The Global Fund’s new strategy for the period 2017-2022 has a strong focus on the sustainability of investments. This includes supporting countries that are transitioning from Global Fund support to domestic reliance for their disease programs.
In recent years, there has been a growing chorus calling on the Global Fund to develop a clear sustainability and transitions policy. The need for this policy is based on mounting evidence that transitions are not adequately planned for. Transitions are often hard to anticipate and hastily implemented. For example, the Fund’s withdrawal out of China in 2013 has been said to have been earlier-than-expected, leading to challenges in securing funding mechanisms for civil society (see “The Global Fund’s China Legacy”). In addition, Thailand’s decision to transition over just a two-year period in 2015-2016 has been viewed by some as too swift to ensure proper handover (see GFO article).
As a result, transitions can threaten the continuity and coverage of vital health services. This threat is especially acute for key populations, as services for criminalized and marginalized groups are often not eagerly absorbed by governments. For instance, in 2007 when Russia’s income status meant it was ineligible for further Global Fund money for HIV, the country witnessed a massive scale-down of harm reduction services as the Global Fund left and the government refused to continue supporting these vital programs. There were reports of a surging HIV epidemic among drug users during this time. A similar HIV outbreak among drug users in Romania in 2011 has been linked with the significant decline in harm reduction services following the Global Fund’s exit.
Responding to these concerns, The Global Fund has developed a sustainability, transition, and co-financing policy. This policy was approved by the Board at the 35th Board Meeting on 26-27 April 2016 in Abidjan, Côte d’Ivoire. See Figure for a high-level overview of the new policy.
Figure: The Global Fund’s new sustainability, transition and co-financing policy
The sustainability, transition, and co-financing policy is based on four key principles:
- Differentiation – the policy and associated processes should be tailored as much as possible to a country’s income level, epidemiological context, disease burden, human rights and gender contexts, and other context-specific factors.
- Alignment - requirements related to sustainability and transition should be linked with existing national systems and/or processes.
- Predictability - countries should have as much advance notice and time as possible to adequately plan for transition, including accessing resources for the process.
- Flexibility – countries and the Global Fund should have the leeway to adapt certain elements of this policy to better suit a particular country and/or regional context.
A central premise of the Fund’s new policy is that all countries should be doing sustainability planning in an ongoing manner, regardless of their income status or disease burden. In other words, the policy encourages countries to be planning for future sustainability challenges, including transition, long before they must do without Global Fund support. Previously, countries would typically only begin sustainability planning after learning they would no longer be eligible to receive funds, or if they were specifically requested to do so by a country team.
With the new policy, The Global Fund will invest in and support countries to institutionalize sustainability planning in their national health strategies, national strategic plans for the three diseases and health financing plans. The aim is to promote early and ongoing sustainability planning at country level so that Global Fund programs can increasingly be implemented through existing country systems.
The policy will also introduce transition workplans, which can be used as the basis for funding requests in countries that are preparing for transition. This approach will be paired with support to countries to assess their readiness to transition, both programmatically and financially.
The Fund will also provide direct transition funding once a country becomes ineligible (see article in this issue on the Fund’s new eligibility policy). Transition funding will be made available for up to one three-year allocation period.
In order to incentivize countries to increase their domestic funding ahead of a transition, the policy also contains new co-financing requirements (previously called counterpart financing) to ensure that countries are assuming responsibility for interventions for key and vulnerable populations as they move closer to transitioning. (GFO expects to provide more information on the co-financing portion of the policy in a future issue.)
There are other elements of the new sustainability policy which aim to encourage greater prioritization of key populations within the context of transition. Going forward, all eligible upper-middle-income countries must focus 100% of their funding request on interventions that maintain or scale-up evidence-based interventions for key and vulnerable populations. Previously, UMICs were required to demonstrate that 100% of their funding requests would cover underserved and most-at-risk populations and/or highest-impact interventions.
While many aspects of this new policy are welcomed by stakeholders, there are still some uncertainties. The policy calls for “timely notification of potential transition,” but is unclear how and when countries will be notified.
Further, there are potential pitfalls with the policy’s approach to only providing transition funding once a country becomes ineligible, and only for three years. While the policy’s central message is that sustainability and transition planning should be done by all countries regardless of where they are in the development continuum, it is not clear how countries will put systems in place ahead of transition if funding is not available early on to do so. Specific transition funding is likely needed before a country becomes ineligible, to ensure greater transition preparedness. According to a recent paper on transitions published jointly by APMGlobal Health and Aidspan, good practice models suggest that responsibly managed transitions should take at least five years, and points out that some of the more successful handovers have taken over eight years.
According to Ivan Varentsov, Global Fund Advocacy Adviser at the Eurasian Harm Reduction Network, the new policy does not provide enough clarity on the key areas where transition is needed. He noted that previous consultations on the issue from the Eastern Europe and Central Asia region identified four critical areas for transition: finance, policy, program, and governance. Others have said transitions need to be considered across six tenets (see GFO article). “Clear definition of such areas will indicate priorities where the Global Fund will invest its transition funding, and where countries will need to focus their responses,” Varentsov said.
In a letter to the Global Fund Board and Secretariat, Dr Bart Janssens, Director Operations for Médecins Sans Frontières, the sustainability, transition and co-financing policy relies excessively on country-income classification to limit the scope of interventions that can be funded. “This restricts implementation based on context-specific and inclusive assessments of needs,” he said.
The Global Fund Sustainability, Transition and Co-Financing Policy, Board Document GF-B35-04, should be available shortly at www.theglobalfund.org/en/board/meetings/35. A copy of the MSF letter is on file with the author.