Dr Ade Fakoya 10 th IAEN Preconference July 2018 Contents Background Global Fund investments Sustainability transition and cofinancing policy Key bottlenecks and challenges Country examples ID: 753127
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Sustainability, Transition and Co-financing - Investing to End Epidemics
Dr Ade Fakoya
10
th
IAEN Preconference, July 2018Slide2
Contents
BackgroundGlobal Fund investmentsSustainability, transition and co-financing policy
Key bottlenecks and challenges
Country examples
Catalytic Funding initiatives to support Key Population programmingSummary
1Slide3
Significant Progress Made -- 22 million lives saved to date
2Slide4
Understanding sustainability
3Slide5
Four Pillars of
Global Fund Strategy 2017-22
P
laces
a strong emphasis on the need to support sustainable responses for epidemic control and successful transitions away from direct grant supportS
tresses
the need to support countries to use existing resources more efficiently and to increase domestic resource
mobilization
BUILD RESILIENT
& SUSTAINABLE
SYSTEMS FOR
HEALTH
MAXIMIZE IMPACT
AGAINST
HIV, TB AND
MALARIA
PROMOTE & PROTECT
HUMAN RIGHTS AND
GENDER EQUALITY
MOBILIZE INCREASED
RESOURCESSlide6
Global Fund is investing in HIV/AIDS in
> 100 countries globally in the current allocation cycle (2017 – 2019)
Total GF HIV investment (2017-2019)
> US$ 5.2 billion
Allocation amount ≈
US$
5.1
b
Catalytic investment
=
US$
200
m
HIV
The top 10 countries
with HIV grant allocations account for
57%
of
GF investment in HIV
&
67%
of the
estimated
global HIV burden
(UNAIDS
data 2017
)
Global Fund accounts for
8
%
of
global
HIV funding and 20% of international financingSlide7
*Based on windows 1-5 submissions by countries (as of May 2018); does not include Nigeria and South Africa that are among top ten HIV allocations.
HIV
Catalytic investment (
US$
200
m
)
million
for HIV
Global Fund investment by modules in windows
1-5
*
:
almost
US$ 3.1 b
so far in this funding cycle
HIV
Matching funds
=
US$
150 m
Multi-country proposals
=
US$
50 m
Matching funds
=
US$
150
m
Scale-up
evidence-based interventions with a focus on the highest burden countries with the lowest economic capacity and on key and vulnerable populations disproportionately affected by the three diseases (US$ 50M) – 9 countriesScale-up programs to support women and girls, including programs to advance sexual and reproductive health and rights (US$ 55M) – 11 countriesIntroduce
and scale-up programs that remove
human rights barriers
to access to health
services (US
$
45M) – 20 countries
Multi-country
(Sustainability
of services for key
populations) = US$50 mLAC region (17 m; 2 grants anticipated: 1 for Latin America, 1 for Caribbean)EECA region (13 m) SEA region (12.5 m)MENA (7.5 m)Slide8
Goal of STC – Investing to end HIV, TB, and Malaria
The desired outcome
Sustainability
A process
Transition
One of the tools
Co-financing
Goal:
Investing to End the Epidemics Slide9
The STC policy outlines a
more proactive, comprehensive, structured approach to supporting countries to address transition bottlenecks and prepare for transition from Global Fund financing, in line with other approved Board policies.
The STC Policy instituted a number of changes to explicitly
mitigate
transition related risks, including: 1) Formalization of Transition Funding, 2) Tailored Co-Financing Requirements, 3) Greater emphasis on early transition planning and GF support for transition planning, 4) Increased attention to sustainability across the entire portfolio to mitigate long term transition risks
Under the STC policy, the Global Fund is working closely with countries to address transition and sustainability challengesSlide10
Why the STC Policy and the Global Fund’s focus on transition?
The changing nature
of global health financing
To ensure impact,
the need to increasingly focus GF resources and investments on those countries with greatest need and least ability to payChallenges with previous Global Fund transitions
, particularly for key and vulnerable populations
Recognition that
successful transitions are hard and require resources
Commitment of GF to partner with countries
to more proactively prepare for transition
in order to
sustain the gains
and continue to scale even beyond Global Fund financing
9Slide11
1
A need to embed sustainability across the portfolio
, regardless of where a country is on the development continuum
Enhanced focus on domestic
financing (overall increases of funding) and
co-financing of core interventions
(greater uptake of Global Fund financed interventions) across the entire GF portfolio
Accelerating efforts to prepare for transition
as a country moves to higher income status and/or lower disease burden, particularly for UMICs (all disease burden) and LMICs (less than high burden)
Recognition that efforts to address sustainability and transition
need to be flexible
, given the varied
financial and epidemiological context of countries
across the development continuum
3
2
4
Key
pillars/principles
of our work across the S, T, and C
10
Systematic efforts to work with partners
(including technical agencies, bilateral partners, development banks, civil society partners, and others) to leverage capacity, collaborate on joint priorities, and accelerate STC efforts
5Slide12
Fully
transitioned
Funding request based on Transition Work-plan
Co-Financing requirements along the development continuum work towards enhancing financial and programmatic sustainability, eventual transitions and gradual, progressive absorption of key program costs
LICs
LMICs with
high / extreme / severe disease
burden
LMICs
with less than high
disease burden and
all UMICs
Ineligible
“Final Grant”
Focus on long-term
sustainability planning,
including:
Strengthened National Strategic Plans
Increased focus on health financing and development of health financing strategies
Enhanced alignment with country systems
Efficiency and Optimization
Gradual absorption of key program costs
Focus on sustainability and
transition preparedness,
including:
All sustainability activities +
Transition planning
Directly addressing transition challenges in grant design
Increased focus on interventions for key populations
Accelerated
co-financing
of all key interventions
Maximum 3 years transition funding
95 components
*
90 components
69
components
12
components
*
Note: numbers are based on disease components that received a country allocation and exclude multi-country grants (except RAI initiative). While there are certain flexibilities for COEs under the STC policy, they are included here.
