What is Transition ?

The Global Fund 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.”

The rationale for transitioning is based on the core belief that planning for sustainability is inherent to programme design and should be considered by recipient countries as early as possible in the development continuum. Transition planning and investment should thus be envisaged in all stages from advocacy project design and implementation to training and evaluation.

The challenges of transition have particular consequences in the fight against infectious diseases such as HIV/AIDS, TB and malaria. Deterioration of the once established and effective components to reduce morbidity and prevalence can lead to a resurgence of new infections, with a loss of all previous investment, unnecessary human suffering, the risk of spill-over effects to other countries and a setback in efforts to achieve the SDG to end these diseases by 2030.

That is why we, the Friends of the Global Fund Europe, want to encourage a broad debate on which relevant actors at state level, civil society, the international community and international health institutions could contribute to ensure that these transition processes are as successful as possible and that no one is “left behind”.

Countries that have faced or that are currently going through transitions start providing insight into some issues that are important to consider, identifying weaknesses or achievements of transitions so as to improve practices. On its side, the GF has also recognized that a number of key questions should be carefully considered during transition planning.

Key questions of transition planning:

To give you a better understanding of the transition process, the following section answers and explains the key questions

Programmes for key and vulnerable populations

Key populations can be the first victims of unsuccessful transitions. Because of legal restrictions, social marginalization or prejudice they face increasing difficulties accessing information, harm reduction services for people using drugs, or HIV prevention for sex workers or men who have sex with men (MSM), that NGOs who have lost funding cannot provide anymore.

Capacity and role of non-state actors in service provision

NGO activities and services in favour of key populations are paramount in achieving progress in the response to the 3 diseases, in the fight against HIV / AIDS in particular. In some countries facing transition though, social contracting has not been put in place in due course, leaving NGOs without access to state funding for service provision.

Ownership of key interventions and integration into national systems

Integration of HIV, TB or malaria services into national health systems is key to manage transitions, both from an epidemiological perspective to achieve combined treatment delivery, and to ensure people-centred prevention and care. The transition period should be used to integrate services as much as possible in an effort to optimise the use of resources, identify gaps and potential overlaps, and also to optimize the health services coverage /architecture in the country.

Fiscal capacity and domestic financing

Switching to progressive government financing of key interventions is a significant factor of success for transitions. As recipient countries are progressively upgrading to higher income status, they should increase their fiscal capacity in parallel, as well as their ability to finance disease programmes and their health systems at large, thus allowing the Global Fund to dedicate more resources to those countries who need it most.

Integrating salaries and operational costs into national health budgets

Gradual integration of prevention, treatment and care costs into national budgets during the transition phase should be considered carefully by stakeholders. Failure to do so would result in inadequate budgeting, and in a possible disruption of service provision to vulnerable and key populations, and possible subsequent resurgence of epidemics. Adequate resourcing is also one of the critical components to training and retaining of qualified medical workers who are the cornerstone of any sustainable health system.

Strong monitoring and evaluation (M&E) systems

Capturing and analysing data for action is at the core of efficient health interventions. Gathering such data, particularly around key and vulnerable populations who fall through the cracks of official statistics, often relies on non-governmental organisations, who stop collecting information when unfunded, thus rendering epidemics transmissions unchecked for months or years !

Reliable and efficient health products procurement and supply chain systems

Procurement and supply chain management is a key element of successful transitions. The procurement of affordable and quality medicines for prevention, treatment and care of patients is at the core of national HIV / AIDS, malaria and TB programmes. However, transitioned countries with small caseloads of patients sometimes lose timely access to quality prevention tools, diagnostics and treatments at affordable prices, as their orders are considered too small by major pharma companies to raise commercial interest, thus putting transitions at risk. To prevent such difficulties, the Global Fund has recently piloted access to wambo.org (an online platform that allows eligible countries to purchase quality-assured medicines and medical products at negotiated prices) to transitioned countries.

Quality therapies and diagnosis

According to WHO, more than 100 countries have incorporated the WHO provisions of Good Practices in the Manufacture and Quality Control of Drugs (“GMP as recommended by WHO”) into their national medicines laws, and more have adopted its provisions in defining their own national GMP rules. But some countries that transitioned had not adhered to the WHO Scheme, as procurement through the Pooled Procurement Mechanism PPM[1] provided all guarantees in terms of quality, delivery lead-time and pricing. Managing their own procurement for HIV and malaria drugs, these countries often had to resort to one-time waivers instead of upgrading their protocols to WHO standards, creating uncertainties as to quality over time.


