1. Sustainability, Transition and Co-financing - Investing to End Epidemics
Dr Ade Fakoya
10th IAEN Preconference, July 2018

2. Contents Background Global Fund investments
Sustainability, transition and co-financing policy
Key bottlenecks and challenges
Country examples
Catalytic Funding initiatives to support Key Population programming
Summary

3. Significant Progress Made -- 22 million lives saved to date
Working closely with countries, the Global Fund partnership has achieved significant success and significant progress has been made – saving millions of lives
But, the global health financing landscape is changing, and there is a need for the Global Fund partnership and countries to significant strengthen the sustainability of our investments.

4. Understanding sustainability

5. Four Pillars of Global Fund Strategy 2017-22
MAXIMIZE IMPACT AGAINST HIV, TB AND MALARIA
Places a strong emphasis on the need to support sustainable responses for epidemic control and successful transitions away from direct grant support
Stresses the need to support countries to use existing resources more efficiently and to increase domestic resource mobilization
BUILD RESILIENT & SUSTAINABLE SYSTEMS FOR HEALTH
PROMOTE & PROTECT HUMAN RIGHTS AND GENDER EQUALITY
MOBILIZE INCREASED RESOURCES
Start with the strategy which shifted resources to countries with highest disease burden and lowest ability to pay AND put emphasis on increased domestic investments.

6. HIV
Global Fund is investing in HIV/AIDS in > 100 countries globally in the current allocation cycle (2017 – 2019)
Total GF HIV investment ( )
> US$ 5.2 billion
Allocation amount ≈ US$ 5.1 b
Catalytic investment = US$ 200 m
Global Fund accounts for 8% of global HIV funding and 20% of international financing
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)

7. HIV Catalytic investment (US$ 200 m)
million for HIV
Matching funds = US$ 150 m
Multi-country proposals = US$ 50 m
Global Fund investment by modules in windows 1-5*: almost US$ 3.1 b so far in this funding cycle
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 countries
Scale-up programs to support women and girls, including programs to advance sexual and reproductive health and rights (US$ 55M) – 11 countries
Introduce 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 m
LAC 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)
*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 prevention modules consist of : Prevention programs for general population, Comprehensive prevention programs for sex workers and their clients, Comprehensive prevention programs for people who inject drugs (PWID) and their partners, PMTCT, Prevention programs for MSM and TGs, Prevention programs for adolescents and youth, in and out of school, Comprehensive prevention programs for MSM, Prevention programs for other vulnerable populations, Specific prevention interventions (SPI), Comprehensive prevention programs for TGs. Other modules consist of: Payment for results, Removing legal barriers to access, Programs to reduce human rights-related barriers to HIV services, Comprehensive programs for people in prisons and other closed settings, TB care and prevention, MDR-TB, Case management and other module

8. Goal of STC – Investing to end HIV, TB, and Malaria
The desired outcome
Sustainability
Goal: Investing to End the Epidemics
A process
Transition
One of the tools
Co-financing
The STC Policy pulls together three interrelated themes to provide the GF with a structured, comprehensive approach to strengthening sustainability and better managing transitions, with the overall goal of ensuring our investments have impact, help to end the epidemics, and support countries to move toward UHC
Transition – a process, whereby the Global Fund will gradually move away from financing countries.
Sustainability – the desired outcome of all of our investments. How do we ensure that we create impact in the short term, and that impact is sustained?
Co-Financing – one of the tools, but just one of them, to help us get there.
With the overall goal of investing our funds more strategically to help end the epidemics.

9. Under the STC policy, the Global Fund is working closely with countries to address transition and sustainability challenges
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

10. 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 pay
Challenges 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
Why STC Policy and greater focus on transition? (Slide 2)
The STC Policy and the Global Fund’s overall approach to transitions grew out of 1) recognition about the changing nature of health financing, 2) the very real challenges and lessons learned from early transitions, 3) the need to increasingly target GF investments where needed most to fight the diseases, 4) The recognition that transitions will be hard, and the GF increasingly needs to be a good partner
The changing nature of global health financing
Increasing reliance on domestic financing to fund health systems and the national disease response, stagnant or potentially decreasing ODA
To ensure impact, GF needs to increasingly strengthen the focus of our investments on those countries with greatest need and least ability to pay
We must be constantly looking at where our resources will have most impact, and where countries can finance the disease responses with less external support
Previous challenges with transitions in some of the regions that were the first to fully transition away from the Global Fund, particularly for services provided to key and vulnerable populations (for example, in the EECA region).
For example, service disruption, reliance on the fund for key interventions at the time of transition, structural bottlenecks to successful transitions not addressed, lack of planning, lack of phase out of GF services, etc.
Recognition that successful transitions are hard and require resources
Transitions will be hard, and the GF is committed to being an increasingly good partner to support countries to prepare for transition from Global Fund financing, sustain the gains, continue to scale
Codified commitment of GF to partner with countries to prepare for transition, sustain the gains, and continue to scale even beyond Global Fund financing

