Political and Governance Challenges to Achieving Global HIV Goals with Injecting Drug Users: The Case of Pakistan

Document Type: Original Article


1 Department of Economics, School of Humanities and Social Sciences, Information Technology University, Lahore, Pakistan

2 Rockefeller College of Public Affairs and Policy, University at Albany, Albany, NY, USA


The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently set the ambitious “90-90-90 target” of having 90% of people living with HIV (PLHIV) know their status, receive antiretroviral therapy (ART), and achieve viral suppression by 2020. This ambitious new goal is occurring in a context of global “scale-down” following nearly a decade of heightened investment in HIV prevention and treatment efforts. Arguably international goals spur action, however, setting unrealistic goals that do not take weak health systems and variations in the nature of the epidemic across countries into consideration may set them up for failure in unproductive ways that lead to a decline in confidence in global governance institutions. This study explores how policy actors tasked with implementing HIV programs navigate the competing demands placed upon them by development targets and national politics, particularly in the current context of waning international investments towards HIV.
To examine these questions, we interviewed 29 key informants comprising health experts in donor organizations and government employees in HIV programs in Pakistan, a country where HIV programs must compete with other issues for attention. Themes were identified inductively through an iterative process and findings were triangulated with various data sources and existing literature.
We found both political and governance challenges to achieving the target, particularly in the context of the global HIV scale-down. Political challenges included, low and heterogeneous political commitment for HIV and a conservative legal environment that contributed towards a ban on opiate substitution therapy, creating low treatment coverage. Governance challenges includedstrained state and non-governmental organization (NGO) relations creating a hostile service delivery environment, weak bureaucratic and civil society capacity contributing to poor regulation of the health infrastructure, and resource mismanagement on both the part of the government and NGOs.
Our findings suggest that in a context of waning international attention to HIV, policy actors on the ground face a number of practical hurdles to achieving the ambitious targets set out by international agencies. Greater attention to the political and governance challenges of implementing HIV programs in low- and middle-income countries (LMICs) could help technical assistance agencies to develop more realistic implementation plans.


Supplementary File 1 (Download)


Main Subjects

"Watch the Video Summary"

  1. WHO. About the 3 by 5 Initiative. Treat three million people with HIV/AIDS by 2005. http://www.who.int/3by5/about/initiative/en/.  Published 2018. Accessed July 22, 2018.
  2. UNAIDS. “15 by 15” - a global target achieved. http://www.unaids.org/en/resources/documents/2015/15_by_15_a_global_target_achieved.  Published July 19, 2015. Accessed July 22, 2018.
  3. UNAIDS. Strategies for “getting to zero” and stopping new HIV infections among injecting drug users discussed as Commission on Narcotic Drugs opens in Vienna. http://www.unaids.org/en/resources/presscentre/featurestories/2011/march/20110323cnd.  Published March 23, 2011. Accessed July 22, 2018.
  4. UNAIDS. 90–90–90 - An Ambitious Treatment Target to Help End the AIDS Epidemic | UNAIDS. http://www.unaids.org/sites/default/files/media_asset/90-90-90_en.pdf.   Published January 2017. Accessed December 10, 2016.
  5. Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral Therapy for the Prevention of HIV-1 Transmission. N Engl J Med. 2016;375(9):830-839. doi:10.1056/NEJMoa1600693
  6. KFF. Financing the Reponse to HIV in Low- and Middle Income Countries: International Assistance from Donor Governments in 2015. https://www.kff.org/global-health-policy/report/financing-the-response-to-hiv-in-low-and-middle-income-countries-international-assistance-from-donor-governments-in-2015/. Published July 2016. Accessed January 8, 2017.
  7. Dieleman JL, Haakenstad A, Micah A, et al. Spending on health and HIV/AIDS: domestic health spending and development assistance in 188 countries, 1995–2015. Lancet. 2018;391(10132):1799-1829. doi:10.1016/S0140-6736(18)30698-6
  8. Kenworthy NJ, Parker R. HIV scale-up and the politics of global health. Glob Public Health. 2014;9(1-2):1-6. doi:10.1080/17441692.2014.880727
  9. Benton A. HIV Exceptionalism: Development through Disease in Sierra Leone. Minneapolis: University of Minnesota Press; 2015.
