1. Eannaso Domestic REOURCE MOBILIZATION TRAINING
Sustainability, Transition & Co-financing (STC): Policy, Progress & Challenges
Eannaso Domestic REOURCE MOBILIZATION TRAINING
4 October 2019
Dr. gemma M. Oberth, regional pLATFORMS cOORDINATOR (global fuND crg si)

5. The Policy
Approved at the 35th Global Fund Board Meeting in April 2016 in Côte d'Ivoire
Key points:
Long-term sustainability is a fundamental aspect of development and global health financing
Experience shows that supporting countries to sustainably transition from Global Fund support requires significant time
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 programs such as interventions for key and vulnerable populations

7. The Global Fund’s Transition Process

9. The Global Fund’s Co-Financing Requirements

10. 2014-2016 Co-financing commitment areas: Examples
Source: Aidspan (2015) The “fair share” of shared responsibility

11. 05 06 04 01 03 02 An integrated approach 01 Planning 02 Financing
04 Enabling Environment
01 Planning
Insufficient domestic investments to address human rights related barriers, and continued legal and policy environments that restrict access to services
Need for greater, early, robust identification of country specific bottlenecks and transition and sustainability planning, aligned with broader country planning and budgeting
Efficiency
05 Civil Society 05
Civil Society 06
02 Financing
Strengthen the ability of civil society to continue providing services, engaging in advocacy, and mobilizing sufficient additional resources to ensure a robust continued role in disease responses
Insufficient domestic financing and co-financing of GF supported interventions, with a particular focus on services for key and vulnerable populations; ongoing treatment financing concerns
Planning 04 01
Enabling environment
06 Efficiency
03 Health Systems 03
Financing 02
Sub-optimal use of external and national resources, and need for ongoing integration of vertical disease programs into health systems
Limited service integration and need to engage with health system related reforms
Need for strengthening and aligning monitoring, evaluation, and data systems
Challenges to ensure continued access to quality-assured health products with domestic finance, including sufficient capacity of domestic procurement systems
Health Systems
*The list is not exhaustive and will always be determined by country context

12. Early Planning: Key areas of support and illustrative examples
15 countries in LAC and 17 countries in EECA conducted TRAs in various forms and developed sustainability or transition strategies and work-plans. 05 06
Planning 04 01
Kazakhstan, Kyrgyzstan, Kosovo, Ukraine: incorporated the transition plans into the National Disease strategies (costed, with timelines, responsible implementers). 03 02
Dominican Republic and Cuba integrated the HIV sustainability strategy/transition work-plan in the new HIV NSP Jamaica working under the same approach for the development of its costed NSP
Armenia established a Technical Working Group on Transition under CCM, and recently hired a Transition Coordinator to drive the sustainability agenda at country level.  
Transition Readiness Assessments (TRAs)
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
EL Salvador and Guatemala integrated TB sustainability strategy in the new TB NSPs
Ukraine: implements Transition Plan, which aims at gradual takeover of funding for TB and HIV programs (20%-50%-80%) and strengthened health systems
Malaysia conducted a tailored in-depth assessment of the program and submitted a solid Transition Workplan for its last cycle of funding  
Guyana set up Sustainability Steering Committee, chaired by the Vice-Minister of Health, to guide the development and conduct the oversight of the Sustainability Strategy.

13. Financing: Key areas of support and illustrative examples
EECA: effectively used the co-financing requirements to increase MOH commitment and budgeting for specific interventions (Belarus - for ARV and anti-TB drugs; Moldova – co-funding HIV prevention services; Montenegro and Serbia increased x 2/3 times commitments for HIV prevention services; Kazakhstan increased the governmental share of total HIV funding from 70% to 87% in 2016). 05 06
Financing 04 01 03 02
EECA: effective absorption of ART procurement by governments: domestic financing increased from 18% in 2015 to 80% in 2020
Cuba: committed to provide additional funding for ARVs and started in 2019 purchasing ARV through the PAHO Strategic Fund.
Kosovo: government has committed to funding 100 % of commodities for key populations by 2021
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
Haiti: Global Financing Facility launched aiming synergies between donors, MOH and MOF for sustainability strategy and increased domestic funding for health.
Sri Lanka: grant with significant component of ensuring government commitment to co-financing and piloting CSO funding via governmental PR
Dominican Republic: government fully absorbed the financing of ARVs, committed to scale up treatment with domestic funds and to fund 10-25% of costs of prevention activities for key populations by 2021.
Panama committed to fully absorb HIV adherence counsellors and to absorb prevention and testing interventions for key populations currently funded by Global Fund (50% by year-2 and 100% by the year-3), while continuing expanding the scale of those interventions.
Suriname and Guyana: coordinated support with partners for completion of National Health Accounts and tracking of co-financing commitments as part of grant agreement
*Source: Programmatic Gap Tables for Allocation Cycle

