably designed institutional arrangements. Chapter 3 therefore discusses the leadership, institutional arrangements and capacity building necessary to direct, manage and implement the national response.
A very large proportion of the national response budget is for the procurement of goods and services. The ease (or difficulties) inherent in this process is therefore a major factor contributing to the success of implementation. Chapter 4 therefore describes the commodities and procurement procedures and how these are affecting the response; and makes recommendations for improved control and efficiency.
Having identified the gaps and constraints that are affecting the national response, the next step is to recommend appropriate action to rectify those deficiencies; but translating a recommendation into a practical strategy that will work will require resources and the commitment of those who can contribute to the success of the specific actions. This means identifying who exactly are the relevant stakeholders, where they stand on the related issues, why there is resistance and how to overcome it, and how best to engage the interested parties and build consensus and support. A stakeholder analysis will provide that information and should be used as a key tool in formulating the next NSF and PIP. With this in mind, we briefly undertook a stakeholder analysis that is presented in chapter 5. NACP/PACP may wish to refine this analysis.
Chapter 6 deals with the gaps and constraints. It examines the major issues and the challenges that will be faced in dealing with them, including a closer look at coverage, quality of care, coordination, capacity and public-private partnership (PPP) arrangements.
The final section of the report sets out the recommendations for scaling up the response, filling gaps and resolving constraints. However, deciding what priority to attribute to the recommended actions is rendered difficult by their sheer number and complexity. To show how they relate to each other andto assist in determine a practical order of priority, we conclude with a matrix (Table 9), which groups the gaps and constraints (issues) and the recommendations under four broad strategies. Table 9 will doubtless require refinement, but it will form the basis for developing the NSF for 2007-2011.
For ease of reading, very few sources or references are mentioned in this report, hence it should be read in conjunction with the SRA report which is fully sourced and contains an extensive bibliography.
2.Progress against the Nine Priority Areas of the NSF
2.1The Nine Priorities of the NSF
This chapter assesses the progress of the national response by reference to the following nine priority areas and related goals set out in the current NSF: