Global Health Transitions and Sustainable Solutions The Role of Partnerships: Proceedings of a Workshop (2019) / Chapter Skim
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2 Global Health Transitions
2 Global Health Transitions
Pages 5-38
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DEMOGRAPHIC AND HEALTH TRANSITIONS To start his presentation Evans described the relationship between development, demography, and transitions in health. The premise of this relationship is that as societies develop, they transition from high fertility to low fertility and from high mortality to low mortality.
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Turning to a different type of transition, Evans noted a major programmatic transition occurring in global health -- the end of the GPEI. As the world inches closer to universal certificated polio eradication, the GPEI is winding down, and as it comes to a close, Evans emphasized the importance of retaining the skills, knowledge, and human resources developed and supported through the initiative's 30-year history (the GPEI transition is described in detail later in this chapter)
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. The Global Fund to Fight AIDS, Tuberculosis and Malaria is a partnership between governments, civil society, the private sector, and those affected by these diseases.
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Other health financing institutions, such as Gavi and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) , have different eligibility criteria that determine transitions in the levels and types of support (see Box 2-1)
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FIGURE 2-2 World Bank country policy institutional assessments. NOTE: IDA = International Development Association.
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. Gavi's sustainability approach for country transitions recognizes the following: • Domestic financing is key but is not enough.
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In addition to challenges with adjusting to loss of financing, some posttransition countries have struggled with the loss of Gavi's technical support as well as the political status that an alliance such as Gavi confers. Cornejo shared several findings and lessons from Gavi's experiences to date with country transitions (see Box 2-2)
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12 FIGURE 2-4 Gavi financing eligibility. NOTE: GNI = gross national income; pc = per capita.
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Cornejo closed his remarks by noting that there is no silver bullet for successful country transitions. Rather, he suggested the focus during transitions should be on getting the basics right: there is no substitute for appropriate regular planning, budgeting, disbursement, and execution.
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is advising the process. Transition strategy and planning focus on three core objectives: sustaining polio eradication, managing GPEI's legacy assets, and supporting countries in their transition out of GPEI support and funding.
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Martin closed by sharing that GPEI is discussing how to use its assets for other global health initiatives, including for Gavi and the Joint External Evaluation process for the Global Health Security Agenda. The Global Fund to Fight AIDS, Tuberculosis and Malaria Matthew MacGregor of the Global Fund described the organization's approach to transitions from external financing and supporting countries in the process.
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Systematic efforts to work with partners (including technical agencies, bilateral partners, development banks, and civil society partners) to leverage capacity, collaborate on joint priorities, and accelerate STC efforts The STC policy formalized the concept of transition funding for disease components with existing Global Fund grants that have become newly ineligible in order to address bottlenecks in the transition process
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The Global Fund works with partners to coordinate technical assistance by seeking ways of increasing countries' domestic financing, assisting in overcoming bottlenecks in the transition process, and improving the efficiency of investments. MacGregor also noted a challenge unique to the Global Fund: it is often active in places where other multilateral and bilateral donors have already transitioned.
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SOURCES: As presented by Matthew MacGregor on June 13, 2018. Figure created by the Global Fund.
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Ikuo Takizawa of the Japan International Cooperation Agency (JICA) expressed concern that the polio surveillance systems would be challenging for other disease programs to use given the robust level of funding polio has received versus others.
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Martin pointed out that all 16 countries are supported by technical advisory groups, interagency coordination committees, and Gavi, which is a member of the GPEI's Transition Management Group. Concurring with Matthew MacGregor's remark in his presentation that governments are not readily persuaded to support key and vulnerable populations or civil society organizations, Takizawa wanted to know how successful the Global Fund has been in dealing with governments on this issue.
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Proposals to shift development assistance away from grant financing and toward global public goods are being made; however, Evans emphasized that this shift will only be successful if coupled with effective domestic resource use and mobilization. Evans suggested that the growing body of work on projections of financing for health can help to stratify countries based on likely trajectories for domestic resource mobilization.2 These projections illuminate a small but significant minority of countries with a 40- to 50-year trajectory for developing a strong engine of national financing.
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She added that community engagement plays a critical role in fostering country ownership (see Box 2-5 on the Research Fairness Initiative for an example of supporting country ownership presented at the workshop)
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Country ownership is critical for creating sustainable solutions in transitioning countries, she said. Related to country owner ship is the issue of power relationships between partners with different resources to bring to the table.
