achieving successful transitions ) Robert Hecht 8 April 2019 - - PowerPoint PPT Presentation

Initiating a new era in sustainable results-based AIDS responses (and achieving successful transitions)

Robert Hecht

8 April 2019 UNAIDS Sustainability Workshop Geneva

Main messages to take away

1. “Sustainability” and “Transition” are becoming the new watchwords of the AIDS response – for good reason 2. We are beyond the golden moment of donor funding – are countries ready to increasingly take over? 3. We have made huge strides on S&T in recent years – but we need to move faster and get real, about what needs to be done and about what won’t work, too 4. We need to extract and apply the key lessons from our efforts to date –

• ur learning is too slow, e.g.,

a) Dominant S&T risks = key population programs and domestic financial expansion b) Start transition planning early, but imminent transition focuses the mind (Costa Rica, Algeria) c) National (multisectoral councils and MoH programs) and global players (UNAIDS, Global Fund, and PEPFAR) are not yet aligned – we are stepping on our toes

5. We need to work together urgently

a) Better and standardized analytical tools b) Better processes, sequencing, dialogue c) Better data d) Translate analysis into action – a lot of studies but much few less impact

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For today

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Review past investments and progress in the HIV response Define sustainability and transition (S&T) in the context of HIV and why it matters Discuss four key cross-cutting problems and point to solutions Provide an overview of the Sustainability Meeting agenda and objectives

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Over $500 billion dollars has been spent on the HIV response in low- and middle-income countries -- leading to remarkable achievements

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Source: IHME, 2017; Global Burden of Disease database 2016; UNAIDS estimates, https://www.iasociety.org/Web/WebContent/File/ICAP%20Bellagio%20Report%20- %20Leveraging%20HIV%20Scale-up%20to%20Strengthen%20Health%20Systems%20in%20Africa.pdf

 21.7 million people on ART  New HIV infections down 47% since 1996

 Systems strengthening:

Enhanced utilization of SRH Improved infection control Task-shifting and health worker training Improved procurement, supply chain, and laboratory services

UNAIDS 2018, PCB slides

AIDS response has given largest boost to increased life expectancy across Africa (2003-2016)

…however progress is fragile, and the epidemic is far from being controlled

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• 1.8 million new

infections in 2017

• Incidence has

increased in Eastern Europe (+29%) and the Middle East (+12%) since 2010

Global progress has been made towards the Fast Track targets, but is still short of 90-90-90

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Source: https://www.avert.org/global-hiv-and-aids-statistics

Macro economic, sectoral, and political factors will also condition HIV responses and S&T efforts

Macroeconomic Sectoral Political LMIC growth rates GGHE/GGE LMIC acceptance of KPs, human rights laws and practice Taxation policy and revenue collection effort GGAE/GGHE LMIC priority to health and HIV Emergent economies (e.g., China) UHC policy and effort (e.g., SHI coverage) LMIC commitment to UHC OECD economic growth

• utlook

OECD attitude toward aid

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Funding for HIV has been levelling off in recent years and the global response does not have the needed resources

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5 10 15 20 25 30 2010 2011 2012 2013 2014 2015 2016 2017 Resource Availability by Funding Source (USD Billions) Domestic USG GFATM Other donor Fast-track 2020 target

Resource needs for fast-track 2020 target

https://www.avert.org/professionals/hiv-around-world/global-response/funding

What do we mean by sustainability and transition?

9 Consideration of human rights Financial sustainability Epidemiological sustainability Political sustainability Structural sustainability Programmatic sustainability

1The global fund strategy 2017-2022

Components of sustainability: Oberth & Whiteside, 2016

Sustainability and transition are interlinked

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Transition The process by which a country, or a country- component, moves towards fully funding and implementing its health programs

independent of donor support while

continuing to sustain the gains and scaling up programs as appropriate.1 Sustainability A program is defined as sustainable when it is able to maintain service coverage at a level that will provide continuing control of a health problem even after the removal of

external funding.1

1The global fund strategy 2017-2022

Components of sustainability: Oberth & Whiteside, 2016

Four overarching challenges related to sustainability and transition of the HIV response that must be urgently recognized and resolved for success

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Problem Solution

Country needs, capabilities and risks are different S&T responses must be tailored so they are specific and relevant to varying country

• typologies. One size does not fit all

Programs for key and vulnerable populations are heavily donor-funded and run major risks during S&T Implementing social contracting to ensure the sustainability of CSOs and their ability to reach key populations Donor funds are flat or falling but domestic funding is not increasing fast enough Rapidly and dramatically increasing domestic financing and improving efficiency; maintain global solidarity and support to country-led programs of sustainability Poor transition coordination and planning among donors and countries is undermining S&T Coordinating key actors and developing better tools at global and country levels – we urgently need new rules of engagement and they must be followed

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Solution 1. Tailoring S&T responses so they are specific and relevant to varying country typologies. One size does not fit all