  10. Kenworthy N. Mistreated: The Political Consequences of the Fight against AIDS in Lesotho. Nashville: Vanderbilt University Press; 2017.
  11. Dionne KY. Doomed Interventions. The Failure of Global Responses to AIDS in Africa. Cambridge: Cambridge University Press; 2018.
  12. Moyo D. Dead Aid: Why Aid Is Not Working and How There Is a Better Way for Africa. Basingstoke: Macmillan; 2009.
  13. Grepin KA. HIV donor funding has both boosted and curbed the delivery of different non-HIV health services in sub-Saharan Africa. Health Aff Proj Hope. 2012;31(7):1406-1414. doi:10.1377/hlthaff.2012.0279
  14. Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health issues? Health Policy Plan. 2008;23(2). doi:10.1093/heapol/czm045
  15. Kenworthy N, Thomann M, Parker R. From a global crisis to the ‘end of AIDS’: New epidemics of signification. Glob Public Health. 2018;13(8):960-971. doi:10.1080/17441692.2017.1365373
  16. Mussa AH, Pfeiffer J, Gloyd SS, Sherr K. Vertical funding, non-governmental organizations, and health system strengthening: perspectives of public sector health workers in Mozambique. Hum Resour Health. 2013;11. doi:10.1186/1478-4491-11-26
  17. Pfeiffer J, Johnson W, Fort M, et al. Strengthening health systems in poor countries: a code of conduct for nongovernmental organizations. Am J Public Health. 2008;98(12):2134-2140. doi:10.2105/AJPH.2007.125989
  18. Halle M. Opinion: The SDGs are good enough and it’s time to stop analyzing and start acting. Devex. https://www.devex.com/news/sponsored/opinion-the-sdgs-are-good-enough-and-it-s-time-to-stop-analyzing-and-start-acting-91074.  Published September 20, 2017. Accessed August 15, 2018.
  19. Clarke JS. 7 reasons the SDGs will be better than the MDGs. The Guardian. September 20, 2017. https://www.theguardian.com/global-development-professionals-network/2015/sep/26/7-reasons-sdgs-will-be-better-than-the-mdgs.  Accessed August 15, 2018.
  20. Sachs JD. From Millennium Development Goals to Sustainable Development Goals. Lancet. 2012;379(9832):2206-2211. doi:10.1016/S0140-6736(12)60685-0
  21. Easterly W. The SDGs Should Stand for Senseless, Dreamy, Garbled. Foreign Policy. September 28, 2015. https://foreignpolicy.com/2015/09/28/the-sdgs-are-utopian-and-worthless-mdgs-development-rise-of-the-rest/.  Accessed August 15, 2018.
  22. Weber H. Politics of ‘Leaving No One Behind’: Contesting the 2030 Sustainable Development Goals Agenda. Globalizations. 2017;14(3):399-414. doi:10.1080/14747731.2016.1275404
  23. ICSU. Review of Targets for the Sustainable Development Goals: The Science Perspective. https://council.science/cms/2017/05/SDG-Report.pdf.  Published 2015. Accessed August 15, 2018.
  24. Leclerc-Madlala S, Broomhall L, Fieno J. The ‘end of AIDS’ project: Mobilising evidence, bureaucracy, and big data for a final biomedical triumph over AIDS. Glob Public Health. 2018;13(8):972-981. doi:10.1080/17441692.2017.1409246
  25. O’Laughlin B. Trapped in the prison of the proximate: structural HIV/AIDS prevention in southern Africa. Rev Afr Polit Econ. 2015;42(145):342-361. doi:10.1080/03056244.2015.1064368
  26. Abdullah MA, Shaikh BT. Review of HIV response in Pakistan using a system thinking framework. Glob Health Action. 2015;8(1):25820. doi:10.3402/gha.v8.25820
  27. Mansoor H. UN expresses concern over HIV prevalence in Karachi. DAWN website https://www.dawn.com/news/1329445.  Accessed August 25, 2018.  Published 2017.
  28. HIV/AIDS in Pakistan. World Bank website. http://www.worldbank.org/en/news/feature/2012/07/10/hiv-aids-pakistan.  Accessed July 20, 2018. Published July 10, 2012.