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PEPFAR spearheaded an effort to align PEPFAR, Global Fund, and host country HIV/ AIDS budgets. They completed a resource mapping exercise to provide data that are more comprehensive and that clearly define the program elements for which each entity is responsible.
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. cessful in controlling the epidemic were those that received the most funds from the Global Fund and PEPFAR, demonstrating that success is not solely a resource issue but is dependent on how those resources are used and on policies that ensure those resources have maximum impact.
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. FIGURE 2-8 HIV treatment coverage in South Africa.
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U.S. Agency for International Development In opening her remarks, Pelzman noted the convergence between the workshop's focus and USAID's current priorities under dministrator A Mark Green: country transitions to self-reliance and private-sector engagement.
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Pelzman turned to USAID's priority focus on private-sector engagement, particularly in the context of supporting country transitions and new forms of partnerships between USAID and partner countries. Successful private-sector engagement in global health can increase impact, use USAID resources strategically, and build sustainability in programs to support countries as they transition from donor assistance, Pelzman said.
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Reach more of the target population by drawing on private sector resources and expertise or by accessing Operate more efficiently or cost-effectively by adapting private sector channels private sector expertise, skills, or tools Achieve procurement savings from more competitive Enhance USAID program sustainability with handover markets that facilitate access to health products and strategies, revenue-generating business models, and open or expand markets for commercial actors commercially viable local private sector partners FIGURE 2-9 Effects of USAID's Bureau for Global Health's private-sector engagement activities. SOURCES: As presented by Kerry Pelzman on June 13, 2018.
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However, USAID had maintained relationships with them and those relationships provided a crucial entry in mobilizing an emergency response. Japan International Cooperation Agency Providing a perspective from another bilateral global health- unding f agency, Takizawa described JICA's policies and approaches to country transitions.
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However, as the host countries develop, JICA is shifting its model to more of a mutual dialogue. For example, JICA recently hosted a delegation from Kenya that included the ministry of health as well as representatives from the ministry of finance, the national parliament, and the counsel of governors for a dialogue on domestic resource mobilization to achieve UHC.
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Moreover, she suggested that in choosing a partner, USAID should consider not only the large international companies but also in-country, for-profit channels, such as pharmacies and clinics that could facilitate contact with new types of "customers." TRANSITIONS AT THE COUNTRY LEVEL Jo Ivey Boufford of the New York University College of Global Public Health moderated the final panel of the day. Four speakers explored the degree to which developing countries are ready to undergo a transition that will bring to an end or reduce their dependence on donor assistance.
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He categorized them as three types. The first type is the transition of external financing instruments, including Gavi and the Global Fund.
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He pointed to the example of supply chain management. There have been initiatives to create efficiencies in the supply chain for externally financed commodities, but these initiatives do not extend into the rest of the health sector even though pharmaceuticals account for a large portion of total health spending in the country.
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Switching to his specific tasks as deputy director general with the Indian ministry's National AIDS Control Organization, Goel emphasized the need to work in a partnership between the public and private sectors to "mount multisectoral responses in order to reach the largest number of people with awareness messages, preventive activities, and care and treatment." India's AIDS council has signed a partnership agreement with 16 nonhealth ministries that provide services such as awareness activities, staffing integrated counseling and testing centers, and treating sexually transmitted diseases. Partnerships were also formed with some 200 private-sector firms covering a wide range of activities that bring people into contact with AIDS health facilities.
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Buoyed by the success of the six-county experience, the Kenyan government has gone a step further in launching a "big four agenda" that covers universal health care, food security, and affordable housing and manufacturing. Americas Region Providing a perspective on a regional collaboration to address a specific health issue, Fitzsimmons described some of the transitions the national immunization programs in the Americas experienced since the Expanded Program on Immunization launched 40 years ago.
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In response, Pate noted that transition means many things to many people or sectors. The Global Fund and Gavi, for example, approach transition from the viewpoints of their organizational missions.
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38 GLOBAL HEALTH TRANSITIONS AND SUSTAINABLE SOLUTIONS of transition. To answer Kilonzo's question about the role of the private sector, Pate pointed out that the private sector has the competence, skills, and mindset to do what many governments are unable to do efficiently.
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