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Countries vary in their level of domestic financing and type of epidemic, with huge implications for S&T

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Challenge 1

UNAIDS, 2018 AVERT, 2019

Share of Domestic Financing Generalized epidemic Concentrated epidemic among key populations High (>80%)

• Latin America
• Eastern Europe and

Central Asia

• North Africa

Medium (50-80%)

• SA, Namibia,

Botswana

• Asia Pacific
• Middle East and North

Africa Low (0-50%)

• East Africa
• West/Central Africa

In these two country groupings, the emphasis of S&T actions are different

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Challenge 1

UNAIDS, 2018 AVERT, 2019

Country Type Predominant Sustainability and Transition Actions

• 1. Concentrated

Epidemic (mostly MIC)

• Substituting for external funding for KP programs
• Contracting and funding CSOs
• Political economy of KP activities
• Integrating HIV into health systems
• Developing targeted technical capacity
• 2. Generalized

Epidemic (LMIC)

• Mobilizing more domestic resources
• Political economy of health and HIV generally
• Increasing efficiency
• Developing broad national technical and

managerial capacity

Donors differ in the criteria used by donors to assess S&T readiness and risks – we need to unify our methods

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Challenge 1 SID Categories

Governance, Leadership and Accountability National Health System and Service Delivery Strategic Investments, Efficiency, and Sustainable Financing Strategic Information

Transition Readiness Assessment Modules

Summary of GF Support Epidemiological Situation and Programmatic Context Institutional, Human Rights, and Gender Environment Health Financing and Transition Service Delivery, Procurement, HRH, and Infrastructure Civil Society Organizations PEPFAR SID Guidelines; Global Fund Sustainability Tools, Aceso/APMG 2017

Solution 2. Implementing social contracting to ensure the sustainability of CSOs and their ability to reach key populations

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CSOs are essential to reaching key populations who are often the most marginalized and hard-to-reach, with limited access to HIV

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Challenge 2

Community Adapted

• KP representatives
• Tied to communities
• Well-equipped to tailor

services for KP Advocates

• Support human rights
• Advocate for access to services

Enhancers of Testing and Treatment Effectiveness

• Can find missing cases
• Improve adherence to treatment
• Reduce loss to follow-up

Partners in Prevention

• Peer connections
• Independent
• Trusted

In most LMICs key population programs through CSOs are financed primarily by PEPFAR and the GF

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9% 85% 6%

El Salvador

13% 65% 22%

Guatemala

69% 20% 11%

Honduras

4% 48% 48%

Panama

25% 75%

Nicaragua

PEPFAR GF Country

Source: COP Central America, PEPFAR (2017)

Challenge 2

Key populations are at-risk if countries do not own these donor- financed programs following transition

The (famous) case of Romania

Key lessons:

• Government commitment to KP and HIV prevention services
• Domestic budget for CSOs, HIV prevention and KP
• Social contracting mechanisms and plans in place early before transition

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Challenge 2

Donor transitions form HIV programs: What is the impact on vulnerable populations?, 2018

Pre-transition

Funding:

• 1% of domestic expenditure

for HIV prevention services

• Prevention funded by Global

Fund and UNODC HIV prevalence among PWID:

• 1% (2009)

2010

Post-transition

Funding:

• No domestic funding for CSO

harm reduction programs  collapse

• Obtaining substitute funding

from European countries in 2015 HIV prevalence among PWID:

• 53% (2013), 29% (2017)

A happier story -- Mexico’s CENSIDA

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Donor transitions form HIV programs: What is the impact on vulnerable populations?, 2018

Best practices:

• Federal laws promote activities carried
• ut by CSOs -- over 40,000 registered

and allowed to receive public funding

• CSOs compete to implement KP

screening, HIV prevention and treatment adherence

• CENSIDA allocates US$5+ million for

social contracting

• Smooth transition when Global Fund

left Mexico Challenge 2

Areas for improvement:

• Some CSOs that received institutional

support from the GF were not prepared to take over service delivery immediately following transition – more capacity strengthening

• Results from CSO programming are

not considered in distributing subsequent grants – more accountability and results-based contracting

Countries must address the obstacles to designing a successful social contracting mechanism

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Donor transitions form HIV programs: What is the impact on vulnerable populations?, 2018 UNAIDS, 2018

Challenge 2

Effective social contracting mechanism

Transparency and accountability to ensure fairness and effectiveness in funding allocation Political commitment to support CSOs serving marginalized populations CSO technical and managerial capacity to enter contract and perform effectively Legal and administrative mechanisms permitting and facilitating social contracting

Solution 3. Rapidly and dramatically increasing domestic financing and improving efficiency to make the most of every dollar and guard against the shock of transition

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Although domestic resources have been rising and now comprise about half of all HIV spending…

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Challenge 3

UNAIDS, 2018

Domestic (56%) US-G bilateral (25%) Global fund (10%) All other international (9%)