14. Health Systems: Key areas of support and illustrative examples
Moldova, Kyrgyzstan: Mandatory health insurance covers HIV and TB services 05 06
Health
Systems 04 01
Ukraine, Azerbaijan, Turkmenistan: strengthened access to quality assured affordable drugs via international procurement platforms. 03 02
Dominican Republic: supporting the expansion of HIV/TB service integration. Coordinated support with partners to advocate and provide technical support to ensure coverage treatment under health insurance.
Kyrgyzstan, Tajikistan, Uzbekistan: access to quality assured affordable drugs via in-country drug registration.
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
Haiti: ongoing support for integration of reporting in DHIS2 platform and analysis of Health Facility Assessment data to assess cost-effectiveness of interventions (focus on HRH) by health site
Sri Lanka: cross-programmatic efficiency analysis that supports integration of disease specific services through ongoing Primary Health Care restructuring .
Bolivia, Cuba, Ecuador, El Salvador, Honduras, Guatemala, Nicaragua and Paraguay: Collaboration project with PAHO to strengthen public health national supply chains to promote technical independence and long term sustainability.
Bolivia, Paraguay, Honduras and El Salvador: Collaboration with PAHO and UNAIDS to support definition of HIV comprehensive package of services for key populations and integrated national information systems that permit measurement and analysis of data on coverage and quality of services for key populations

15. Enabling Environment: Key areas of support and illustrative examples
Belarus, Bosnia and Herzegovina, Kyrgyzstan, Moldova, Montenegro, Serbia, Tajikistan, Ukraine and Uzbekistan: using UNDP framework, countries completed assessment of legal framework related to CSO contracting as providers of prevention services for key and affected population. 05 06
Enabling
Environment
Jamaica and Honduras, Armenia, Ukraine, Kyrgyzstan: Comprehensive assessment and work plans of legal and regulatory barriers for access to services for key and affected populations, leading to increasing investments on human rights related interventions in the countries and building the case to include costed-comprehensive human rights programs in the National Strategic Plans. 04 01 03 02
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
South East Asia multi-country*:
grant on ensuring sustainability of services for key populations via i) appropriate scale-up of service delivery for key populations including securing an enabling environment; ii) ensuring long-term programmatic and financial sustainability; and iii) enhancing capacity and leadership for continued advocacy from within key populations.
Latin America and Caribbean multi-country: Key actors in HIV and TB responses join forces to advocate for good quality and fully funded accessible services for key and vulnerable populations as well as enabling legal and policy environments for the HIV and TB responses.
*Multicountry grant covers Bhutan, Lao, Malaysia, Sri Lanka, Mongolia, Papua New Guinea, Philippines and Timor-Leste

16. Community System Strengthening
Community System Strengthening: Key areas of support and illustrative examples
Montenegro, Serbia, Georgia, Ukraine: alignment of unit costs for HIV prevention services of key population for improved efficiency and basis of domestic takeover of services. 05 06
Community System Strengthening 04 01 03 02
Macedonia: extensive support to ensure no disruption of service upon transition, advocacy and capacity building, resulting in $1m annual domestic funding of HIV prevention services
Kosovo: comprehensive TA to set up policy and procedures for public procurement of health services delivered by CSOs.
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)
Belize:  Support the setting up of an umbrella CSO network that helps organize and coordinate smaller CSOs to represent them in accessing public funding.
Costa Rica, Dominican Republic, Kazakhstan, Mongolia: Piloting CSO contracting under MOH with domestic co-financing
Guyana: coordinated support with partners to advocate and support development of procedures and implementation of public funding for CSOs. Launch of first public call for proposals in 2019.
Belize, Bolivia, Peru, Panama and Dominican Republic: support to conduct 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
Panama: support to set up the policy and procedures for public procurement of health services delivered by CSOs

17. regional and country dialogue, with partners
Strengthening Public Financing of Civil Society Service Provision (i.e., “Social Contracting”)
Strengthening public financing of service provision to key and vulnerable populations is essential to efforts to control the epidemics; particularly since a significant percentage of these programs are still dependent on external financing across the GF portfolio
Enhanced efforts in to support effective transition to domestic financing and management, but need for scale up in
DIALOGUE
Technical
assistance
Foster global,
regional and country dialogue, with partners
Improved
capacity and knowledge
Leverage grant design and A2F cycle
DESIGN
Global consultation on government financing of programs implemented by civil society with partners, civil society and governments (October, 2017)
“Latin America and Caribbean regional meeting on public financing of CSO for the delivery of services: progress, challenges and lessons learned” (June 2018)
Regular engagement and joint country work with partners, including UNAIDS, USAID, UNDP, others
Inclusion of thematic area in regional and global meetings (ie, WHO meeting on transition to domestic financing)
Aligning GF grants (SR contracting, M&E) to public procedures and systems
Using GF grant funds to pilot contracting mechanisms
Strengthening CSO linkages with government services
Supporting capacity building for government and CSOs
Negotiating co-financing commitments for absorption of interventions for KVP implemented by CSOs
Strengthening CSO cost-efficiency & communication of their contributions to national responses
Supporting accountability mechanisms (i.e. patients scorecards, community-led monitoring)
Need to highlight that advocacy work will not be funded in most cases.
KNOWLEDGE
TECHNICAL ASSISTANCE
Inclusion of module within internal STC Course focused on enhancing capacity for key GF Secretariat stakeholders
Collection of and development of best practices and lessons learned
Development of Diagnosis tool on Public financing for CSO health service delivery, to strengthen analytics alongside sustainability and transition planning.
In-depth analysis on domestic mechanisms available to publicly fund delivery of services via STE-SI.
Step-by-step support to organizing public procurement of health services delivered by CSOs (from technical specifications, to contracts, to M&E)

