Transition & sustainability
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International funding of health programmes has been experiencing significant constraints over recent years, leading to the first moves to shift the financial burden of health programmes from external donors to sustainable domestic sources.
International support for health programmes grew dramatically from the year 2000, but since the global economic crisis in 2008 has started to level off. This has led to donors looking for increased domestic funding from governments to match or complement donor funding, while the progress of some developing countries from “low” to “middle” income classification means that these countries are no longer eligible for funding from certain donors.
At the same time, health programmes aim to achieve significantly higher targets, including universal health coverage (UHC). Nevertheless, despite unprecedented levels of health aid, fewer than 60% of all persons infected by HIV are on treatment, well short of UNAIDS 90-90-90 targets, and only a small number of low income countries have introduced HPV vaccines nationwide to prevent cervical cancer, despite WHO recommendations.
Planning a transition from donor to domestic support
There is a need to conduct transition readiness assessments with the government and partners. Such assessments look into several factors including the country’s epidemiological context, domestic funding and budget priorities, the policy and legal environment, and support for human rights, gender equality, and key and vulnerable populations.
In the planning stage, a range of domestic stakeholders need to be identified and invited to participate; the ministry of finance, and legislative committees on health may be essential parties, in addition to the ministry of health. Domestic advocacy groups and NGOs should be engaged too.
Increasing domestic finances
To leverage additional domestic financing there is a need to support domestic advocacy for increased health spending, and to assess what alternative innovative financing mechanisms can be developed to reduce dependence on donors, such as the Zimbabwe AIDS Levy, established in 1999, or the India Health Fund.
There is often political advocacy needed to ensure that all interventions appropriate to a particular country’s disease epidemiology (including interventions that focus on some criminalized or marginalized key populations) are eventually transitioned to domestic financing. This can be challenging if enabling policies, practices and laws are not in place.
There may be a need to change legislation to allow for the public sector to contract with non-public sector providers, such as civil society organizations (CSOs), known as “social contracting“. Social contracting is a financing option by which governments finance programmes, interventions and other activities implemented by civil society actors, and can be crucial to the success of health programmes in countries where key populations are disproportionately affected by the three diseases and are often criminalized or marginalized. CSO capacity should be strengthened while donors are still present to ensure that CSOs are prepared for both service delivery and advocacy activities and are able to deliver services adequately and to advocate for their sustained financing after the exit of external financing.
Global health security
Strong systems for health are essential for ensuring domestic sustainability and moving towards UHC. Capacity development of health systems and national health workers, such as community health workers, ensure a more sustainable response to health needs.
The impact of transition on key populations
A recent study by The Centre for Policy Impact in Global Health made five concrete recommendations for donors and countries for the transition planning process:
- There is a need for strong political will for the HIV response, and an understanding of the importance of HIV programmes for key populations, should be established before transition. Political leaders need to be sensitized to the challenges surrounding HIV and key populations and local champions cultivated.
- Transition planning should start early, be a country-driven process supported by donors and transition planning tools and be tied to a monitoring and reporting mechanism.
- Budget lines should be created for the inclusion of HIV programme activities for key populations in ministry of health budgets before transition, Donor co-financing requirements should similarly ensure that countries are substantially supporting HIV programme activities for key populations before transition.
- Social contracting should be introduced in pre-transition countries. Such contracting should include (1) strong technical and managerial leadership, (2) monitoring and evaluation to ensure that CSOs meet service delivery targets and have the established capacity to deliver services, and (3) the flexibility to cover innovative and potentially controversial activities, such as advocacy and defence of human rights.
- In countries where stigma and discrimination make it hard to implement nationwide policies and programmes for key populations, sub-national units of government (provinces, municipalities, etc.) can sometimes still take action to support services under the rules of decentralization.
The Global Fund defines transition as the process by which a country moves towards fully funding and implementing its health programmes independent of Global Fund support. It is aiming to improve the sustainability of its programmes through moving progressively from external-donor financing toward domestically funded health systems.
According to the Global Fund’s Eligibility Policy once a country reaches upper-middle Income status, it is no longer eligible for funding if there is less than a ”high” disease burden. The Eligibility Policy allows for up to one allocation of transition funding following a country’s change in eligibility.
The Global Fund approach to supporting countries for sustainability of programmes and to successfully transition includes:
- investing in and providing support for the development of robust, inclusive (including key and vulnerable populations), quality, evidenced-based national health strategies, disease specific strategic plans and health financing strategies
- aligning requirements to ensure that Global Fund financed programmes can be implemented through country systems in order to build resilient and sustainable systems for health
- supporting countries to assess their readiness to transition both programmatically and financially and ensure robust planning, allowing transition work plans to serve as the basis for funding requests
- providing transition funding for up to one allocation period upon becoming ineligible
- applying graduated co-financing requirements, ensuring that the revised application focus and co-financing requirements align domestic financing incentives to ensure that as countries move closer to transition, they take up key programmes, such as interventions for key and vulnerable populations