  29. Emmanuel F, Salim M, Akhtar N, Arshad S, Reza TE. Second-generation surveillance for HIV/AIDS in Pakistan: results from the 4th round of Integrated Behavior and Biological Survey 2011–2012. Sex Transm Infect. 2013;89(Suppl 3):iii23-iii28. doi:10.1136/sextrans-2013-051161
  30. UNODC. World Drug Report 2014. http://www.unodc.org/wdr2014/.  Accessed December 10, 2016. Published June 2014.
  31. BBC. Pakistan battles against hidden HIV-Aids menace. BBC News. August 10, 2011. http://www.bbc.com/news/world-south-asia-14399963.  Accessed January 21, 2017.
  32. Sheikh SS. A village in Punjab suffers as the government dithers. Her Mag. November 22, 2017. http://herald.dawn.com/news/1153912.  Accessed July 20, 2018.
  33. UNAIDS. Country profiles: Pakistan. HIV and AIDS. Data Hub for Asia-Pacific. Review in slides. http://www.aidsdatahub.org/Country-Profiles/Pakistan.  Accessed January 22, 2017. Published September 2016.
  34. UNDP. Report of the National Consultation on Law and Policies Affecting Human Rights, Discrimination and Access to HIV and Health Services by Key Populations in Pakistan. https://www.aidsdatahub.org/sites/default/files/publication/rbap-hhd-2016-report-of-the-national-consultation-on-law-and-policies-pakistan.pdf.  Accessed August 24, 2018. Published 2016.
  35. Rana A. UN body accused of promoting heroin substitute. The Express Tribune. April 24, 2014. http://tribune.com.pk/story/699588/un-body-accused-of-promoting-heroin-substitute/.  Accessed January 22, 2017.
  36. Mansoor H. No Aids commission in Sindh months after passage of law. DAWN. July 16, 2014. http://www.dawn.com/news/1119525.  Accessed August 21, 2018.
  37. UNDP. Scan of Law and Policies Affecting Human Rights, Discrimination and Access to HIV and Health Services by Key Populations in Pakistan. http://www.asia-pacific.undp.org/content/rbap/en/home/presscenter/pressreleases/2015/01/21/new-un-report-calls-for-changes-to-legal-environment-to-enhance-hiv-response-in-pakistan.html.  Accessed August 21, 2018. Published 2014.
  38. Kurji Z, Premani ZS, Mithani Y. Analysis of the health care system of Pakistan: lessons learnt and way forward. J Ayub Med Coll Abbottabad. 2016;28(3):601-604.
  39. National AIDS Control Program. Global AIDS Response Progress Report 2014 - Country Progress Report Pakistan. http://www.unaids.org/sites/default/files/country/documents/PAK_narrative_report_2014.pdf.  Accessed August 24, 2018. Published 2014.
  40. National AIDS Control Program. Global AIDS Response Progress Report 2015 - Country Progress Report Pakistan. http://www.unaids.org/sites/default/files/country/documents/PAK_narrative_report_2015.pdf.   Accessed August 24, 2018. Published 2015.
  41. Ministry of Finance. Pakistan Economic Survey 2015-2016.  Accessed August 24, 2018. Published 2016.
  42. Pakistan Bureau of Statistics. Pakistan National Health Accounts 2013-2014. http://www.pbs.gov.pk/content/national-health-accounts-pakistan-2013-14.  Published 2016. Accessed August 24, 2018.
  43. Emmanuel F, Thompson LH, Salim M, et al. The size and distribution of key populations at greater risk of HIV in Pakistan: implications for resource allocation for scaling up HIV prevention programmes. Sex Transm Infect. 2013;89(Suppl 2):ii11-ii17. doi: 10.1136/sextrans-2013-051017
  44. The Global Fund. Implementing Partners. The Global Fund to fight AIDS, Tuberculosis and Malaria. http://www.theglobalfund.org/en/implementers/.  Accessed January 21, 2017. Published 2017.
  45. NACP. People & Structure. National AIDS Control Programme. Ministry of National Health Services, Regulation and Coordination. Government of Pakistan. http://www.nacp.gov.pk/howwework/peoplestructure.html.  Accessed January 21, 2017. Published 2016.
  46. Zaidi S, Mayhew SH, Cleland J, Green AT. Context matters in NGO-government contracting for health service delivery: a case study from Pakistan. Health Policy Plan. 2012;27(7):570-581. doi:10.1093/heapol/czr081
  47. Ministry of Narcotics Control. Mandate, Schedule II [Rule 3(3) Rules of Business 1973]. April 2018. http://www.narcon.gov.pk/index.php?page=mandate.
  48. Walsh KC. Putting inequality in its place: rural consciousness and the power of perspective. Am Polit Sci Rev. 2012;106(3):517-532. doi:10.1017/S0003055412000305
  49. Boyatzis R. Transforming Qualitative Information: Thematic Analysis and Code Development. Thousand Oaks, California: SAGE Publishers; 1998.
  50. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006;5(1):80-92. doi:10.1177/160940690600500107
  51. Tkatchenko-Schmidt E, Atun R, Wall M, Tobi P, Schmidt J, Renton A. Why do health systems matter? Exploring links between health systems and HIV response: a case study from Russia. Health Policy Plan. 2010;25(4):283-291. doi:10.1093/heapol/czq001
  52. Emerson RM, Fretz RI, Shaw LL. Processing fieldnotes: Coding and memoing. In: Writing Ethnographic Fieldnotes. Chicago: The University of Chicago Press; 1995:142-168.
  53. Hewitt-Taylor J. Use of constant comparative analysis in qualitative research. Nurs Stand. 2001;15(42):39-42. doi:10.7748/ns2001.
  54. Bate A, Donaldson C, Murtagh MJ. Managing to manage healthcare resources in the English NHS? What can health economics teach? What can health economics learn? Health Policy. 2007;84(2–3):249-261. doi:10.1016/j.healthpol.2007.04.001
  55. Fox AM, Goldberg AB, Gore RJ, Bärnighausen T. Conceptual and methodological challenges to measuring political commitment to respond to HIV. J Int AIDS Soc. 2011;14(Suppl 2):S5. doi:10.1186/1758-2652-14-S2-S5
  56. Frederickson HG. Whatever Happened to Public Administration? Governance, Governance Everywhere. In: Ferlie E, Lynn Jr LE, Pollitt C, eds. The Oxford Handbook of Public Administration. Oxford: Oxford University Press; 2005:282-304.
  57. Gilson L, Lehmann U, Schneider H. Practicing governance towards equity in health systems: LMIC perspectives and experience. Int J Equity Health. 2017;16(1):171. doi:10.1186/s12939-017-0665-0
  58. Lewis M, Pettersson G. Governance in Health Care Delivery: Raising Performance. The World Bank; 2009. doi:10.1596/1813-9450-5074
  59. Siddiqi S, Masud TI, Nishtar S, et al. Framework for assessing governance of the health system in developing countries: gateway to good governance. Health Policy. 2009;90(1):13-25. doi:10.1016/j.healthpol.2008.08.005
  60. WHO. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for Action. http://www.who.int/healthsystems/strategy/everybodys_business.pdf.  Accessed August 24, 2018. Published 2007.
  61. Ciccone DK, Vian T, Maurer L, Bradley EH. Linking governance mechanisms to health outcomes: a review of the literature in low- and middle-income countries. Soc Sci Med. 2014;117:86-95. doi:10.1016/j.socscimed.2014.07.010
  62. Glatman-Freedman A, Cohen M-L, Nichols KA, et al. Factors affecting the introduction of new vaccines to poor nations: a comparative study of the Haemophilus influenzae type B and hepatitis B vaccines. PloS One. 2010;5(11):e13802. doi:10.1371/journal.pone.0013802
  63. Fryatt R, Bennett S, Soucat A. Health sector governance: should we be investing more? BMJ Glob Health. 2017;2(2):e000343. doi:10.1136/bmjgh-2017-000343
  64. Lazarova EA. Governance in relation to infant mortality rate: evidence from around the world. Ann Public Coop Econ. 2006;77(3):385-394. doi:10.1111/j.1467-8292.2006.00311.x
  65. Rajkumar AS, Swaroop V. Public spending and outcomes: Does governance matter? J Dev Econ. 2008;86(1):96-111. doi:10.1016/j.jdeveco.2007.08.003
  66. Fukuyama F. State-Building: Governance and World Order in the 21st Century. Ithaca, New York: Cornell University Press; 2004.
