“It is unlikely that Panama’s HIV-related civil society can effectively survive the exit of the Global Fund or gain a greater foothold as a full partner in [the] planning, implementation and monitoring of the national HIV response.” This is a key finding of the transition readiness assessment (TRA) report commissioned by the Panama country coordinating mechanism (CCM). Despite this gloomy assessment, however, the report calls for measures to strengthen civil society organizations (CSOs).
The 80-page report was completed by consultants from Aceso Global, a non-profit that provides strategic healthcare advisory services, and APMG Health, a social benefit corporation that works to improve the health and well-being of marginalized populations. Financial and technical support was provided by the Global Fund. A copy of Panama’s TRA report is available here.
The TRA report was developed using a modular Guidance Tool, also developed by Aceso Global and APMG Health. The tool, which was commissioned by the Global Fund, was also used earlier this year in Cuba, Paraguay and the Dominican Republic.
Panama’s TB component is currently receiving its final regular allocation owing to Panama’s classification as a moderate-disease-burden, upper-middle-income country. Panama’s HIV component is still eligible for Global Fund support. However, World Bank projections indicate that Panama will become a high-income country prior to the next allocation period, which would make Panama’s HIV component ineligible for both regular funding and transition funding from the Global Fund. Consequently, there is a strong possibility that the current HIV allocation will be Panama’s last. As a result, in December 2016 the Global Fund recommended that Panama’s 2017-2019 allocation, which totals $2.7 million, be used to fund a joint HIV/TB transition grant. Panama will submit a funding request tailored to transition in Window 4, in February 2018.
According to the Global Fund’s Funding Request Instructions: Tailored to Transition, the funding request should outline the country’s sustainability and transition-related programmatic and financial gaps. These gaps should be identified and prioritized by undertaking a TRA and/or an equivalent analysis of transition and sustainability at the country level. This assessment forms the basis for developing a transition work plan, which ultimately guides the funding request and must be submitted with it.
The Global Fund Sustainability, Transition and Co-Financing Policy states that transition funding is not expected to be used to maintain the status quo of current grants or to extend for additional time the activities currently financed by the Global Fund. Instead, it should provide support to the transition process.
In Panama, the Global Fund Secretariat was involved in every step of the process of developing the TRA, facilitating initial contact with the CCM, with the consultants hired to conduct the TRA, and with in-country stakeholders (including community and civil society actors); providing relevant background documents to the consultants; undertaking country visits; and reviewing draft reports.
Civil society response
The TRA report identified financial, programmatic and governance gaps, bottlenecks and risks that need to be addressed. One area that requires attention is the sustainability of the civil society response. CSOs working on HIV are currently active in the response across all key populations, but are not well integrated into the formal response. There is currently only one CSO, PROBISIDA, receiving funding from the government through the Ministry of Health (MINSA).
The government is considering using social contracting to CSOs to provide HIV prevention services, but the model it is now using only funds medical services, which is vastly different from the community-based outreach interventions that are currently being funded but that are in danger of disappearing once Global Fund support ceases.
“Development of a broadened social contracting system for provision [of] HIV services, including prevention, for key populations is both possible and necessary,” the TRA report said. “Given the political will available to assist in funding non-state actors to implement health interventions, it is ideal to lay the foundation for a sustainable social contracting program.” The report said that this entails, among other things:
- developing and budgeting a specific prevention plan (based on scientific evidence) which includes provision of services by CSOs;
- strengthening community systems, including skills development, training on specific issues and conflict resolution processes;
- bolstering the mechanism for social contracting within MINSA; and
- strengthening government technical capacity for issuing tenders, and conducting transparent selection, monitoring and supervision of projects.
The report stated that in order to support the implementation of an enhanced combination prevention strategy and the social contracting mechanism mentioned above, it will be necessary to greatly expand the capacity of HIV CSOs for cooperation and joint program implementation with the government; and to build their technical capacity for program management under the new funding paradigm. This will require extended mentorship and support from external actors, the report said, and may also be supplemented by strengthening linkages to regional networks.
