Minutes of OIG Exit Meeting

MINUTES

CCM MEMBERS MEETING & OIG EXIT MEETING

11 AM, 11 TH OCTOBER 2013, CONFERENCE ROOM, NACP

NATIONAL INSTITUTE OF HEALTH (NIH), CHAK SHAHZAD, ISLAMABAD

CCM Coordinator welcomed the Inspector General, Office of the Inspector General, Global Fund to fight AIDS, TB and Malaria, and members of his team. After recitation of Holy Quran, there was a brief round of introduction. Chair CCM/Secretary, Ministry of National Health Services, Regulations and Coordination, in his welcome remarks said that the GF programs are flagship programs for the ministry and government attaches great importance to these programs. He said that the approach of GF is an innovative one – emphasizing on transparency/accountability and partnership of civil society/community. These are unique features. He said that we are looking forward to the finding s of the OIG and assured that the recommendations will be complied with.

The Inspector General in his address thanked the Chair, Vice Chair and CCM Pakistan for their cooperation and facilitation in conducting this review. He said that his visit to Pakistan within Five weeks of assumption of his duties reflects the importance of Pakistan. He also thanked the three PRs for extending hospitality, cooperation and facilitation. The team had nothing but compliments for the PRs the way they engaged with us. He termed his visit to Leprosy Center as fascinating. Regarding the visit he said that three things struck him – the facility was immaculate, it was very well organized and the third is the pride with which the people were working there, which you could see and feel. He said this is a good example of how TB needs to be tackled. He highlighted the approach of the OIG and said that we pride ourselves on operating professionally and with respect, to participate and to work in a collaborative approach. We try to engage so that there are no surprises. No one or very few people like to be audited/investigated, but unfortunately that is the job of OIG. To do that we have to be balanced and provide appropriate context, both the things are critical. He said that our recommendations are our best thoughts and are not setting stones. We look to this committee and all the participants to find the right answers and the best answers. If we agree, what the issues are, we can create best possible solutions.

Tracy Staines, Audit Manager, OIG GFATM, thanked the Chair and Vice Chair for making arrangements and allowing the access to the OIG team members. She apologized for not making it last year as the stakeholders did not get a chance to showcase the work they have done. She appreciated the tireless support of the GF Secretariat and the country team. She also highlighted the importance of Pakistan especially TB, which contributed to the Inspector

Minutes of OIG Exit Meeting Page 1 General’s visit, in first few months. She told the house that this time two reviews were carried out – one is information and data underlying risk assessment of Pakistan’s grants and the other is Quality of Services, of the programs being implemented. While introducing the Inspector General, she elaborated upon his vision, which will help guide our way and improve GF, how we make recommendations and move forward. The testament for importance of Pakistan’s fight against the three diseases is the fact that he has visited Pakistan.

She also told the house that we will also see good practices, excellent ways of working and innovative thinking in implementing your programs that can be shared with whole of GF and off course to suggest room for improvement and to highlight the standards, you and other programs are setting so that other programs will be able to reach those high standards

She requested the members to help in improving/finessing the report. She also requested for inputs in terms of recommendations. She said that this meeting would provide an opportunity for on the spot feedback. She also highlighted the process of feedback to the OIG and in case of any problem she should be contacted and would provide the contact details. She also told about the formal ways of providing the inputs. She very specifically mentioned that they would welcome ongoing constructive feedback from all the stakeholders. She told that an overall report will be published, Country specific chapters are published after each country’s visit. She also told that the Inspector General’s suggestion to move away from dictating what the recommendations should be – people to determine what are the corrective actions, they will highlight where the risks are not mitigated and ask CT for suggested actions to mitigate risks. That’s a collaborative process you would be able to feed into.

She introduced the team members to the members of CCM. She said that she would like to listen to the thoughts of the CCM Members. She said it is called QUART, basically it is the risk assessment, which GF has introduced this year.

Agustinus Mangampa, OIG Team leader told that he will be sharing the key findings after which there will be a Q&A session. This is the risk assessment validation. He told that there are five objectives for carrying out this audit:

Assess whether in the Global Fund risk model: • Key risks are identified, properly assessed and correctly ranked • Main contributing factors have been identified and properly assessed • Mitigating actions for key risks are adequate effective and timely • Grant “heat maps” consistently reflect residual risks • Resultant risk assessment is applied in decision-making related to the grant He told about the review process – 3

Conduct an assessment tool at the GF Secretariat - review of documents and discussions with country team

In country: Validation, Interviews, site visits and the big meeting.

