Sustainability & Transitions

Sustainability & Transitions

Position Paper & Talking Points Developed Country NGO Delegation

1. Introduction

The Global Fund is withdrawing its support from higher income countries(MIC and UMIC) based on the premise that these countries can take care of their own. There were also no deliberate steps taken on the part of the Global Fund to prepare countries that have become ineligible to assume financial responsibility of the programs. The key question here is whether these countries are “ready, able and willing” to assume full responsibility for funding of AIDS, TB and malaria programs and what the Global Fund’s role is in facilitation of sustainability and responsible transition in these countries.

Transition is not business as usual

Based on a number of civil society consultations it is clear that transition is not business as usual, neither is transition just a technical issue! It is a strategic issue for the Global Fund to consider as part of its 2017-2021 Strategy development. Countries (i.e. governments and civil society) – and their partners, such as the GF, other donors and technical partners – cannot continue going down the same road, but must share responsibility for planned, gradual transition to country ownership of HIV, TB and malaria responses, and increased domestic funding.

2. A Global Fund SustainabilityTransition Policy - addressing a policy gap

GF deliberations on sustainability and transition should be based on the Global Fund’s vision and core mission as reflected in the GF Framework Document. The recent call for a Sustainability Transition Policy points to a policy gap that should have been addressed a long time ago.

Addressing this gap should not only be inspired by assumed austerity or changing donor priorities, nor just by a focus on countries that are transitioning out of GF eligibility, but driven by strategic reflections on the GF’s role in achieving sustainable impact in fighting the three pandemics in all countries that are faced with challenges to respond to these pandemics, regardless of their income levels.

The concept of sustaining programmatic gains is central as sustainability is not just keeping the status quo. Sustainability is also not about “when we can pull out”, but about “what needs to be in place” in order to reach appropriate levels of prevention and treatment program coverage to reach epidemic control and having critical enablers in place.

A Global Fund Board discussion on the Fund’s responsibility to achieve sustainable impact and how therefore sustainability assessments could be operationalized at country level, is of equal importance as the work on the Equitable Access Initiative (1), political donor considerations around eligibility of countries for aid (2), and the allocation methodology discussion (3).

One could actually argue that the Global Fund’s definition of sustainability, and subsequently its role and responsibility in achieving sustainable impact, should inform (and therefore precede) the EAI and the discussion on the allocation methodology.

In the end it is the outcome of these combined processes (not one alone) that should determine the Fund’s role as a funder of sustainability and responsible transitions.

As part of aGlobal Fund Sustainability & Transition Policythe GF needs to determine a definition of “sustainability”, “transition” and of “graduation criteria”, and develop a “transition readiness assessment” tool.

2.1.Definition of sustainability

The GF framework document states that “the purpose of the Global Fund is to attract, manage and disburse additional resources through a new public-private partnership that will make a sustainable and significant contribution to the reduction of infections, illness and death, thereby mitigating the impact caused by HIV/AIDS, tuberculosis (TB) and malaria in countries in need.”

Any definition of sustainability for the Global Fund should therefore promote continued impact in the fight against the three diseases[1], particularly for key populations.” [2]

The SIIC15/10 paper suggests the following operational definition: “A program is defined as sustainable when it is able to reach and[3]maintain service coverage at a level that will provide continuing control of a health problem even after the removal of external funding.”

This definition of sustainability seems to be very much focused on “services” and “disease control”, which runs the risk of missing out on the critical enablers of health, human rights and responsible transition.

The GF TERG2013 [4] suggests the following operational definition for a sustainability plan: “A long term plan for assurance that programmatic, financial and organizational gains at national and community levels as a result of the Global Fund support will be maintained or increased as Global Fund financing is reduced”. This definition seems more helpful since it reflects a more comprehensive and inclusive approach.

Given the GF’s existing commitment to contribute to a sustainable response to ATM, a sustainability assessment and transition readiness assessment(see “Sustainability & Transition plan” below) should help the GF to determine a funding contribution to a country/program, both in terms of funding level as well as strategic focus of that contribution.

2.2.Definition of transition

The GF’s definition is “The mechanism by which a country moves towards fully funding and implementing its health programs independent of donor support (financial or otherwise)”.Transition includes transition from support altogether (after having become ineligible) and to a decreased level of support due to income classification change. [5]

Responsible transition should also entail that countries are given notice and sufficient time to plan and implement the transition process with the full involvement of all key country stakeholders and key development and technical partners at all stages. Sustainability planning should be part of each grant at an early stage.

