In low-and middle-income countries, the health sector is under pressure to expand the coverage of services while also increasing the domestic resources funding them. But, with the amount of external resources available for health decreasing, domestic government co-financing requirements increasing, and new mechanisms like the Global Financing Facility (GFF) driving a shift from grants towards mixed funding, the pressure on countries' limited (albeit growing) fiscal space is on. Countries are transitioning away from aid and coordinated action is critical to ensure this change does not hinder the progress made so far or undermine the vision of Universal Healthcare Coverage (UHC).
What are we talking about when we talk about 'aid transition'?
Despite the strong focus on the shift in financing sources, transition is not only a question of money, nor of who will be funding vertical programmes after donors have left. Amongst the wealthier of the transitioning countries, it may be more a priorities ditch than a financing ditch that these countries are faced with. In this context of deciding financing priorities, transition becomes about:
- Legitimacy—who sets the agenda; who is involved in decision making and how; and how should prioritisation be defined and decided?
- Transparency and accountability—because it requires radical reform in the way information is gathered and used for decision-making. This includes agreeing which data are (or ought to be made) available and to whom; how outcomes are monitored and fed into domestic and global decision-making process; and what evidence and decision mechanisms can be used to ensure investment and prioritisation decisions are actually implemented.
- Governance—defining how it is managed while continuing to progress towards universal health coverage (UHC), and what role technical partners, donors, and transitioning countries have to play to sustain hard won health outcomes.
Key considerations for a successful transition
Despite the many initiatives on transition, there remains a gap in appreciating and acting on these multiple dimensions in the process of becoming independent from aid. We believe that there is now an important opportunity to re-frame the agenda, for both dialogue and information sharing, and for taking action.
The starting point for our analysis looked at transition as one of the shocks that health systems need to respond to, as well as an opportunity for strengthening systems' resilience capacity. Our new paper 'Navigating aid transition in the health sector', which provides a framework for discussions on transition of donors to lower levels of financial support in low and middle-income countries, begins by summarising the key factors to be considered to manage transition processes. It then offers what we think is a practical way forward for accelerating systems reforms by leveraging the transition process. We conclude that:
- Managing transition requires coordinated action that brings together donors and countries’ decision-makers to develop realistic and common health targets
- Technical assistance models need reform to effectively manage transition in a useful and integrated way
- Current transition management needs an independent mediating and monitoring platform to convene, coordinate and technically support joint planning for transition from systems and country perspectives
Barriers to success
National and global stakeholders need to come together to address three major barriers to sustainable transition management:
- Meaningful and equitable engagement of the right (global and national, public and private) stakeholders at different stages of transition processes is essential to build legitimacy and ensure inclusion of decision makers, as well as of those who will be most affected by the changes due to transition. This includes in-country stakeholders and development partners: from different departments in the Ministries of Health, to civil society and patients' groups, from the authorities regulating procurement and drugs manufacturing, to Ministries of Finance and national insurance agencies. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) Country Coordination Mechanism experience in Tanzania, Zimbabwe and Malawi is an example of where such engagement is perhaps not happening as effectively as it could. In this context, HIV programmes and ARTs in particular seem to dominate the prioritisation debate, and the combination of limited resources with expensive existing commitments, stifle opportunities for inclusive and meaningful deliberation.
- Data availability is currently very limited. Both countries and donors are planning and making decisions around transition without the necessary information. Information on who is being asked to fund what—for example, in terms of healthcare commodities, to what level and at what price—is limited. Programmatic and financial data classification and definitions vary across countries. Domestic allocation and spending are often reported late, with many implicit assumptions. They are not aligned to budget and accounts documents, which in turn makes it very difficult to quantify the impact and trade-offs of transition in relation to national budgets and fiscal space. Methodology and study limitations are too often not made explicit, and results cannot be modified or adapted. Data for transition planning and management are a Common Good for Health and must be made available for scientific or technical review as well as for accountability reasons.
- Independent and publicly shareable research and evaluation on the transition process, and its effects on financing and outcomes is scarce and hard to find, but it is essential for ensuring accountability against global and local commitments. Evidence and learning are currently being produced or commissioned, for the most part, in an ad hoc fashion. Additionally, they are oftentimes subject to confidentiality concerns preventing publication, and are developed outside of a common methodological framework which would allow for cross-country learning and comparisons. When or if they are published, it is put up on the sites, hubs and outlets of different donors, academics and consulting firms making it challenging to locate*. As a result, important reports oftentimes stay “hidden” and end up becoming outdated in the absence of a process of regular review and update. But it is such independent monitoring and research that is needed to address questions which go beyond the scope and mandate of individual institutions involved in specific aspects of transition. Transition is about a lot more than a specific disease or technology and must be considered within a longer time frame, which must bypass electoral and project cycles, in order to monitor outcomes and assess strategies' results.
One could start addressing the main issues and needs above by following a shared and dynamic pathway for transition planning and implementation. Figure 1 below is a simplified representation of the process we think is needed to facilitate transparent, accountable, and coordinated action to manage transition amongst all stakeholders. It is a simplified version of the non-linear and repeated interactions required amongst technical partners, donors and transitioning countries.
An independent aid transition observatory
Applying such a transition framework ought to be a coordinated and well-resourced exercise.
Indeed, to complement other existing initiatives on transition, and to play an overarching mediator role, we recommend the establishment of an independent observatory able to convene stakeholders, facilitate fully representative dialogue and information sharing, and evaluate efforts and implementation of agreed strategies (“a convener, coordinator of activities, generator of analytical content, clearinghouse for knowledge, and facilitator of knowledge translation”) as also proposed elsewhere. This would build on the work of initiatives such as UHC2030 and the WHO Accelerators combining two crucial traits: (a) independence from a disease, technology, population, or geography focused agenda, and (b) agility to act in response to requests from policymakers, national and global.
Such a global observatory for transition could be a hybrid between a WHO style public health observatory (albeit with an international remit) on one hand, and the International Initiative on Impact Evaluation, 3ie, which with dedicated resources, staff and a clear mandate aims to kickstart a global dialogue on transition that goes beyond individual donor funded programmes.
The global observatory would:
- produce robust and widely agreed principles and methods, tools, and case studies on transition;
- directly support and monitor on-going transition processes through specialised technical assistance and capacity building against domestic and global standards;
- host an open-data repository and evidence clearinghouse; and
- coordinate transition planning efforts and dialogues between stakeholders.
The form in which this would come (e.g., hub and spokes, single institution, network of existing institutions with a secretariat), how it would be funded (development partners, national governments), and its governance and detailed functions are open questions. But as a necessary first step, the international community must recognise the need for a more systematic, responsive, and independent arrangement to inform transition from aid, and hold those driving the process locally and globally accountable. The independent observatory embodies the non-competitive nature of the coordinated efforts required to ensure that transition does not hinder progress towards UHC.
We at CGD and Options will be hosting more events and discussions on transition in the weeks to come and look forward to working with all interested in this important process*.
This news article summarises a paper 'Navigating aid transition in the health sector: An issues paper of priority areas and practical recommendations for donors, countries and the provision of technical assistance', written by Alice Sabino, Olivia Tulloch, Amy Jackson in 2019. Read the full paper here.
*For example DFID funded an informative report on Ghana’s aid transition in July 2018 through HEART, of which we secured a copy but is not (no longer) online. The GFATM funded R4D produced a similar analysis on transition in relation to the three infectious diseases and we understand many more similar analyses are being produced for different countries by expert groups such as Pharos but they remain in disparate sites and are hard to source.