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Ghada Muhjazi¹, Marty Makinen², Samira Abdelrahman³, Amel Ben Said⁴, Alex Earle⁵, Hoda Atta¹ and Yvan Hutin¹

¹World Health Organization Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Dr Ghada Muhjazi: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ). ²George Washington University. ³Research & Innovation Program, Wad Medani College of Medical Sciences and Technology, Sudan. ⁴Ministry of Health, Tunisia. ⁵World Health Organization, Geneva, Switzerland.

Abstract

Background: HIV, tuberculosis and malaria (HTM) services receive financial support from the Global Fund and need to plan for sustainability and transition from external funding.

Aim: To recommend actions for addressing key sustainability and transition issues in 15 countries receiving Global Fund grants in the WHO Eastern Mediterranean (EMR) Region.

Methods: We reviewed documents, interviewed key informants, and conducted case studies in Sudan and Tunisia to highlight key considerations for sustainability and transition from Global Fund that is tailored to the EMR and the health system building blocks. Sustainability considerations should align with the health system building blocks, including governance, financing, service delivery, workforce and health product management, with the addition of considerations for key and vulnerable populations because of their particular importance for HIV and tuberculosis services.

Conclusion: While hoping for economic growth and reduction of the burden of HTM, EMR countries need to prepare for transition from Global Fund support. Proactive steps that are tailored to the health system building blocks and address the needs of key and vulnerable populations should progressively increase national capabilities as well as resources dedicated to HTM.

Keywords: tuberculosis, HIV, malaria, Global Fund, funding, health systems, sustainability, Sudan, Tunisia

Citation: Muhjazi G, Makinen M, Abdelrahman S, Ben Said A, Earle A, Atta H, et al. Preparations for sustainability and transition from Global Fund support in the Eastern Mediterranean Region. East Mediterr Health J. 2023;29(8):664–672. https://doi.org/10.26719/emhj.23.088 
Received: 25/12/22; Accepted: 01/06/23

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo ).

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Introduction

Sustainable transition from external assistance is defined as a “health system’s ability to sustain or increase effective coverage of priority interventions and associated outcomes towards Universal Health Coverage (UHC)” (1). This definition emphasises that sustainable transition is based on coverage outcomes.

The question of sustainable transition has been a priority consideration for HIV, TB and malaria (HTM) services, which receive substantial donor support, particularly from the Global Fund. Although there are concerns about financial sustainability, HTM services and related health programmes need to focus on efficiency-enhancing efforts as they transition to public, domestic financing (2). Such efficiency can be attained partly through integration or better alignment of HTM services with other services in the health system, along with the use of cost-effective technologies and implementation models. To increase public, domestic resources devoted to HTM services, countries need to gradually increase allocation of government fund while leveraging additional resources where relevant. Resources can be allocated from the proceeds of economic growth and through reprioritization of government spending in favour of health (3).

WHO, along with the Global Fund, has been encouraging and supporting countries in the Eastern Mediterranean Region (EMR) to embed sustainability in their national strategies, plans and programme designs. Boosting sustainability will strengthen countries’ health systems over time to efficiently manage services and be less reliant on donor support. Through cautious management of donor resources, governments can mitigate the risk of a performance decline or collapse, thereby maintaining HTM service continuity and improving coverage.

To address the issue of sustainability of HTM services in the EMR context, the WHO Regional office for Eastern Mediterranean Region (WHO/EMRO) supported the development of key considerations for sustainability and transition from Global Fund support by EMR countries. Global Fund-supported countries can then choose from the menu, actions that best fit their context in addressing sustainability and transition of their priority health programmes. The recommended actions are intended to help countries embed sustainability and transition in their planning and implementation of overall health strategies, disease specific strategic plans, as well as Global Fund grants, regardless of income level or transition status.

Methods

WHO/EMRO prepared these key considerations based on document reviews, key informant interviews, and two case studies in Sudan and Tunisia. Reviewed documents included guidance and policy publications, tools, and data from WHO, Global Fund, UNAIDS, UNICEF, the World Bank, and International Monetary Fund.

We conducted key informant interviews (KII) with 17 global, regional and country experts from WHO, Global Fund and UNAIDS. Selection of KII participants was based on their work portfolio and included those directly engaged in policy formulation and control programmes for the 3 diseases at WHO/EMRO and WHO headquarters and had experience in health system strengthening and health financing. A checklist of questions was developed, which was modified when needed to adapt to a participant’s portfolio. In general, the interviews addressed challenges to attaining sustainability, the different dimensions of sustainability and lessons learned from different countries. We requested participants to share for review any relevant documents or case studies relevant to the issue.

We conducted two case studies simultaneously in Sudan and Tunisia, including a mix of quantitative and qualitative data collection, a review of national documents, and key informant interviews with national stakeholders. We used the results of the two case studies to enrich the development of the key considerations.

WHO/EMRO convened a consultative meeting involving 9 Global Fund-supported countries in Cairo, Egypt, in June 2022 to review the draft document and discuss the relevance, feasibility and requirements for implementation of the set of actions.

Challenges and opportunities to strengthening service sustainability in EMR

Domestic financing by Global Fund eligible countries in EMR

Overall, countries receiving Global Fund support in the EMR did not substantially depend on external financing for health (Figure 1). Four of the 10 countries received more than 5% of their overall financing from external sources and 5 received 1% or less. Only Djibouti received more than 20% external financing. However, dependence on external financing differed for the 3 disease programmes supported by the Global Fund (Figures 2,3,4). For HIV, 3 of 7 countries depended on the Global Fund to finance HIV services by more than 30%. For TB, 7 of 12 countries depended on the Global Fund by 60% or more. For malaria, 5 of 7 countries depended on Global Fund by more than 75%.

