Board Approves Sustainability, Transition, and Co-Financing (STC) Policy

Strategy and Policy Head Harley Feldbaum presented on the STC Policy.

The STC Policy defines sustainability as “the ability of a health program or country to both maintain and scale up service coverage to a level, in line with epidemiological context, that will provide for continuing control of a public health problem and support efforts for elimination of the three diseases, even after the removal of external funding by the Global Fund and other major external donors.”

The policy defines transition as “the mechanism by which a country, or a country-component, moves towards fully funding and implementing its health programs independent of Global Fund support while continuing to sustain the gains and scaling up as appropriate.”

It defines co-financing as “[pertaining] to pooled domestic public resources [including government revenues, government borrowings, social health insurance, and debt relief proceeds including Debt2Health arrangements with the Global Fund] and domestic private contributions that finance the health sector and NSPs [(National Strategic Plans)] supported by the Global Fund.”

The four principles of the policy are:

  1. Differentiation – the policy and associated processes are differentiated based on a country’s place within the development continuum according to income level, epidemiological context, disease burden, human rights and gender contexts, and other regional, country, and context specific factors
  2. Alignment – wherever possible, Global Fund requirements related to sustainability and transition should build off already existing systems or processes in country
  3. Predictability – wherever possible, countries should have sufficient notice, time, and associated resources to plan for transition
  4. Flexibility – country level implementers and the Global Fund should have the flexibility to adapt certain aspects of this policy to particular country and regional contexts for impact and to maintain services

The policy draws on:

  • Development Continuum Working Group report entitled “Evolving the Global Fund for Greater Impact in a Changing Global Landscape” (March  2015)
  • Secretariat paper on Sustainability and Transition presented to Strategy, Investment, and Impact Committee (SIIC; June 2015)
  • Technical Evaluation Reference Group (TERG) thematic review on Sustainability and Transition presented to SIIC (September 2015)
  • Equitable Access Initiative (EAI) findings

The Global Fund’s approach “is based on the central premise that planning for sustainability is an integral part of program design and should be taken into account by all countries regardless of where they sit on the development continuum” and includes:

  • Investing in and providing support for the development of robust, inclusive (including key and vulnerable populations), quality, evidence-based National Health Strategies, Disease-Specific Strategic Plans, and Health Financing Strategies
  • Aligning requirements to ensure that Global Fund-financed programs can be implemented through country systems in order to build Resilient and Sustainable Systems for Health (RSSH)
  • Supporting countries to assess their readiness to transition both programmatically and financially and ensure robust planning and allowing transition work plans to serve as basis for funding requests
  • Providing transition funding for up to one allocation period upon becoming ineligible (the Secretariat does have flexibility to extend funding beyond the one allocation period)
  •  Applying graduated co-financing requirements and associated application focus requirements

The Board paper states the following:

… experience shows that planning a transition from Global Fund support takes time and resources.  In many countries this involves addressing complex issues such as changing legislation to allow for the public sector to contract with non-public sector providers such as civil society organizations, effectively supporting domestic advocacy for health spending, and improving procurement processes and access to ensure that countries can purchase key commodities such as second line ARVs and MDR TB drugs at efficient prices.  There is often also significant political advocacy needed to ensure that the interventions appropriate to a particular country’s disease epidemiology are eventually transitioned to be supported in their entirety through domestic country budgets.  Aspects included in this policy, such as timely notification of potential transition, support for transition readiness assessments and the availability of transition funding serve to ensure that future transitions from Global Fund are well planned and supported.  …  The co-financing and focus of funding requirements of this policy aim to stimulate increased domestic financing for health and for the three disease programs.  Simultaneously, they seek to encourage progressive up-take of recurrent costs of key program components [including, but not limited to, recurrent human resource associated costs, procurement of essential drugs and commodities for the three diseases, and rights-based programs for key and vulnerable populations, which are in line with epidemiological context and informed by evidence, as appropriate] to encourage and incentivize complete financing of all aspects of a country’s three disease programs as countries approach transition to full domestic funding.

The changes in the new Co-Financing Policy from the current Counterpart Financing Policy include:

  • Tailoring co-financing requirements along the development continuum to ensure that they support the health sector and incentivize investments in line with national priorities:
    • At the lower end of the continuum, emphasis is on domestic investments to build resilient and sustainable systems for health and move towards universal health coverage; along with minimal requirements to co-finance Global Fund supported programs.
    • As countries move along the development continuum, expectations are set for progressively higher co-financing of disease programs and key program components, such as interventions for key and vulnerable populations and systems strengthening interventions aimed at critical barriers to sustainability
  • Requiring that all countries progressively absorb the costs of key program components such as:
    • Recurrent human resources
    • Procurement of essential drugs and commodities
    • Interventions for key and vulnerable populations
  • Requiring engagement with key stakeholders such as Ministries of Finance and the institutionalization of mechanisms for annual monitoring of co-financing requirements
  • Explicit focus on progressively increasing government expenditure on health in high-burden countries who have a low prioritization of government spending on health and/or low capacity for domestic revenue capture through implementation of robust health financing strategies to meet Universal Health Coverage (UHC) goals
  • Greater flexibility to engage on co-financing issues depending on:
    • Fiscal space
    • Disease burden
    •  Transition requirements
    • Regional and other operating contexts, including Challenging Operating Environments (COEs)

The Secretariat will establish a Transition Team to:

  • Support Country Teams
  • Facilitate sustainability and transition planning with financial, human rights, key populations, gender, procurement, and other relevant expertise
  • Document and share best practices
  • Engage with key stakeholders

In response to questions from Implementer Group Board Delegations, Harley was unable to provide a current list of transition countries, and he stated that the STC Policy would not apply to current transition countries.

Below is a an STC Policy diagram:

STC Policy diagram

STC Policy diagram

Below is the Eligibility, Focus of Application, and Co-Financing chart:

Eligibility, Focus of Application, and Co-Financing chart

Eligibility, Focus of Application, and Co-Financing chart

The Board approved the STC Policy.

The previous Counterpart Financing Policy remains applicable to grant programs originating from the 2014-2016 allocation period.