11. Key pillars/principles of our work across the S, T, and C
A need to embed sustainability across the portfolio, regardless of where a country is on the development continuum 1
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 2
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) 3
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 4
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 5
The STC Policy is based on a number of core pillars / principles (Slide 2):
Given the breadth of themes related to sustainability and transition, the STC policy provides a framework for key focus areas across the portfolio, based on a number of key principles:
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 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 (low and moderate disease burden)
Recognition that efforts to address sustainability and transition need to be flexible, given the varied financial and epidemiological contexts of countries across the development continuum
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 related efforts

12. Transition preparedness priorities
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
LMICs with
high / extreme / severe disease
burden
LMICs
with less than high
disease burden and
all UMICs
Ineligible
“Final Grant”
LICs
95 components*
90 components
69 components
12 components
Focus on long-term sustainability planning, including:
Focus on sustainability and transition preparedness, including:
Maximum 3 years transition funding
Fully
transitioned
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
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
*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.
The STC Policy and the Development Continuum
There is a lot in the STC Policy, so it’s often best to think about it in the context of the entire Global Fund portfolio and what is often referred to as the “development continuum”
Essentially, the STC policy asks different things of countries depending on where they are on this continuum, with a:
Focus on long term sustainability in low income and lower middle income countries with high disease burdens (where the Global Fund has the majority of its allocations, and where we expect countries to remain eligible)
Focus on preparing for transitions amongst all UMICs and LMICs with less than high burden disease burden. Although not all of these are “transitioning at the current time,” this is where we are most likely to transition from Global Fund financing, and where we need to see an enhanced emphasis on transition planning, accelerated co-financing, and addressing bottlenecks to transition with grant and other financing.
The STC Policy also includes a “transition funding” period, so that when country components become ineligible, they can “smooth” the process of transition from GF financing with additional funds that can support a country developed transition work-plan
11 countries and 12 disease components are receiving this funding in this cycle
The policy modified co-financing requirements to make them more tailored, targeted, and progressive the closer a country gets to transition from Global Fund financing. Including:
Greater commitments required for countries when they reach middle income status (two times minimum commitment)
Greater focus on sustainability and transition bottlenecks and key and vulnerable populations, as well as gender and human rights related barriers, for all Upper Middle Income countries

13. Understanding Transition -- Which disease components are transitioning now?
ALBANIA
ALGERIA
BELIZE
TURKMENISTAN
DOMINICAN REPUBLIC
CUBA
PANAMA
SURINAME
SRI LANKA
PARAGUAY
BOTSWANA
12 disease components in 11 countries are transitioning / exiting
from Global Fund support in the allocation cycle

14. 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.)
Increasing 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
Significant progress, but real and expected challenges
There has been significant progress made to strengthen the sustainability of Global Fund financed investments, and to support transitions (both before, and since the development of the policy). For example:
Many regions – particularly those who are closer to GF transition – have assumed a significant amount of the overall disease response, and fully fund most of national programs (including health products, service provision, human resources, etc)
And since the policy was passed, we have seen a much greater focus on transition in the day to day “business” of the GF – from funding request development to TRP review to efforts to support country planning – as well as more commitments to financing key interventions, including for services for key and vulnerable populations