18. Illustrative Examples
Strengthening Public Financing of Civil Society Service Provision (i.e. “Social Contracting”)
Illustrative Examples
Montenegro, Serbia, Georgia, Ukraine: alignment of unit costs for HIV prevention services of key population for improved efficiency and basis of domestic takeover of services.
Kazakhstan, Tajikistan: strengthening of CSOs capacity to deliver services + advocacy towards long-term sustainability
Dominican Republic, Panama, Costa Rica: co-financing commitments+ key milestones set in performance framework to ensure institutional follow-up
Ukraine, Belarus: grant support multiple pilots to set- up and strengthen CSO contracting at municipal, regional and national level
Panama, Albania, Kosovo: comprehensive TA to set up policy and procedures for public procurement of health services delivered by CSOs.
Montenegro, Serbia: GF and domestic funds are managed together through national CSO contracting mechanisms.
Belize:  Support the setting up of an umbrella CSO network that helps coordinate smaller CSOs to represent them in accessing public funding.
Morocco: manual outlining the modalities of engagement of CSOs with the MOH + trainings for CSOs on social contracting
Botswana: along with partners supported government to define a roadmap to put social contracting in place + support to develop the mechanisms.
Guyana: coordinated support with partners to advocate and support development of procedures and implementation of public funding for CSOs + costing of CSOs services. Launch of first public call for proposals in Q
Peru, Bolivia, Paraguay, Suriname, Honduras, Ecuador: Conducted Diagnosis tool on Public financing for CSO health service delivery
Colombia: grant designed to allow replication of the public contracting of CSO after GF exit
Multi-country grants in AELAC & MENA: grants focused on the sustainability of services for key and vulnerable populations, including increasing of domestic funding for interventions targeting KVP, strengthening/expanding CSO contracting mechanisms.

19. Efficiency: Key areas of support and illustrative examples
EECA: in partnership with UNAIDS is updating OPTIMA HIV estimates to prepare for Allocation cycle country dialogues 05 06
Efficiency
Armenia, Azerbaijan, Belarus, Moldova, Tajikistan, Ukraine: piloting and evaluation of performance-based financing for scaling up TB and HIV case finding, OST schemes 04 01
Belarus: OPTIMA HIV results used 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 03 02
Georgia, Mongolia: Integration of HIV and Hepatitis C activities
Support allocative efficiency studies
Supporting technical efficiency (costing) studies
Treatment and service delivery integration and optimization
Encouraging cross- programmatic integration analysis
Lao: Integration of service delivery is encouraged through Payment for Result scheme at provincial level, and alignment with country systems is achieved via joint investment with WB
Haiti: Modelling to assess optimal size and geo-location of Community Health Workers nationally in collaboration with World Bank.
Jamaica and Dominican Republic: Assessment of the integration of HIV program in the rest of the health system in terms of governance, health financing, health management system and service delivery and development of roadmap for incremental integration.
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
Honduras, Dominican Republic, Guyana, Jamaica, Guatemala, OECS: conducted technical efficiencies studies on prevention for key populations to identify opportunities for efficiency and quality improvement for prevention and testing services.
Latin America: Increasing use of pool procurement mechanisms, resulting in significant efficiencies for certain country programs

20. Leveraging Catalytic Funding to Support STC Objectives
Summary: Catalytic funding directly contributes to STC policy implementation by addressing strategic sustainability, transition and domestic financing challenges
Sustainability, Transition, and Efficiency Strategic Initiative (STE SI) ensures funds for technical assistance to strengthen transition planning, address specific transition challenges, strengthen capacity of key stakeholders on transition and sustainability, strengthen health expenditure tracking, provide TA for implementation of health financing strategies in priority portfolios, support domestic health financing advocacy in priority portfolios, and improve investment efficiency of GF supported programs by supporting allocative, cross-programmatic, and technical efficiency assessments across the GF portfolio
CRG Strategic Initiative supports engagement of community and key population groups in transition and sustainability processes, targeted TA and advocacy activities
Key Populations and Sustainability Multi-Country Funding provide 59.5 million in funding to support multi-country and regional strategies to address key transition and sustainability challenges