…donors still pay for the bulk of HIV programs In high burden, Sub-Saharan African countries

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9% 12% 12% 12% 16% 16% 91% 88% 88% 88% 84% 84% 0% 50% 100% Tanzania Mozambique Uganda Kenya Zambia Malawi

AIDS expenditure by financing source

Source: IHME

International Domestic

Countries differ in terms of transition risk depending

• n donor reliance for prevention financing

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31 6 15 29 31 41 99 96 69 62 94 85 71 69 59 50 100 Botswana Zambia Uganda South Africa Panama El Salvador 38 Guatemala Honduras Dominican Republic 4 1 Prevention as a share of total HIV expenditure Domestic International

Prevention spending by financing source and as a share of total HIV expenditure Challenge 3

Source: COPs 2018, NASAs Central America Sub-Saharan Africa

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There are a variety of approaches countries are taking to mobilize more domestic funds and/or improve efficiency

Challenge 3 Social health insurance/UHC: Thailand has included HIV services as part of UCS benefits package; HIV being integrated in UHC benefits in most regions (e.g., Colombia, DR, Morocco, Estonia) General tax financing: South Africa allocates more resources to health as a share of total government expenditures (14%) and 10%+ of health spending for HIV Increased efficiency: Switching to a differentiated care model in Tanzania could save up to $20 M annually; switch to DTG-based treatment will save another $20+ million Improved public financial management: The World Bank and the Global Fund are strengthening public financial management (e.g., pay for performance) to get more AIDS bang for the buck

https://www.healthpolicyproject.com/pubs/7887/SouthAfrica_HFP.pdf

More money for HIV More HIV services for the money

Solution 4. Coordinating key actors and developing better tools at global and country levels – we urgently need new rules of engagement and compliance

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Global Fund

• Global Fund’s Special Initiative
• TRAs and Roadmaps
• Sustainability Strategies
• Civil Society Workshops

World Bank

• Flagship Courses
• Analysis of technical and allocative

efficiencies BMGF

• The Global Health Cost Consortium
• MAP-IT tool

PEPFAR

• Sustainability Index Dashboard
• Domestic Resource Mobilization
• Sustainability Framework

UNAIDS

• TRAs and Roadmaps
• Investment Cases
• PPC paper on sustainability
• Stigma index

In recent years, donors have focused on sustainability and transition at country and global levels

Challenge 4

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• 1. No timeline detailing priority

issues or sequencing of studies for S&T

PEPFAR SID Sustainability Assessment & Strategy Transition Readiness Assessment & Roadmap APMG Social Contracting Diagnosis Tool

• 2. No clear pathway translating

analysis to policy dialogue

• 3. Mixed country

engagement and limited political will to ensure S&T policy and roadmap action items are implemented

• 5. Uncoordinated

documentation and dissemination of findings

• 4. Weak monitoring

mechanisms to ensure implementation

Limited sharing

• f lessons

learned

The use of these tools is important and they have high potential for impact, but there are gaps, duplications, and a lack of coordination

Challenge 4

Additional tools and improved coordination are needed to ensure the success of sustainability and transition processes

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• 1. Establish a sustainability

framework & timeline detailing priority issues and sequencing of studies for S&T agreed upon by countries and donors

PEPFAR SID Sustainability Assessment & Strategy Transition Readiness Assessment & Roadmap APMG Social Contracting Diagnosis Tool

• 2. Ensure high-

level analysis translates to policy dialogue

• 3. Attain country

engagement & political will to ensure S&T policy and roadmap action items are financed and implemented

• 5. Develop a S&T

Repository of tools and best practices to strengthen coordination and impact

• 4. Employ monitoring mechanisms to

ensure accountability, track progress of actions items over time, adjust roadmaps, and inform future S&T policy and actions Document examples of successful translation from analysis to policy Document & share lessons learned from implementation of S&T action items

Challenge 4

Cambodia and Tanzania provide positive examples of sequencing of studies, country ownership, and donor coordination Tanzania:

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Cambodia:

Transition Readiness Assessment and Roadmap: Led by UNAIDS PEPFAR SID completed before and informed the TRA and Roadmap Global Fund Transition Readiness Assessment Tool developed Input from country stakeholders: National AIDS Authority and MOH

Investment Case: Led by UNAIDS and commissioned by TACAIDS

Data from BMGF costing project and expenditure harmonization study Input from country stakeholders: NACP and updated National M-S Strategic Framework PEPFAR expenditure data and costing studies

Challenge 4

This workshop creates a special opportunity to look honestly at and tackle the obstacles to sustainability and transition

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Generate urgency Tackle the dominant challenges Move toward a unifying Framework and chart a path forward Spell out the roles and responsibilities of key national and global actors

How can we work together to improve HIV sustainability and transition, protect the gains made, and end the epidemic?

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CSOs Countries

Technical partners

Donors

Only through sustainable HIV responses and coordinated transition planning can we take global HIV from this…

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