“There is urgent need for sustainability planning for CSOs, beyond the ability to apply for social contracts for service delivery from the Panamanian government,” the report stated. The report recommended that that funding partners active in the region, including both PEPFAR and the Robert Carr Civil Society Networks Fund, be engaged to identify funding opportunities for supporting this work.
The report also recommended that the CCM and the country team work jointly to explore opportunities to introduce a funding model similar to what is being considered in Montenegro, whereby any future grant funds for CSOs from the Global Fund are awarded to the government specifically to be implemented via the social contracting mechanism. [Editor’s note: We hope to be able to describe the Montenegro model in a future GFO article.]
The TB response has very limited civil society engagement, but the TRA report said that what does exist does not appear to be sustainable once the Global Fund withdraws. The government has contracted with former TB patients to become “TB promoters.” The report said that although this is believed to have been an effective model, it is not very sustainable (for a variety of reasons, including that the promoters work in isolation from each other). “There may be opportunities for further organization and development of these cadres of promoters through integration with HIV service organizations,” the report said.
Beyond social contracting, there is a need to strengthen the capacity of CSOs. Dayra Garcia, executive director of Asociación Viviendo Positivamente, an association of people living with HIV, told Aidspan that “we are very worried by the withdrawal of the Global Fund. Civil society capacity is weak and there are no resources to strengthen it.” It will be imperative to build civil society’s technical capacity to collaborate with one another as well as with the government and to manage and implement programming, she added.
The TRA report stated that CSOs are understandably resistant to being solely dependent on their own governments, due to the limitations that dependence imposes on their ability to advocate for legal and policy changes that require government action – and the fact that it puts them at the mercy of ever shifting budget priorities. The report recommends that support for community systems strengthening be requested from the Global Fund’s Community, Rights and Gender Special Initiative, including through regional grants.
The good news is that in the case of Panama, national financing for HIV and TB is relatively assured. The government already transitioned smoothly to financing immunization programs; it currently finances 69% of the HIV program, and the MINSA delivery system manages most aspects of the program. However, there are some obstacles to overcome. The national budgeting system has built-in rigidities. There are few incentives for effecting efficiencies or savings or for allowing the MINSA to reprogram savings.
However, based on the findings of the report, even if Panama is able to reduce inefficiencies and duplication to free up resources and to find creative and innovative mechanisms to finance the takeover of existing programs – there is still a need to scale up interventions that successfully target the reduction of stigma and discrimination in hard-to-reach communities and among key and other vulnerable populations. That said, scaling up interventions does not fall within the parameters of transition funding – although it is an absolute prerequisite to achieving the goal of ending the AIDS epidemic by 2030.
The next step will be to develop a work plan based on the recommendations of the TRA that is practical, measurable and costed, and that includes a detailed outline of steps that the country will take to ensure that at the end of three years, the entire response is funded by domestic resources.
Transitions in the rest of LAC
Aidspan plans to continue to report on the transition process in Panama as well as in other countries in the region. According to the Global Fund’s 2017 Eligibility List there are several countries in Latin America and the Caribbean that are receiving their final regular grants from the Global Fund 2014-2016 allocations and that will be eligible for transition funding in the current allocation period for the following components:
- Belize (TB) (will submit joint-HIV/TB request)
- Cuba (HIV)
- Dominican Republic (TB)
- Panama (TB) (will submit joint HIV/TB request)
- Paraguay (TB)
- Suriname (TB) (will submit joint HIV/TB request)
The Paraguay malaria grant is also coming to an end; however, the malaria component will not be eligible for transition funding due to having very few cases.
With the exception of Cuba, which has already submitted a funding request (it is currently in the grant-making stage), the above-mentioned countries expect to submit their funding requests in February 2018.
The Dominican Republic has recently completed its TRA; Paraguay’s TRA is currently being finalized; and Belize and Suriname have yet to begin preparing their TRAs. It is up to each country to decide whether they wish to make their TRA reports public. So far, Panama and the Dominican Republic have decided to do so.