ISLAMABAD: The federal government has lost its mandate to fight HIV as the Global Fund (GF) has declared Pakistan sub-recipient of its $72 million aid.

The aid will be given to the United Nations Development Programme (UNDP) and the private sector which will spend it in the country. However, as UN agencies spend a large chunk of funds on management expenses, such as on salaries and security, only a meagre amount will actually be spent on the people of Pakistan, it is feared.

Moreover, in case of an outbreak in places like Ratodero (Sindh), the UN agency may not be able to deal with it due to issues of access and mobility.

However, Ministry of National Health Services (NHS) spokesperson Sajid Shah said the UNDP was a credible agency and hoped that it would use the funds most transparently.

Funds to be spent by UNDP, private sector; Sindh, Punjab oppose move

Pakistan has an estimated 197,943 HIV patients as per Asian Epidemic Modelling. Till Dec 2020, 24,362 patients were on antiretroviral therapy (ARV) medicines across Pakistan.

There are 49 HIV treatment centres in the country, which are providing diagnostic tests and lifelong support of ARV medicines free of cost.

An official of the National Aids Control Programme (NACP), who is not authorised to speak on record, said the demand for next grant of the GF for 2021-23 was submitted by the NACP in Sept 2020.

“However the GF implemented Additional Safeguard Policy (ASP) on Pakistan. The then NACP manager Dr Baseer Achakzai resisted the move and Sindh and Punjab also expressed reservations over the decision,” the official said. “However, the federal government removed Dr Baseer from his position.”

The official said it was a strange decision as the ASP was applied to those countries in which civil war was going on and which had severe corruption and other issues that showed that the government could not deliver.

According to letters written by Sindh Health Minister Dr Azra Fazal Pechuho to the executive director of the GF and available with Dawn, the provincial government has reacted to the move and claimed that without consultation with the Sindh government, a large portion of the grant has been allocated to private sector, which has no or little experience of dealing with communities suffering from HIV.

The GF has allocated $72m for fighting HIV in Pakistan, of which $22m will be given to private sector and the remaining amount to the UNDP. Earlier the funds were given to the NACP.

Dr Pechuho’s letter stated that most of the funds had been allocated for management cost of private sector and this did not adhere to the “Value of Money” policy of the GF.

Similarly, according to a letter from Punjab, written by Health Secretary retired Captain Mohammad Usman Younis and available with Dawn, the ASP is implemented in case of civil unrest, an influx of displaced persons, government instability, identified fraud and inadequate national programme capacity.

The letter said the target set for private sector principal recipient was very low and proposed per unit cost was very high. The capacity of selected private principal recipient was far behind the public sector’s capacity in terms of infrastructure, human resource, skills, experience, geography coverage etc.

“Your kind self is requested to ask GF authorities to revoke ASP for Punjab,” Mr Younis said in the letter written to the NHS secretary.

However, according to a letter sent by head of Grant Management Division, GF, Mark Edington, to Special Assistant to the Prime Minister on Health Dr Faisal Sultan and available with Dawn, the GF has been investing in Pakistan since 2002 and over $600m has been disbursed, with increased investments from one grant period to the next.

“The following grant cycle will allocate nearly 300 million USD for the fight against the three diseases [HIV, TB and Malaria]. I am writing today to communicate our decision to invoke the Additional Safeguard Policy (ASP) on the GF Pakistan portfolio with immediate effect. The ASP is intended to protect our investments in a country and to ensure more effective program implementation, in the interest of the people we serve. In particular, the ASP enables us to define implementation arrangements, in collaboration with our partners and after a thorough discussion with stakeholders in the country,” the letter states.

“We have over the last couple of years observed a worrying epidemiological trend particularly in Pakistan’s response to Tuberculosis and HIV, where case notifications of Tuberculosis stagnate or even decrease, and the HIV incidence rises almost unmitigated. We feel that notably our Public Sector Principal Recipients have not yet found an adequate way to transform domestic and external funding into a convincing approach to overcome those challenges. We are not satisfied with the role and performance of the “Common Management Unit” (CMU) and don’t see the strength of leadership necessary at this level to balance the centrifugal forces of devolution and to enable Provinces to build stronger and more effective programs. The ASP is invoked as a temporary measure, aimed at refocusing the discourse in country on our joint endeavor, the fight against HIV, TB and Malaria,” the letter adds.

An official of the Ministry of NHS, requesting anonymity, said some elements in the GF wanted to accommodate private sector.

“The Punjab and Sindh governments tried to resist the move but the federal government did not bother to take a stand. So $50m, which was to be given to the NACP, will be given to UNDP and Pakistan will be sub-recipient. Management expenses of the UN agency will be manifolds more, as compared to the government agency, as foreign staff will deal with it and there will be huge expense on their security and salaries. Moreover, the UN agency staff will not be able to get access to remote areas of country such as Ratodero where an outbreak was reported,” he said.

“It will be strange as signing authority of the grant is the NHS secretary but Pakistan will be sub-recipient of UNDP. Moreover, as per psyche of society, people may not trust a UN agency for treatment and protective measures due to which number of patients can increase,” he said.

However, NHS spokesperson Sajid Shah said: “The funding belongs to GF so it has every right to give the funding to anybody who can deliver more effectively. The thing is that the treatment and medicine should be provided to the patient transparently and we are sure that the UNDP is capable of doing so.”

Published in Dawn, March 15th, 2021