[1]Establishment in 2009 to guarantee a cost effective and efficient procurement process by compensating for countries’ procurement bottlenecks and supply chain management weaknesses, and facilitating timely access to pharmaceuticals and health products, the PPM is a “Global Fund strategic initiative that aggregates order volumes on behalf of participating grant recipients to negotiate prices and delivery conditions with manufacturers.” In 2018, the Pooled Procurement Mechanism managed US$1 billion in orders, serving grant recipients in 63 countries, and generated US$ 175 million savings.

Procurement

Legislative barriers due to national procurement regulations  in countries facing transition do not always allow direct public procurement of HIV and malaria medicines via tenders, as the PPM was often the sole procurement channel available, guaranteeing quality, timely deliveries and good pricing. Therefore, national laws must be adapted prior to transitioning and include new provisions allowing public procurement of HIV, TB and malaria products through competitive bids. As the PPM should remain available to transitioned countries through the wambo.org platform, beyond the current piloting, this should however be less of an issue in the future for some countries.

Pricing

The PPM lies on framework agreements with pharma companies, whereby negotiated prices allow recipient (and now some transitioned) countries to avoid paying patent rights. As soon as countries have to procure medicines on their own, they lose access to negotiated prices and have to deal with pharma companies on the basis of the TRIPS agreement[2]. An additional problem lies in commitments imposed by the EU in Association Agreements with neighbouring European countries, under TRIPS. The Agreement on Intellectual Property Rights imposed increased monopoly patent protection periods for pharmaceutical products in many countries, leading to increased pricing of HIV treatment, and in many Low and Medium Income Countries with limited health insurance coverage, to out-of-pocket payments by key and vulnerable populations, and when prices soar, to medicines becoming unaffordable to the poorest.


[2] The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) is an international legal agreement between all the member states of the World Trade Organization (WTO). It sets down minimum standards for the regulation by national governments of intellectual property (IP) as applied to nationals of other WTO member nations. TRIPS was negotiated at the end of the Uruguay Round of the General Agreement on Tariffs and Trade (GATT) in 1994 and is administered by the WTO. It entered into force on 1 January 1995.

Governance during and after transition

In countries where the GF operates, Country Coordinating Mechanisms (hereafter CCMs) were put in place. CCMs are national committees  that submit funding applications to the Global Fund on behalf of the entire country. They have also proven as a useful platform for actors from different areas of the national health community – civil servants from Finance and Health Ministries, epidemiologists, faith leaders, representatives of sex workers, women’s rights activists, CSOs etc – to meet, communicate and exchange perspectives.

While CCMs are generally inclusive and operational as long as the GF provides grants to recipient countries, those have no obligation to maintain CCMs in place as such once the GF pulls out, raising questions as to continued inclusiveness of various stakeholders, transparency and ownership of the response in terms of prevention, treatment, or coordination and information-sharing on the long run. Governments should thus put mechanisms in place to ensure that these issues are duly taken care of during and after transitions.

(Credits: Retha Ferguson/Pexels)
(Credits: Retha Ferguson/Pexels)

Find on this page all the information about the transition process itself, and the complications that come with it:

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Links

Center for Global Development - July 2018

Projected Health Financing Transitions: Timeline and Magnitude

Global Fund - September 2018

Global Fund: Audit Report Global Fund Transition Management Processes

Global Fund - March 2018

Global Fund : Eligibility List 2018

UHC 2030 - March 2018

Online meeting of the UHC2030 working group on sustainability, transition from aid, and health system strengthening

Global Fund - March 2018

Projected Transitions from Global Fund support by 2025 – projections by component

Technical Report - February 2018

Transition from External Aid: Challenges and Opportunities

EU2017.ee - December 2017

Outcome of the Senior-Level Policy Dialogue Addressing HIV and TB Challenges: from Donor Support and Emergency Response to Sustainable Health Systems

Open society foundations public health program - December 2017

Lost in Transition: Three Case Studies of Global Fund Withdrawal in South Eastern Europe

UHC2030 Technical Working Group Report - March 2017

Technical Working Group on Sustainability, Transition from Aid and Health Systems Strengthening

Guidance Note - January 2017

Sustainability, Transition and Co-financing of programs supported by the Global Fund

AIDSPAN - March 2016

Transitions from donor funding to domestic reliance for HIV responses

Euroasian Harm Redduction Network - August 2015

The Impact of the Global Fund's withdrawal on harm reduction programs - case study

UNITED NATIONS Department of Economic and Social Affairs - July 2014

Recipients and Contributors: Middle income countries and the future of development cooperation

Overseas Development Institute - June 2011

The role of aid to middle-income countries: a contribution to evolving EU development policy

Institute of development studies - September 2010

Global Poverty and the New Bottom Billion: What if Three-Quarters of the World’s Poor Live in Middle-Income Countries?