âToday you give me syringes, tomorrow you might come and handcuff meâ, protested Kamal , the Chief Executive Officer of Naya Sewaira , the biggest NGO in Pakistanâs HIV/AIDS sector. We were interviewing Kamal whilst sitting in the air-conditioned head office of Naya Sewaira in Islamabad, adjacent to the showroom where injecting drug users, their wives and children, dependent upon this NGOâs detoxification units, were selling expensive leather handbags and other hand-made products. This NGO was about social enterprise rather than charitable service, since its main purpose was to give ex-drug users training in intensive farming techniques for the production of high-yield crops, which it would sell at a profit.
Gesticulating dramatically with his hands, Kamal made his designer wristwatch jangle. He was explaining how the injecting drug users would respond to attempts by the government authorities to take over HIV/AIDS prevention services, including needle exchange. Kamal was referring to the lawâthe 1997 Control of Narcotic Substances Actâwhich criminalizes non-therapeutic drug use in the country. Kamalâs view was that the government could not simultaneously provide care for drug users as well as lock them up. If a government official tried to engage in HIV/AIDS prevention, argued Kamal , members of the risk populations would be right to be wary. âTheyâll say âis he an outreach worker, or does he work for the anti-narcotics force?ââ, an objection that summed up the conundrum of Pakistanâs HIV/AIDS response. In Pakistan, as in other South Asian countries, the ârisk populationsâ amongst whom epidemics spread are not only socially and economically marginalized but also criminalized. Although injecting drug users, men who have sex with men , sex workers and transgendered people are targeted by policies and interventions, the governmentâs hands are tied. To reach out to these criminalized populations, it must depend on NGOs.
In the early 2000sâagainst the counsel of some of the countryâs most prominent public health activists and epidemiologistsâthe World Bank managed to convince the government of Pakistan that HIV/AIDS should be declared an area of public health needing of urgent intervention on the grounds that if the epidemic were not contained within the risk groups, the virus would likely spread to the general population quickly. This was in the context of a growing regional HIV/AIDS epidemic in neighbouring South Asian countries (NACP 2007a, b). By 2003, only 1579 cases of HIV and 202 cases of AIDS had been diagnosed in Pakistan, but it was estimated that there were some 85,000 HIV/AIDS cases in the countryâthus the vast majority of them were undiagnosed. The prevalence rate was estimated at 0.1%, a considerable percentage because of the sheer size of Pakistanâs population (NACP 2007a, b). Injecting drug use was a particular concern, as drug trafficking-for-arms during the Afghan war in the 1980s had left hundreds and thousands of heroin and opium addicts as a legacy (Haq 2003). Behavioural studies in the 1990s had indicated alarmingly high levels of needle sharing and other risky practices in these populations (UNODC and UNAIDS 1999), and when bio-behavioural surveys of injecting drug users in some of Pakistanâs major cities were subsequently carried out in 2004, it was found that up to 25% were infected with HIV/AIDS (NACP 2005).
As in other countries in the early 2000s, Pakistanâs HIV/AIDS response was âscaled-up â (Kenworthy and Parker 2014), that is to say, it received a âsudden injection of new fundsâ (Farmer 2013, p. xvii) consistent with the tripling of development aid for health in general over the same period (Weigel et al. 2013). Accompanying these funds came a ânew technocracyâ of economistic assessment techniques (Biehl and Petryna 2013, p. 8), a sovereignty of âmetricsâ identifying âwhat worksâ, and a preference for interventions that are âscalableâ and evidenced to be cost-effective in resource-poor settings (Adams 2016). As Kenworthy and Parker (2014) observe, the âscale-upâ of a HIV/AIDS response involves more than a simple expansion of services, strategies and treatments. It involves a vast assemblage of resources, manpower, expertise, strategies and technologiesââa culture of practice in which new ideological frameworks become dominant and normalisedâ, including philosophies of efficiency , transparency , participation , capacity-building and empowerment , to name a few (p. 2).
