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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 local stakeholders – with the aim of transitioning funding 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 compliment donor funding, while the growth in economies of some developing countries from ‘low’ to ‘middle’ income classification has led to these countries becoming no longer eligible funding from certain donors.
At the same time, health programmes are aiming to achieve significantly higher targets, and committing to Universal Health Coverage. For example, despite unprecedented levels of health aid, less than 50% of all persons infected by HIV are on treatment, well short of UNAIDS 90-90-90 targets, and only a handful of Gavi-supported countries have introduced HPV vaccine nationwide to prevent cervical cancer, despite WHO recommendations.
Effectively supporting domestic advocacy for increased health spending.
Improving procurement processes and access to ensure that countries can purchase key products at efficient prices.
There is often significant political advocacy needed to ensure that all interventions appropriate to a particular country’s disease epidemiology (including interventions that focus on some criminalised key populations) are eventually transitioned given the legal framework.
Changing legislation to allow for the public sector to contract with non-public sector providers such as civil society organizations, 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 criminalised.
Transition plans should align with other changes in the health system, for example, the adoption of social insurance. Plans for transitioning financing should have incremental, verifiable milestones.
In the planning stage, a range of domestic stakeholders need to be identified and invited to participate; for example 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.
Social Contracting in Domestic HIV Financing
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 their 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.