15. Key transition bottlenecks and challenges
Significant Progress and Significant Challenges
Key transition bottlenecks and challenges
…Planning
Early, robust identification of country specific bottlenecks and country owned transition and sustainability planning
…Financing
Improved domestic financing and sufficient co-financing of GF supported interventions, with a particular focus on services for key and vulnerable populations
…Health systems
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
…Enabling environment
Addressing enabling environment and human rights related barriers to access services
…Civil Society
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
…Efficiency
Despite progress, we are seeing and should expect ongoing challenges:
This is given the complexities of moving from externally financed programs to fully managed and financed national disease responses.
While challenges vary depending on country context, there are particular challenges related to: 1) continued provision of services (and scale of services) and increased domestic financing of services for key and vulnerable populations, 2) Lack of early, country owned planning; 3) sustainable financing for CSOs, 4) health systems challenges, including procurement and access to quality, affordable health products
Key and Vulnerable Populations – When we think about challenges related to key and vulnerable populations, the question really is to what extent can the GF can foster national ownership of aspects of national disease responses that have been traditionally externally financed, and where there is sometimes reluctance to support them?
Co-Financing Policy -- Our co-financing policy works to encourage specific investments and incentivize domestic co-financing of key interventions, particularly for key pops
Application Focus Requirements -- Our application focus requirements ensure Global Fund financing is spent on RSSH transition bottlenecks, or programs for key and vulnerable populations, as well as gender and human rights related barriers.
Early Transition Planning -- Recognizing that transition takes time and must start early, how can we proactively and more comprehensively support early transition planning?
The policy emphasizes the need to invest in transition analysis and planning, and we are actively supporting countries with transition readiness analysis and the development of costed work-plans (25 TRAs already covering 45 disease components)
We have embedded transition considerations into the ongoing work of the Secretariat, including enhancing the Funding Request focus on transition (Transition application), the TRP capacity (SISF experts), and the transition focus of GAC reviews
Civil Society Financing – When we think about civil society financing, the question is how can we ensure that the capacity developed within civil society organizations and their essential role in reaching the most vulnerable – often financed by the Global Fund -- is not lost?
We are increasing our efforts to foster more public financing of civil society led service provision (social contracting), given the essential role civil society plays in reaching key and vulnerable populations
Systems Related Transition Bottlenecks – Many challenges exist related to strengthening health systems and addressing specific systems related bottlenecks, including M&E, PSM, Integration into health systems, etc.
To what extent can the GF influence the types of political and policy related decisions at the national level that will impact transition success?
For example, we know that there are real challenges with the procurement of quality, affordable health products as countries move of Global Fund financing of commodities to national financing. But many of the “solutions” of these problems involve complicated domestic decisions about how a country manages their procurement. We can support and we are, but our influence is limited
Strengthening the efficiency (allocative, technical, cross-programmatic) of national programs
This list is not exhaustive and will always be determined by country context

16. Transition Readiness Assessments
…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 , which was based in part on the TRA and has committed to funding 100 % of commodities for key populations by 2021
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
We can add here Matts preliminary results on the TRA analysis – we ran X many TRA, of which most translated into Transition Plan and X % went into NSP and other national planning documents. (I only have this info for EECA, but he should have it all)

17. Support Health Financing Strategies at country level
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 agreement
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
We can add here Matts preliminary results on the TRA analysis – we ran X many TRA, of which most translated into Transition Plan and X % went into NSP and other national planning documents. (I only have this info for EECA, but he should have it all)

18. 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 schemes Moldova: The new approach proposed under grant for implementation of prevention programs, ARV adherence programs, and OST programs provides implementing agencies’ funding based on results achieved (beneficiaries covered by services)
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
Largest category, esp if we break down procurement

19. …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
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
We can add here Matts preliminary results on the TRA analysis – we ran X many TRA, of which most translated into Transition Plan and X % went into NSP and other national planning documents. (I only have this info for EECA, but he should have it all)

20. Capacity building for CSOs to access public funding
…Civil 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 & PWID Montenegro: With the support of partners, grant will use country mechanism to strengthen sustainable financing of CSOs service provision to key populations
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)
We can add here Matts preliminary results on the TRA analysis – we ran X many TRA, of which most translated into Transition Plan and X % went into NSP and other national planning documents. (I only have this info for EECA, but he should have it all)

21. Support allocative efficiency studies
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 programs
Support allocative efficiency studies
Supporting technical efficiency (costing) studies
Treatment and service delivery integration and optimization
Encouraging cross-programmatic integration analysis
We can add here Matts preliminary results on the TRA analysis – we ran X many TRA, of which most translated into Transition Plan and X % went into NSP and other national planning documents. (I only have this info for EECA, but he should have it all)
Bhutan, Mongolia, Timor-Leste, Sri Lanka: AUTUMN TB
Mongolia, PNG, Malaysia: AEM Optimizer for HIV

22. Review of 2017 – 2019 allocation period
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.

23. Multi-country Approaches
Catalytic funding : 2/3 supports Key populations
Matching Funds
Multi-country Approaches
Strategic Initiatives

24. Multi-country proposals to support sustainability and transition
= 50million USD

25. Summary
Sustainability is multi-dimentional and relevant for all countries across the development continuum
Focus 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

26. Acknowledgements and Thanks
Matthew McGregor
Obinna Onyekwena
Aji-Mallen Sanneh
David Traynor
Ed Ngoksin
Malgorzata Matysek

27. Back up

28. 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
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
Source: Global Fund Eligibility List 2017
Note: This list is based on only countries that received a country allocation in the allocation cycle and excludes multi-country grants and COEs.