In the civil society consultations, countries indicated that they must be timely informed by the GF on the timeline within which the GF expects them to transition. All indicated that 1-2 grant cycles are minimum! In addition the countries must be informedon a timely basis aboutthe technical and financial resources available to them to plan and execute the transition plans successfully.

2.3. Graduation/transition criteria.[6]

Development of “graduation or transition” criteria (informed by the work of Equitable Access Initiative) is necessary to assess a country’s readiness to transition (prior to the end of grant) or to assess why a country failed to transition. Such an assessment tool should help reviewing the presence of critical enablersor disablers for health, human rights, and responsible transition, such as:

1. Policy enablers:

• National HIV/TB/drug strategy endorsed and funded by government, relevant services supported by policy/ legislation (e.g. harm reduction) and mechanisms supported by policy/ legislation
• Removal of legal barriers and criminalization

Inclusion of new professions (social worker, outreach worker, peer educator)

Policy disablers:

• Criminalization of drug use
• Quazi-legal status of harm reduction
• Absence of professional and educational standards

1. Financing enablers

• State budgetallocatesfunds for all critical elements of the HIV/TB/Drugs response
• Costed action plans are based on epidemiological data/need
• Financing mechanism allow implementation by CS

1. Governance, leadership and accountability enablers

• Well-functioning governance body oversees the HIV/TB/Drugs response

1. Programmatic enablers

• M&E structures and practices in place to monitor
• Local organizational capacity in place to procure and manage supplies, deliver services that meets the needs

3. Sustainability TransitionPlans

Our delegation fully supports the Development Continuum WG when it states that “The Global Fund should support country efforts to include sustainability planning from grant inception, consider more appropriate metrics for eligibility and transition (through the Equitable Access Initiative and additional efforts), and establish a responsible transitions policy ...”[7]

Establishing such Sustainability & Transition Plans requires:

-Specific GF guidelines for countries on the content and process for developing sustainability & transition plans from grant inception.

-A country dialogue process should aim to develop a ‘country compact’ and a Sustainability & Transition plan, involving all stakeholders, including national Governments (Ministry of Health, Finance) and civil society and key affected populations, donors, technical partners and agencies to ensure buy in.

-Each Sustainability & Transition plan should have a “sustainability assessment” and/or a “transition readiness assessment”that includesan analysis of legal frameworks, mechanisms for engagement and policy dialogue, availability of mechanisms to fund civil society, etc.

-The plan should detail a longer-term vision for supporting comprehensive programming (that includes services and critical enablers), pitfalls that may impact sustainability, and ways to mitigate those pitfalls.

-Global Fund and technical partners need to play an advisory and capacity building role in the development and implementation of the sustainability & transition plans and encourage linkages with NSP’s.

-Proper planning and timelines: experience so far indicates that achieving responsible transitioning out requires at least two allocation terms (2 x 3 years).

-The plan should be designed to ensure that during implementation, the program is always co-funded by both the Global Fund and the country. This requires determination of progressive increased funding responsibilities for the government.

-The plan should include a monitoring and independent evaluation plan of a countries’ readiness for transition, roll-out of transition processes and successfulness of transition.

-Urgent attention is required for countries in transition where programs for key populations risk funding cuts, including a transition plan for prevention/harm reduction programs and access to medicines.

-Sustainability and Transition Plans should include the provision of continued access to preferential pricing for drugs and a possibility for continued funding of specific interventions (including resource mobilization and human rights advocacy as well as MDR-TB treatment) through (for example) regional programs.

4. What tools do we need for responsible transitioning?[8]

The Global Fund should set aside funds to provide financial and technical support to the countries to implement sustainability plans(source: TERG 2013) and consider the possibility of continuing to fund aspects of a country’s Sustainability & Transition Plan for technical assistance, advocacy and human rights programming (source: Development Continuum paper) at different stages of the grant and after transition.

As part of the Strategy development discussions, the Board should commit to the establishment of aproperly resourcedSustainability and Transitions Fund, which could be part of a funding envelope for strategic initiatives. It should entail a “social contracting and civil society framework” (to allow for specific funding ofdual track funding or the “NGO rule” or targeted funding to encourage involvement of community based organizations and CS in advancing responses to the epidemics among key affected populations, especially in countries where governments are reluctant to support such activities).

[1]SICC15/10 – page 4

[2]addition comes from the Development Continuum WG paper.

[3]“reach and” was added in Istanbul

[4] TERG 2013 report – page 47

[5] GFS slide in the Istanbul consultation, 2015

[6] Slides from EHRN consultations in Istanbul , 2015

[7]Quote from the Development Continuum Working group report

[8]Summary of recommendations made in the consultations in Moldova and Istanbul, 2015