  67. Jolly R. Global development goals: the United Nations experience. J Hum Dev. 2004;5(1):69–95. doi:10.1080/14649880310001660210
  68. Lisk F. Global governance and HIV/AIDS response. In: Global Institutions and the HIV/AIDS Epidemic: Responding to an International Crisis. Abingdon: Routledge; 2010: 
  69. Mikkelsen-Lopez I, Wyss K, de Savigny D. An approach to addressing governance from a health system framework perspective. BMC Int Health Hum Rights. 2011;11(1):13. doi:10.1186/1472-698X-11-13
  70. UNDP. Governance of the HIV/AIDS Responses - Issues and Outlook. http://www.undp.org/content/undp/en/home/librarypage/hiv-aids/governance-of-the-hiv-aids-responses---issues-and-outlook.html.  Accessed August 17, 2018. Published 2008.
  71. Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D. What is the role of informal healthcare providers in developing countries? A systematic review. PLOS One. 2013;8(2):e54978. doi:10.1371/journal.pone.0054978
  72. DAWN. Doctor or quack? DAWN. April 24, 2010. http://www.dawn.com/news/844464.   Accessed January 22, 2017.
  73. Adam T, Hsu J, Savigny D de, Lavis JN, Røttingen J-A, Bennett S. Evaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions? Health Policy Plan. 2012;27(suppl 4):iv9-iv19. doi:10.1093/heapol/czs086
  74. Gilson L, Agyepong IA. Strengthening health system leadership for better governance: what does it take? Health Policy Plan. 2018;33(suppl_2):ii1-ii4. doi:10.1093/heapol/czy052
  75. Abimbola S, Negin J, Jan S, Martiniuk ALC. Towards people-centred health systems: a multi-level framework for analysing primary health care governance in low- and middle-income countries. Health Policy Plan. 2014;29 Suppl 2:ii29-ii39. doi:10.1093/heapol/czu069
  76. Kettl DF. Governance, Contract Management and Public Management. In: Osborne SP, ed. The New Public Governance? New York: Routledge; 2010:239-252.
  77. Batley R. Engaged or divorced? Cross-service findings on government relations with non-state service-providers. Public Adm Dev. 2006;26(3):241-251. doi:10.1002/pad.422
  78. Mcloughlin C. Factors affecting state–non-governmental organisation relations in service provision: key themes from the literature. Public Adm Dev. 2011;31(4):240-251. doi:10.1002/pad.611
  79. Stoicescu C. Global State of Harm Reduction 2012. Towards an Integrated Response. United Kingdom: Harm Reduction International; 2012. https://www.hri.global/global-state-of-harm-reduction-2012. Accessed January 25, 2017.
  80. Pfeffer J, Salancik GR. The External Control of Organizations: A Resource Dependence Perspective. Stanford: Stanford University Press; 2003.
  81. Carpenter DP. The Forging of Bureaucratic Autonomy: Reputations, Networks, and Policy Innovation in Executive Agencies, 1862-1928. Princeton: Princeton University Press; 2001.
  82. Meier KJ, O’Toole LJ. Bureaucracy in a Democratic State: A Governance Perspective. Baltimore Maryland : JHU Press; 2006.
  83. Gilles SM. Needle exchange programs: factors that influence attitudes and local policy [thesis]. Bethlehem: Lehigh University; 1994.
  84. Piot P, Russell S, Larson H. Good politics, bad politics: the experience of AIDS. Am J Public Health. 2007;97(11):1934-1936. doi:10.2105/AJPH.2007.121418
  85. The World Bank. Pakistan - Report of an HIV/AIDS Technical Review Mission. http://documents.worldbank.org/curated/en/514361468090587867/Pakistan-Report-of-an-HIV-AIDS-technical-review-mission.  Accessed October 26, 2016. Published 2001.
  86. Sax S, Marx M. Local perceptions on factors influencing the introduction of international healthcare accreditation in Pakistan. Health Policy Plan. 2014;29(8):1021-1030. doi:10.1093/heapol/czt084
  87. GrzyMala-Busse A. Weapons of the Meek: How Churches Influence Public Policy. World Polit. 2016;68(1):1-36. doi:10.1017/S0043887115000301
  88. Pradhan YV, Upreti SR, Kc NP, et al. Newborn survival in Nepal: a decade of change and future implications. Health Policy Plan. 2012;27(suppl 3):iii57-iii71. doi:10.1093/heapol/czs052
  89. Scott V, Gilson L. Exploring how different modes of governance act across health system levels to influence primary healthcare facility managers’ use of information in decision-making: experience from Cape Town, South Africa. Int J Equity Health. 2017;16(1):159. doi:10.1186/s12939-017-0660-5