He told that GF has categorized risks in four main areas –

Programmatic and Performance risks,

Financial and Fiduciary risks,

Health Services Products risks

Governance, Oversight and Management risks.

Each of the area has underlying risks, and out of 19 risk areas, 14 risk areas were assessed for Pakistan.

He told that the team carried out the visit of CCM Secretariat and interviewed the staff and other stakeholders including.

Chair CCM said that the he was expecting a very harsh audit and it was a pleasant surprise to see that the recommendations are soft. He asked that when was the last audit done? He was told that it was not done before and this is the first time.

Tracy Staines said that she would like to caution about the ease which it can be implemented. Things like exchange rate, things like regulation of private sector will be extremely difficult. There are real challenges/issues in countries like Pakistan, it is big and populous country. She also cautioned to make sure that the recommendations they finalize are implemented.

Marc Saba, Country Director UNAIDS, thanked for a comprehensive presentation. He elaborated upon risk management and asked about the impact of security situation on the implementation of grant. He also asked about the extent to which TB & HIV are collaborated. Tracy, in response to Marc’s questions, replied that there are certain risks which can be mitigated while others can’t. You cannot eliminate risks. She said that they did not focus on TB & HIV area and will be back in Pakistan.

Dr Arshad, Chief Executive Officer, Drug Regulatory Authority (DRA), told that DRA is one year old organization. Pakistan has the 7th largest pharmaceutical manufacturing in the world base. He informed that to be a vendor for WHO purchases, we need WHO accreditations and approval of WHO. Pakistan has already stepped into that. WHO inspectors have visited various facilities – some were successful and would be approved soon. He also told that to upgrade

Minutes of OIG Exit Meeting Page 3 drug testing lab we need technical and financial assistance – more of technical assistance and he would request the house to recommend support for DRA in this respect.

Dr Ejaz Qadeer, NPM, NTP (National Program Manager, National TB Program) told the house that regulation of private sector is being done and legislation has been drafted and submitted to ministry. It has been passed by the Government of Sindh and NTP is working on enforcement of the same in the entire country. He also highlighted the importance of availability of quality drugs in the country – adult, pediatric and MDR, and availability of quality laboratory and they have to go either to India or other regional laboratories. He suggested that DRA & NTP should work in close cooperation for this purpose.

Dr Ghulam Murtaza Dopasi, Provincial TB Program Manager, Balochistan, representing Department of Health, Balochistan, inquired about security of staff members working with GF. He asked that is there any cover or plan for the implementers in case they die during work. Is there any policy to support their families in case of death? Dr Nasir Sarfraz, UNICEF, said that the respected colleague wants to say that “is there any policy of health/life insurance for the staff.

Dr Werner Buehler, Fund Portfolio Manager, Global Fund to fight AIDS, TB and Malaria (GFATM) said that the country should include this in the project note/budget. They have received similar requests from other countries also. Basically, GF signs contract with PR and PR in return signs contracts with the SRs. It can be in any form – passive security, wars, fortified doors or security guards. He further said that it can be included in the budget and he won’t exclude it straight away if it is justified to them. Tracy added that the government has to play its role in preventing anything from happening rather than asking for financial compensation after something has happened. However, we would look into this and would request you to cooperate and include it in the budget.

Mr.Omar Loukili, explained the background of the audit. He told that this is not an evaluation of the program in Pakistan, but a thematic audit or audit of processes. Processes and mechanisms Global Fund has to ensure Quality of Services (QOS). He told that 8 countries were selected and Pakistan is one of them. Assessment of mechanisms to ensure QOS, Processes to monitor QOS from facility level and how this flows back to PR and GF. He said that the objective of this audit was to assess adequacy and effectiveness of the established processes in place for continuous monitoring of improvement for the programs funded by GF. He also told that the audit is in two parts – one at the GF Secretariat and the other in the country. The in-country audit includes assessment of systems in place to assess and monitor QOS. Mechanisms for improvement of QOS and Validation of the systems for quality improvement in selected facilities. He said while doing the audit, we forget about good practices. He said that we will also highlight the good practices which can be copied in other countries. 5

Monitoring of Quality of Services (QOS), Mechanism of QOS and systems for monitoring of QOS. He told the house that they visited 3 OPD sites, 7 GP’s, I private hospital, 2 Public sector hospitals and 2 MDR TB sites.

Giving his general assessment he very specifically said that the TB Program in Pakistan is very good.

Mr Imran Zali, Vice Chair CCM, said that the same issue was brought to the notice of oversight committee during its visit to the TB component. He said that the compensation is too low whereas it should match the market rates, to assure quality and adherence to guidelines. Replying to this, Mr Omar said that this is not a sustainable option. If the donors withdraw the whole system will collapse. PRs alongwith CCM should come up with a sustainable system – a system which not only motivates the GP but is also sustainable for the country in long term.

