Large numbers of countries that have achieved middle-income status are in the process of transitioning away from significant donor aid that they have been receiving for their health programs in recent years — notably in the areas of AIDS, tuberculosis, and vaccine-preventable illnesses, but also in other domains such as family planning. External financial and technical support to these countries is being gradually withdrawn. Millions of lives are in the balance. This is going to be one of the top issues in global health over the coming decade, as the ground shifts profoundly.
Yet neither countries nor donors are well prepared or equipped to manage these transitions, in order to ensure that disease control and other health programs continue to be well run and generate the enormous benefits expected of them. While there are some emerging good practices developed by organizations such as the Gavi Alliance, the Global Fund to Fight AIDS, TB, and Malaria (GFATM), and the US Government's PEPFAR program, the risks and challenges of transition have not yet been fully assessed nor have enough measures been put in place to address these risks and challenges.
There is an urgent need to develop and deploy better tools and data on country transitions in global health. It is time for funders to come together around a common analytical agenda that tackles the major issues in health transitions — including political will and commitment, financing, technical and managerial capacity, and monitoring and evaluation. This agenda needs to be put in place as soon as possible and vigorously pursued over the next few years, if the country transition process is to be successfully managed.
In this blog post, we describe global health transitions and explain the reasons why they are happening now; point to the risks inherent in the transition process; highlight emerging best practices as well as weak and neglected areas; outline what we see as an emerging analytical agenda; and propose next steps to make such an agenda and more coordinated action across countries and donor agencies a reality.
Global Health Transitions — What Are They, and Why Are They Happening Now?
In global health transitions, responsibility for a major health program, including managerial, technical, and financial responsibilities are shifted away from external donor agencies and towards national implementing organizations. Through this transition process, as the country's economy strengthens and its disease burden lessens, external financial and technical support are withdrawn, leaving the country increasingly to fend for itself. There is typically an end-goal, likely to be achieved over a period of several years, after which the program is fully (or predominantly) managed by a national organization and financed with domestic funds. Donors and external technical agencies have either exited or dramatically lowered their profile.
To illustrate, take the example of Gavi. As lower-middle income countries surpass a per capita income threshold, currently set at $1,580, they have five to seven years to gradually take over full responsibility for purchasing vaccines which Gavi had previously subsidized.
Source: Adapted from Juliette Puret, WHO, presentation to Gavi, March 2015
There are two main driving factors propelling these country transitions. First, donor aid for health (DAH) has plateaued over the past few years, after rising rapidly during 2000-2010, and in this constrained environment, donors focus these resources on the poorest countries. The decade between 2000 and 2010 was a "golden era" of rapid increases in DAH in which more than $300 billion of aid was channeled to programs to fight major infectious diseases, including AIDS, tuberculosis (TB), and malaria, and to subsidize the purchase of powerful new vaccines to prevent childhood deaths. But the annual amount of DAH peaked at $38 billion in 2013 and has been flat since then. The largest programs—PEPFAR, the Global Fund, and Gavi ($12 billion a year combined)—are fighting to keep their funding at current levels.
The second factor is working in the opposite direction: as increased numbers of countries have seen steady economic growth and graduated from low-income status to middle-income status in recent years, their need for outside support, and their corresponding income-related eligibility for access to donor financing, have steadily diminished. Admittedly, per capita income alone is a poor proxy for countries' ability to fund and manage their priority health programs without external support. Nevertheless, applying this widely used indicator, the number of low-income countries has fallen from 63 in 2000 to 31 in 2016, and the now more than 70 percent of the world's population live in middle-income countries.
Source: Updated from Sumner, "Global Poverty," 2010
What Are the Risks and Challenges Inherent in these Transitions?
As these transitions unfold, there are multiple risks and challenges faced by the countries and their billions of citizens. From a country government perspective, there is a risk of a too hasty and unplanned withdrawal, which could be enormously destabilizing. In many East and Southern African countries, for example, over 80 percent of AIDS spending comes from PEPFAR and the Global Fund. If they wind down their support too rapidly, it is unlikely that governments will be able to take over in time. If PEPFAR and the GF were to announce their withdrawal simultaneously and without coordination, the problem would be further compounded. Also from a country point of view, governments may face pressure from the departing donor to continue a program or activity that they feel is not a priority — this has arisen, for example, in South Africa where the Western Cape provincial government was less enthusiastic about home-based HIV care than PEPFAR, at the time that PEPFAR scaled back its funding. As a result, many home-based care programs were scaled back, though more recently some have been restored.
From the donor perspective, the clear risk is that the program they have backed might deteriorate or even collapse because of inadequate domestic political support, national funding, and indigenous managerial capacity. The public health gains they helped to generate would be in jeopardy, and the donor's own reputation could be tarnished. Gavi has faced this issue, for example, in transitioning countries like Republic of Congo and Angola, where the government was slow to step up and replace declining Gavi funding for vaccines with its own health ministry budget.