Transition preparedness prioritiesSlide13
12
Understanding Transition -- Which disease components are transitioning now?
ALBANIA
ALGERIA
BELIZE
BOTSWANA
CUBA
DOMINICAN REPUBLIC
PANAMA
PARAGUAY
SRI LANKA
SURINAME
TURKMENISTAN
12 disease components
in 11 countries are transitioning / exiting
from Global Fund support in the 2017-2019 allocation cycleSlide14
Significant Progress and Significant Challenges
Significant progress made to strengthen the sustainability of national programs,
and to support transitions (both
before
and since the development of the STC Policy)Countries approaching transition are assuming a significant amount of the overall disease response, and now fund / manage most of the national programs (including health products, service provision, human resources, etc.)
I
ncreasing
focus on sustainability and preparing for transition
in the day to day “business” of the
Global Fund
– from
the proposals submitted, to the independent review by our technical review panel (TRP), to our efforts to incentivize and support country planning and domestic financing
13Slide15
…Planning
Key transition bottlenecks and challenges
14
This list is not exhaustive and will always be determined by country context
…Financing
…Enabling environment
…Health systems
…Civil Society
…Efficiency
Early, robust identification of country specific bottlenecks and
country owned
transition and sustainability planning
Improved domestic financing and sufficient co-financing of GF supported interventions, with a particular focus on services for key and vulnerable populations
Addressing RSSH related challenges that link with health reforms and service integration
Strengthening and aligning monitoring, evaluation, and data systems
Strengthening procurement & supply chain systems, including ability to access quality health products
Addressing enabling environment and human rights related barriers to access services
Strengthening the capacity of civil society, including the ability to contract with governments to provide services, to engage in advocacy, and to mobilize additional resources
Strengthening the efficiency (allocative, technical, cross-programmatic) of national programs
Significant Progress and Significant ChallengesSlide16
15
Transition Readiness
Assessments
Development of
sustainability and transition strategies and work plans
Updating of National Strategies and documents
Alignment
of Systems (on budget, on system)
Creation of National Working Groups on sustainability and transition
…Planning
Ukraine
:
agreed
Transition Plan, which aims at gradual takeover of funding for TB and HIV programs (20
% -50
% -80
%)
El Salvador
:
the
recently developed National Strategic Plan for TB includes a specific section on Sustainability and Transition, describing the strategic direction on this area, including legislative and policy changes, operationalization of efficiencies and budget advocacy, among others. Kosovo: government endorsed the National HIV Strategic Action Plan 2018-2022, which was based in part on the TRA and has committed to funding 100 % of commodities for key populations by 2021Slide17
16
Emphasis on co-financing commitments to cover key transition risks,
including uptake of services
for key populations and critical health system investments
Support Health Financing Strategies at country level
Support National Health Accounts reporting
Fiscal space analysis support
…Financing
Sri
Lanka
:
grant in the form of budgetary support to align with national systems and
priorities
Kazakhstan
:
the share of government in total HIV funding increased from 70% in 2009 to 87% in 2016, and projected to reach 94-95% in the next implementation period. The incremental investment will support care and ARV scale up and key population programs (including harm reduction
)
Suriname
:
coordinated support with partners for completion of National Health Accounts and tracking of co-financing commitments as part of grant agreementSlide18
17
Support the definition and costing of HIV and TB service packages and their inclusion in mandatory coverage
Advocacy for health reforms to improve costs and quality of service provision
Strengthen national capacities for procurement of quality affordable drugs
Strengthen M&E system, including integration of reporting
…Health Systems
Azerbaijan
:
TB drugs and laboratory
services have
been included in the
mandatory health insurance scheme
Armenia, Azerbaijan,
Belarus, Tajikistan
,
Ukraine
:
Pilots
and their evaluations to use
performance based funding schemes
for scaling up TB and HIV case finding, OST
schemesMoldova: The new approach
proposed under 2018-2020 grant for implementation of prevention programs, ARV adherence programs, and OST programs provides implementing agencies’ funding based on results achieved (beneficiaries covered by services)Slide19
18
Assessment of legal and regulatory barriers for access to services for key affected populations
Support to CSOs for advocacy towards improved access and service quality monitoring