Dr Imran Durrani, GIZ, said that there is mechanism for accrediting the doctors but there is no mechanism for regulation of quality of services.

Dr Nikhat, Bridge Consultants, CSO representing Sindh Province, said that the OIG team has visited Sindh Province and out of 19 Districts, 6 Districts are in Sindh, but nothing has been said about the province. She also said that all the TB patients should be screened for HIV. Dr. Donnard replying to her question said that HIV Prevalence in Pakistan is low and it is difficult to go for screening. All MDR TB cases are screened for HIV and most HIV positive cases should be monitored for TB. Dr. Ejaz, NPM NTP said that they are scaling up TB/HIV component in whole country. Public Private Mix is working on seven different models, in one model MC is working with GPs. One private NGO is looking after several private service outlets. We will see if giving incentives to GPs is effective or not. Vice Chair CCM said that immune-compromised should be tested for TB. Dr. Ejaz informed that there are no recommendations of WHO on serology. We are depending on two things – micros. Luckily now we have gene experts. All high risk groups will be included for gene expert. The blood test tells you about the status of infection and does not inform about the disease, we are relying on gene experts in the centers. Serology and blood tests are not recommended. Prof Dr. Rumina, Aga Khan University, CCM Member representing the educational/academic institution from private sector said that there is an advisory against use of serology in TB, because it gives misleading results, so it is not recommended.

At this stage the Chair CCM said that the performance/implementation of the grant is generally satisfactory. He emphasized on the importance the government attaches to transparency and accountability. The present government has issued various directives to strictly monitor the performance and linked it to the promotion. He also appreciated the efforts of country team,

Minutes of OIG Exit Meeting Page 5 especially Dr Werner, Fund Portfolio Manager, for his untiring support for the implementation. He thanked the Inspector General and his team.

Dr. Werner, updated the house about New Funding Model (NFM). He told the house that it will become effective after the replenishment conference in December. NFM is predictable and flexible i.e., how much money is available for Pakistan, will be communicated to CCM and CCM comes up with a proposal. The decision of how much is needed, what should be proposed and in Pakistan’s context which geographical area gets how much. He highlighted the fact that in the NFM there is enhanced responsibility of CCM. He further stated that there should be enhanced focus on HSS. CCM is not only for GFATM but also HSS. This gives opportunity to MNCH and various population groups. HSS links up with every other intervention. This is a horizontal platform. We lose because a lot of value because of duplication of efforts. There should be concerted effort of all the stakeholders – government, multi-lateral/ bi-lateral partners and civil society, for supply chain management and monitoring and evaluation. He said that part of HSS can be strengthening of ministerial setup – national as well as provincial and strengthening of DRA could be a part. During country dialogue, CT will make and hear suggestions, will provide guidance, but the final decision will be left to CCM/Country to decide about their priorities. There will be broad consultation with all the stakeholders. He also appreciated the efforts of CCM Pakistan for having strong representation of the civil society, but emphasized that to make their involvement meaningful they should speak up. CCM is an ideal forum and provides an opportunity that the voice from the ground/implementers to reach the decision makers sitting in Islamabad. CCM should involve everybody in proposal development and should have an organic approach to improving services delivery. Pakistan should have a solid proposal backed by everyone. FPM also indicated of holding a 1-2 day specialized meeting of extended CCM, meaning that there is strong representation of provinces, Secretary/DG Health, in December this year to work on new guidelines and setting up deadlines for various activities, in order to be prepared for NFM. He urged strong provincial representation in the said meeting.

The Inspector General said that after attending various presentations on NFM, he can very easily say that the main emphasis is on three things. Firstly, where the disease burden is the greatest, secondly, a country’s ability to pay and thirdly, far greater emphasis lies on a robust NSP – NSPs are very important and can critically influence the placement of funds.

Dr Ghulam Nabi Kazi, National Professional Officer for TB, WHO, said that it’s good to see renewed focus on HSS. He said that if we dovetail it with other proposals, it may be beyond the scope of the proposal. How much leverage and latitude, we have? Can it be dovetailed with GAVI Health System Strengthening? Dr Werner said that’s exactly he would like to see, infact, not only GAVI but other components such as link to service delivery of the three diseases, 7

MNCH and LHW, also. There has to be strengthening of national and provincial systems like procurement and warehousing.

The meeting ended with a vote of thanks by the Chair, CCM Pakistan.

Minutes of OIG Exit Meeting Page 7