When Global Fund support ends: Sustainability lessons from transitions in Costa Rica, Fiji, Romania, and Bulgaria
Gemma Oberth, Aidspan/Global Fund Observer
In anticipation of The Global Fund’s new strategy (2017-2022), many are calling for clarity on how the Fund will ensure the sustainability of its investments. This is particularly relevant as the Fund transitions out of many upper-middle-income countries.
When Aidspan approached the Secretariat with questions concerning the Fund’s role in transition planning, the Secretariat responded that it is waiting for directions from the new Strategy currently under development and expected to be approved by the Board at the end of April. Nevertheless, in the absence of a transitions policy, the Secretariat has told several countries that they should not anticipate future funding after the 2014-2016 allocation period, and that they should plan accordingly.
To date, discussions about Global Fund transitions have predominantly centered on HIV grants in Eastern Europe, with a heavy focus on harm reduction. Aidspan has previously reported on this.  But HIV grants in the EECA region are not the only ones that are transitioning. Aidspan has previously reported on the transition in China.  Open Society Foundations (OSF) has documented transitions in Mexico, Jamaica, and Thailand. 
How many others countries are going through this process? How are transitions for TB and malaria grants being managed? With little transparency around which countries are transitioning when, it is difficult to monitor the sustainability of programmes and to avoid potential service disruptions.
Through its research on The Global Fund’s willingness-to-pay policy (see GFO article) , Aidspan became aware that the following countries and disease components are currently going through transitions: Costa Rica (HIV), Fiji (TB), Romania (TB) and Bulgaria (TB). This means that these countries are implementing NFM grants with the knowledge that there will be no future funding from the Global Fund. These are being referred to as “transition grants.” Each country is employing different sustainability strategies to help mitigate the anticipated impact once the Global Fund departs.
Costa Rica (HIV)
Costa Rica’s NFM HIV grant was the first time the Global Fund had invested in the country since Round 3 (2003). “There was an assumption here that this would be the first and last time Costa Rica would get money,” a key informant told Aidspan. This had a significant impact on what the country planned to do with the grant. Key informants suggested that “this is not a standard prevention grant doing outreach. It’s a much more catalytic grant trying to figure out how you better link civil society organizations that are working on these issues [HIV prevention] to funding.”
To this end, portions of the grant are going towards strengthening the Social Projection Board (JPS), a government funding mechanism which ensures local NGOs are able to access public money to deliver HIV services. The transition grant is also working to ensure that there are specific provisions in the JPS for funding NGOs that do prevention work with transgender women and men who have sex with men. “It’s about how you use small and final allocations from the Global Fund in a smart way,” said another key informant.
In two years’ time, Fiji will no longer have Global Fund resources to support its TB programme. Knowing that it is transitioning, the country is heavily prioritising shifting human resources (HR) within the Ministry of Health that are funded by the Global Fund over to government budget lines. According to key informants at the Global Fund Secretariat, this decision to focus on HR sustainability during the transition emanated from local partners, “but naturally we have been discussing sustainability and saying they should shift the HR costs to the country.”
Partners in country note that their transition grant is about strengthening health systems. “We are exploring how best to allocate the government funding after the Global Fund leaves, looking at different models to allocations.” Fiji is also exploring innovative ways to leverage additional funding using its transition grant. Country contacts told Aidspan that part of the 2017 budget might be used to leverage additional money from other lenders and sources to sustain the TB programme once the Global Fund leaves.
Romania has already been through a transition for its Global Fund HIV programme, with poor results. A specific HIV outbreak among drug users (around 2011) has been directly linked to the significant decline in harm reduction services following the Global Fund transition out of the country. 
Now, Romania is managing a transition for the country’s TB grant. Key informants said that based on experience from the country’s HIV transition, the “guiding principle was really to make sure the gains made from Global Fund investment could be sustained after transition.” In order to safeguard sustainability, the National Strategic Plan (NSP) for the Control of Tuberculosis in Romania (2015-2020) has a clear co-financing agreement to guide the transition. “It’s all in the strategic plan, which is essentially a transition plan,” said one key informant. The Global Fund Secretariat told Aidspan that “we made it a requirement for them to make this transition plan before the grant.”
Similar to Romania, Bulgaria is making use of its upcoming five-year NSP to integrate a transition plan for its last Global Fund TB grant. “It was common knowledge that it would be the last grant,” said one key informant. By 2018, the country must be able to take over elements of the TB response that The Global Fund is currently supporting, including second line drugs, lab reagents for MDR-TB and contact tracing nurses. Along with a transition plan in the NSP, Bulgaria is also reforming its TB care approach to make the entire system more sustainable. The reforms involve a shift in service delivery from facility level to community level to make the TB response more affordable. “They want to move away from the Soviet model towards a cheaper home-based model,” said one key informant. “Most of the TB patients are from Roma communities who do not want to be in hospitals anyway.”
The sustainability initiatives in these four countries could provide valuable lessons to others countries currently facing, or soon to face, transition. Establishing government funding mechanisms for NGOs (Costa Rica), leveraging investments to secure loans (Fiji), integrating transition planning into NSPs (Romania and Bulgaria), and reforming service delivery models (Bulgaria), are all good ways to ensure greater sustainability following Global Fund transitions.
The interview data in this article was collected in November 2015 as part of Aidspan’s research on counterpart financing and willingness-to-pay, funded by the Open Society Foundations (OSF). 
Oberth G. Sustainability lessons from transitions in Costa Rica, Fiji, Romania, and Bulgaria. Global Fund Observer (GFO), ( 25 January 2016).
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