Support CSOs inclusion in decision-making
…Enabling Environment
Armenia
:
Planned assessment of legal and regulatory barriers, as a result of prioritization discussions under the transition planning
Belize, Bolivia, Peru
:
Social dialogues in countries to better prepare civil society for engaging on sustainability and transition discussions and planning, developing civil society priorities, and identifying key technical assistance gaps Slide20
19
Capacity building for CSOs to access public funding
Support to MOH/CCM in the assessing optimal arrangements for public procurement of health services delivered by CSOs
Budget advocacy for CSOs
Step-by-step support to organizing public procurement of health services delivered by CSOs (from technical specifications, to contracts, to M&E)
…
C
ivil Society
Kazakhstan
:
Piloting
a social contracting model using government scheme & NGO
model
Costa Rica:
Transition
grant
provides institutional
support
to advance public contracting of health services for key populations implemented by CSOs
Moldova
: In
2017 the National Health Insurance Fund has for the first time contracted 2 NGOs for the delivery of HIV prevention activities for gay, MSM & PWIDMontenegro: With the support of
partners, grant will use country mechanism to strengthen sustainable financing of CSOs service provision to key populationsSlide21
20
Support allocative efficiency studies
Supporting technical efficiency (costing) studies
Treatment and service
delivery integration and optimization
Encouraging cross-programmatic integration analysis
…Efficiency
Belarus
:
Used OPTIMA HIV results in allocation of resources for the next National
Strategy (shifted resources from general population prevention to PWID services) or using OST costing studies to support scale-up advocacy
Montenegro
: Technical support with costing of HIV prevention packages to inform the public purchase of health services provided by CSOs
Lao, Mongolia, Nepal and PNG:
Integration
of service delivery at primary level and integration of support
services and/or
Integration of communicable disease programs with other vertical programsSlide22
21
Background
What we do
Review of 2017 – 2019 allocation period
Recommendations
HIV
Distribution of KP investment as % total value of combined HIV grants of countries
within the same income level
(17-19) demonstrating alignment with focus of proposal requirements
PEPFAR and the Global Fund are the largest funders of key population programs and services in low and middle income countries
the Global Fund is the most prominent external funder of key population programs across much of EECA, LAC, SEA and MENA and a number of countries in west and central Africa.Slide23
22
Matching Funds
Multi-country Approaches
Strategic Initiatives
C
atalytic
funding
2017-2019: 2/3 supports Key populationsSlide24
Multi-country proposals to support sustainability and transition23
= 50million USDSlide25
Summary
Sustainability is multi-dimentional and relevant for all countries across the development continuumFocus should be broader than a financing dialogue and involve a variety of stakeholders
There are several key bottlenecks and challenges in transitioning from external donor support
Need to start early in partnership for success
24Slide26
Acknowledgements and Thanks
Matthew McGregor Obinna Onyekwena
Aji-Mallen Sanneh
David Traynor
Ed Ngoksin Malgorzata Matysek
25Slide27
Back up
26Slide28
27
Source: Global Fund Eligibility List 2017
UMI Components
Albania (HIV,TB), Algeria (HIV), Angola (HIV,TB, Malaria), Azerbaijan (HIV,TB), Belarus (HIV,TB), Belize (HIV,TB), Botswana (HIV,TB, Malaria), Colombia (HIV), Costa Rica (HIV), Cuba (HIV), Dominican Republic (HIV,TB), Ecuador (HIV), Gabon (TB), Georgia (HIV,TB), Iran (HIV), Jamaica (HIV), Kazakhstan (HIV,TB), Malaysia (HIV), Mauritius (HIV), Mongolia (HIV,TB)
,
Montenegro (HIV),
Namibia (HIV,TB, Malaria), Panama (HIV,TB), Paraguay (HIV,TB), Peru (HIV,TB), Romania (TB),
Serbia (HIV),
South Africa (HIV,TB), Suriname (HIV,TB, Malaria), Thailand (HIV, TB, Malaria), Tunisia (HIV),Turkmenistan (TB)
LMI
components with low or moderate
disease burden classification
Armenia (HIV,TB), Bangladesh (HIV), Bhutan (HIV, Malaria), Bolivia (Malaria), Cabo Verde (Malaria), Egypt (TB), El Salvador (TB), Guatemala
(TB, Malaria),
Honduras (TB, Malaria), Kosovo
(HIV, TB),
Lao (HIV), Nicaragua (TB, Malaria), Philippines (Malaria), Sao Tome and Principe (HIV), Sri Lanka (HIV, TB, Malaria), Swaziland (Malaria), Timor-Leste (HIV)
Upper Middle
Income Countries (UMICs)
Low
and Middle Income Countries (LMICs)
with at least one
disease component with low /moderate DB
Transition preparedness priorities under the STC policy
All UMI countries (regardless of disease burden) and LMI countries (with low or moderate disease burden
), not including COEs
Note: This list is based on only countries that received a country allocation in the 2017-2019 allocation cycle and excludes multi-country grants and COEs.