The Board of the Global Fund will discuss, at its 42nd Board meeting next week, the Sustainability, Transition and Co-financing (STC) Policy, and its implementation. This policy insists on, among other aspects, transition planning where a country “moves towards fully funding and implementing its health programs independent of Global Fund support while continuing to sustain the gains and scaling up as appropriate,” according to the Global Fund.
Gains from Global Fund investments in transitioning countries appear fragile, as a spike in new HIV infections among key populations demonstrates. In order to sustain those fragile gains, it will be vital to help countries develop a clear transition plan, which takes into account not only the countries’ strengths, like higher income per capita or the existence of national health coverage, but also the weaknesses of a country’s health system and the constraints of its legal structures.
During the Global Fund's current funding cycle, countries can apply for grants to help them plan for transition, and this is commendable; but those grants lack an emphasis on system strengthening, which is a missed opportunity. Such a system-strengthening component is vital; we argue that the absence of system strengthening contributes largely to the fragility of the gains of the Global Fund investments in upper middle-income countries, especially in the fight against HIV/AIDS.
The Sustainability, Transition and Co-financing policy
The Global Fund Board adopted the Sustainability, Transition and Co-financing (STC) policy in 2016, to replace the Eligibility and Counterpart Financing Policy. In recent months, several reports by Global Fund institutions have highlighted implementation issues related to this policy.
The Technical Evaluation Reference Group (TERG), an independent committee of the Global Fund, reviewed the STC policy implementation and funding in ten countries. The TERG report concluded that the Secretariat made the transformative change within the organization required for the implementation of the STC Policy. The TERG recommended a follow-up review in three years on post-transition outcomes.
It would be important that such a follow-up review extends to countries that had transitioned earlier before the STC policy was adopted. In April 2018, Aidspan described the status of transition especially in Eastern Europe and Central Asia (EECA). EECA and the Latin America and Caribbean (LAC) regions have the highest number of transition countries in the Global Fund.
A review of outcomes in countries that have transitioned is vital for the reputation of the Global Fund, and lessons learned will be useful for the sustainability of all the Global Fund’s investments, because of the potential fragility of gains made as a result of the Global Fund’s investment. The Technical Review Panel (TRP), another independent institution that examines the submissions for funding to the Global Fund, reported that several countries that had previously transitioned from Global Fund support applied anew for funding for a variety of reasons. Among those reasons is the spike in disease incidence or program-specific issues such as the need to address key populations, including migrants. The TRP recommended emphasis on sustainability in transition countries. Sustainability of Global Fund-financed programs implies that the program or the country can control or eliminate either or all three diseases even after the Global Fund and other external donors have stopped their support.
Appropriate planning for sustainability and transition
During the current grant cycle of three years, the Global Fund has provided for specific funding for certain countries or programs to plan for their transition.
It is important to question whether a three-year period and accompanying funding provided are appropriate before a country committed to transition is ‘weaned off’ Global Fund support. A corollary question is what happens to people living with or affected by either one of those three diseases in case of poor transition planning or the absence of transition planning? Will those lives be saved if inadequate prevention, access to treatment, and care follow the transition?
Aidspan reported in the past on countries in the Eastern Europe and Central Asia (EECA) region where the Global Fund exit meant reduced prevention for HIV because the State in some countries cannot legally fund civil society organizations (CSOs). But those CSOs were more effective than State institutions in reaching key populations that are marginalized and whose activities are considered criminal under the laws of their countries. The Global Fund used to fund those CSOs. The European region, where EECA geographically is located, is the only one where the HIV epidemic is increasing, according to the World Health Organization.
Moreover, some countries, or disease components within countries, like the HIV programs in Bulgaria, Bosnia and Herzegovina, Macedonia, and Russia, became ineligible for Global Fund grants before the STC policy was adopted. Those countries did not receive support in planning for transition of their programs and financing before they stopped receiving Global Fund grants.
It is important to study countries with successful and unsuccessful transitions to draw lessons and best practices.
We acknowledge the possibility that the Global Fund Secretariat may have conducted or commissioned such studies to evaluate the outcomes of the transition in some countries. But the Secretariat has published little to no information on the outcomes of the countries that have transitioned, let alone on the methodology of these studies. Even Board members that Aidspan approached for this information appear to be in the dark.
At its upcoming meeting, the Board needs to take a closer look at the outcomes in countries that have transitioned from Global Fund support, and why some of them have come back to request more funding. Unpacking those cases now, at a still relatively early stage, opens a valuable opportunity to learn from mistakes made in a few countries, before these challenges constitute a growing trend.
Now is the right time to ask, understand and act to end the epidemics for good in countries that have transitioned from the Global Fund support.
- The Global Fund Sustainability, Transition and Co-financing Policy’ (GF/B35/04) – Revision 1 Board Decision
- ‘Status of Transitions from Global Fund support in the EECA region,’ GFO 334, 4 April 2018.