From the point of view of civil society organizations (CSO) such as patient advocacy groups and organizations representing vulnerable populations such as sex workers, health transitions can also be threatening, especially in situations where the donors have supported CSOs as advocates or to reach marginalized populations in countries where governments are not committed to such populations and are not open to collaboration with CSOs. While they often enjoy good relationships with donors, they may be viewed more negatively by their own governments. With donor funding dwindling, the CSOs have to find alternative support either from their own governments which may be unwilling to take over such a role—as has been the case with Global Fund-backed CSOs focusing on men who have sex with men (MSM) in Latin America and on injecting drug users (IDU) in Eastern Europe—or from private sources.
The negative impacts of poorly executed transitions could be very large. Many lives are in the balance. At present, for example, over 15 million people are on AIDS treatment in low- and middle-income countries. Life-long therapy for these people cannot be interrupted without jeopardizing both the gains made thus far and the efficacy of the drugs. Similarly, over 65 million children are being vaccinated yearly with products underwritten by Gavi, saving hundreds of thousands of young lives. An additional 8.5 million people with tuberculosis benefit from treatments financed by the Global Fund.
Some Emerging Best Practices, and Areas of Weakness and Risk
As the global health transition process accelerates across more countries, some good practices are emerging. These need to be more widely documented, disseminated, and shared. Gavi, for example, last year revised its policies on country transition for the third time since 2009, putting in place new measures to try to ensure a smooth shift from external to domestic support for immunization programs in lower-middle income countries. These measures include early assessments of country readiness; the design and funding of special grants to countries to prepare the way and ease transitions; the use of flexible rules on the number of years that individual countries have to become financially self-sufficient; and securing affordable prices for vaccines for countries for several years after the transition is complete.
In a similar vein, the Global Fund adopted a new set of policies on transition in mid-2016, including making the timing of country transitions more predictable and transparent, conducting country financial sustainability studies, and requiring countries to provide higher levels of domestic co-financing as they approach the point where Global Fund support ceases. The Global Fund has also commissioned a series of evaluations of national transitions in 10 countries that ended their GF support in 2014-15, in order to learn lessons that can be applied in the future.
PEPFAR is also paying more attention to transition, in the context of its efforts to increase domestic ownership and accountability for national AIDS programs. It has developed a "sustainability index" and is measuring country sustainability as part of its annual performance reviews and country operational planning (COP) exercises.
Still, there are serious weaknesses in the health transition processes taking place and scheduled to occur in the next few years. Country risks are still not being systematically assessed. Many countries lack coherent transition plans. Domestic political commitment to continue serving marginalized groups is low in many places. Domestic financing capacity to replace dwindling donor funds has not been adequately studied, and willingness to step in financially has not been secured in a large number of countries. Often, the dialogue and coordination of transition timetables and actions between countries and donors is weak and could result in serious gaps and interruptions in essential health services.
What Needs to Happen Next?
While better data, tools, and processes alone will not solve the challenges of country transitions, they are important components of any effort by the global health community to improve these transitions. To take two examples, in the area of financial transition, it is vitally important that metrics be agreed and applied widely to project a fair and sustainable pace of change from external to domestic financing, and that the financial transitions of various donors in the same country be more closely coordinated. In the area of monitoring and evaluation, more systematic analysis of transition successes and failures are needed as well as effective mechanisms for the sharing of lessons across countries. Figure 3 offers additional ideas regarding the emerging agenda for research, analysis, and action.
Source: Author's original material
To drive accelerated development and wider use of tools and data on transitions, affected middle-income countries and their external funding partner agencies urgently need to come together around a common analytical agenda. A process for doing so, led by champions, must be mounted as soon as possible.
We would propose that important middle-income countries involved in health transitions, such as Vietnam, India, South Africa, Ghana, and Kenya should be a part of the authorizing champions group. So should the key external agencies, such as Gavi, Global Fund, PEPFAR, the Bill and Melinda Gates Foundation, and the World Bank. A technical secretariat or hub will be required to keep the process moving forward. It could serve as a convener, coordinator of activities, generator of analytical content, clearinghouse for knowledge, and facilitator of knowledge translation. Given the large potential benefits of such an arrangement to countries and their external partners, we would suggest that the activities of the hub be co-funded by several of the donor agencies, who would also have their own separate budgets for studies and technical support on transition in their own area (such as immunization, HIV, etc).
With the pace of transitions expected to increase in the coming years, the time for learning about transitions is now. Without such learning, there is a real danger that many of the investments made in global health thus far will be squandered.
Authors' Note
This commentary builds upon work that the authors carried out while RH was a Managing Director at the Results for Development Institute. SB received support for work on this blog from the Bill and Melinda Gates Foundation through grant number #OPPGH5190. The authors also wish to thank the following persons for their wider collaboration on this topic, even though they did not review and are not responsible for the content of this blog: Michael Chaitkin and Tess Ryckman (R4D), Daniela Rodriguez, Ligia Paina, and Satchi Ozawa (Johns Hopkins Bloomberg School of Public Health), and Shan Soe Lin (Pharos Global Health). Rachel Wilkinson and Lindsey Hiebert (Pharos) assisted in preparing references and graphics for the blog post.
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