The âscaled-upâ version of HIV/AIDS prevention in Pakistan, the Enhanced HIV and AIDS Control Program, was designed by the World Bank as a publicâprivate partnership . Recent years had seen an upsurge in international donor interest in NGOâgovernment partnership in global health in general, but particularly in the field of HIV/AIDS prevention (World Bank 1993, 1997a; Buse and Walt 2000; Grindle 2004; Richter 2004; Pisani 2008). In adopting policies along these lines, Pakistan was merely reproducing the wider global health orthodoxy of the time. NGOs and the private sector were deemed to have a âcomparative advantage in accessing marginalized sub-populations and providing them prevention and treatment services in a cost-effective mannerâ (NACP 2007a, p. 7). In Pakistan there were also, of course, the legal constraints deterring the government from working directly with the criminalized ârisk groupsâ, of which Kamal made so much in his interview.
This book explores the consequences of contracting-out HIV/AIDS prevention and care to NGOs and Community-Based Organizations. This matter is at the heart of the emerging discipline of global health. Farmer et al. (2013), in their programmatic statement on the field, contend that in comparison with its antecedent term, âinternational healthââwhich emphasized the nation state as the âbase unit of comparison and implied a focus on relationships among statesâ ââglobal healthâ encapsulates âthe role of nonstate institutions, including international NGOs, private philanthropists and community-based organizationsâ (p. 10). The pluralizing of the state wherein it comes to share its health governance role with civil society , international financial institutions and donors is thus a key aspect of global health. Recently, GĂłmez and Harris (2016) have observed that governments across the world have âleaned onâ NGOs to reach out to the key populations that are at high risk of contracting HIV/AIDS, and that âpartnerships with civil society at a time when the disease was confined largely to âhigh risk groupsâ ⊠[have] played an important role in stemming the spread of the epidemic and contributing to improved outcomesâ (p. 57). However, they also note country-specific variations in the findings. Amongst the BRICS countries, post-military rule Brazil, with its collaborative relations between state and civil society , produced an aggressive response and successful outcomes (see Biehl 2007 for a historical narrative of the Brazilian âactivist stateâ ). But it was democratic South Africa that had the âworst responseâ, where HIV/AIDS denialism and antagonistic stateâcivil society relations fuelled a delayed response and proved extremely costly in terms of human lives (Robins 2004, 2006; Fassin 2007; Tomer 2009; Mbali 2013). Meanwhile, authoritarian China did âsurprisingly well in spite of its repressive approach and narrow engagement with civil societyâ (GĂłmez and Harris 2016, p. 56). In India, funding from the World Bank âled to a marked growth of AIDS-focused NGOsâ, many of which were later implicated in fraud and failed to live up to rights-based agendas (p. 63). Even so, GĂłmez and Harris appreciate that some Indian NGOs became vocal in challenging the repressive institutions of the state by organizing ââsensitization meetingsâ that have reformulated appropriate behavior of police towards sex workersâ , or by holding the state accountable; they therefore formed a âcritical new part of the Indian strategy on HIV/AIDS preventionâ (pp. 62â63). Historically, then, the link between governmentâNGO partnership and the effectiveness of responses to the HIV/AIDS epidemic remains suggestive, but open to further debate.
Outsourcing HIV/AIDS prevention to non-government organizations is undergirded by three interlinked presuppositions: that NGOs are better at HIV/AIDS prevention than governments, due to their ability to reach the parts of society that governments often cannot; that prevention services are best provided by people who are themselves members of the affected groups; and that infected people must be involved in planning programmes and delivering services (Pisani 2008, p. 174). Pisani calls these presuppositions the âsacred cowsâ of the HIV/AIDS sector. Global health funders demand approaches formed from these presuppositions, through âstrings attachedâ to grants and loans, and therefore governmentsâ hands are tied to them (Beckmann et al. 2014). But as the global HIV/AIDS epidemic evolves, are these fair assumptions? What are the real-life, on-the-ground consequences of outsourcing HIV/AIDS prevention? Is there no alternative to dependence on NGOs? What does the dogma of publicâprivate partnership entail for the delivery of the public good? As scholars or as activists, should we agree with Kamal , the NGO boss introduced abo...