Political instability and disasters in EMR

Apart from the 9 EMR countries classified as challenging operating environment (COEs), others may be experiencing pressure that could impact sustainability of their HTM services. The political instability and conflict that characterize COEs necessitate a heavy dependency on donor support. EMR countries have many refugees and displaced people because of their conflict (Libya, Syria, Yemen) and post-conflict (Somalia and Iraq) situations. Political instability and economic crisis in Lebanon and Sudan further impact domestic funding for, and access to, essential health services, including HTM (Box 1).

Concentrated HIV epidemics

Compared with other regions, EMR faces a fast-growing HIV epidemic, with a 41% increase in new infections and 55% increase in AIDS-related deaths in 2020 compared to 2010. This is largely due to a gap in diagnosis, as the highest risk populations are not tested. Although the HIV epidemic remains concentrated among key populations, including men who have sex with men (MSMs), persons who inject drugs (PWIDs), and sex workers, only 5% of tests in the region in 2020 occurred among these groups. Key populations are underserved not only because the resources are insufficient, but also because of the socio-cultural context of the region, legal barriers, stigma, and discrimination.

Migrant populations

Many countries in EMR have large international migrant populations (4), including migrants from Syria in Jordan; migrants mainly from Sudan, Syria and Yemen in Egypt; rapidly increasing numbers of migrants from Afghanistan in Iran; sub-Saharan African migrants in Tunisia; and South Sudan migrants in Sudan. Other EMR countries have substantial proportions of internally displaced persons (IDPs). Health care services available for international migrant populations or IDPs is not explicitly defined in the overall health policies of many EMR countries. This lack of strategy for migrants has implications for vulnerability and access to services for the 3 diseases.

Universal Health Coverage

EMR countries committed to achieving Universal Health Coverage (UHC) by 2030 by signing the UHC 2030 Global Compact in Oman in 2018 (5). A commitment to UHC is an opportunity to reframe the sustainability and transition agenda towards sustaining coverage results, rather than sustaining externally funded programmes per se. This perspective has implications for the overall approach to sustainability and transition, implying 3 shifts. First, building consensus that what is to be sustained is increased effective coverage of priority health interventions, including HTM interventions. Second, sustainability requires acting on domestic revenue generation and allocation as well as expenditure (efficiency) issues. Third, such actions must be system-wide rather than programme by programme (6).

COVID-19

Following the negative economic growth in 2020 caused by COVID-19, the 2021 estimates of the IMF World Economic Outlook Update (7) and the 2022–2023 projections suggest a resumption of growth in emerging markets and developing economies, including for the Middle East and Central Asia regions, which include the EMR. However, COVID-19 still hinders growth and the duration of the impact of the COVID-19 pandemic as a major constraining economic factor remains uncertain. The negative economic consequences of COVID-19 mean that governments have a smaller revenue base from which to allocate resources to health. Consequently, there is downstream lower allocation for services such as HTM, and a setback in the sustainability of funding for HTM services and interventions is expected.

COVID-19 can make HTM services and interventions more difficult and costly to implement. Findings from the third round of the WHO global pulse survey on continuity of essential health services during the COVID-19 pandemic indicated that 14% of EMR countries reported disruption in HIV testing by more than 50%, and 17% of EMR countries reported disruption in TB diagnosis and treatment services of 26–50% (8). Reasons for the disruptions include an increased need for personal protective equipment, reluctance of people to go to health facilities because of the fear of COVID-19 infection, and the interruption in the supply of HTM commodities.

Human resources and other inputs used to implement HTM services and interventions were diverted to COVID-19 response. A Global Fund assessment of the impact of COVID-19 on HTM services (9) and interventions indicated that staff were reassigned to different units within facilities and to different facilities as part of the COVID-19 response. This led to innovative coping behaviours for HTM services, such as extending drug prescriptions to ensure uninterrupted access, prioritization of patients with high-risk conditions, provision of care for multiple morbidities in a single visit, increased use of telemedicine, and digitalization of medication refills. All these behaviours may increase efficiency if continued post-COVID-19. The use of existing health systems for COVID 19 response has provided lessons about where integration can work (10). Also, COVID-19 raised attention among policymakers to the importance of health to the economy and heightened awareness about the importance of greater allocations of domestic public resources for health, overall, and for the HTM services, specifically.

Sustainability considerations

We present the areas of sustainability considerations by health system function: governance, financing, service delivery, workforce, health product management, and key/vulnerable populations/human rights. Global and regional key informants interviewed recommended the creation of a specific intervention area for key and vulnerable populations and human rights, because of the importance for HIV and TB services. These areas of sustainability are not independent of each other, therefore, their separation should not be interpreted as a divide in the absence of expected interactions. Menus of actions are presented. Because not all actions will be relevant and feasible in every context, countries may choose the actions relevant and feasible for their specific contexts. Table 1 summarizes for each domain the objectives and measures of success.

1.  Governance

Four actions can be considered with respect to governance.

a. Establish a sustainability unit and delegate responsibility and authority to lead and oversee sustainability and transition

The unit assigned the responsibility and authority for sustainability and transition would lead on required changes to regulation, system design (integrating sustainability and transition with other key strategic initiatives of the health sector, such as the pursuit of UHC), and accountability (including a monitoring and evaluation framework and system). This unit would be like a "change management team" that would disband once the changes are attained. In this case, the sustainability and transition team would disband once transition is attained.

b. Transferring the functions of the Country Coordination Mechanism to a national institution

This would allow countries to benefit from lessons from the Country Coordination Mechanism (CCM). New or revised terms of reference may be needed to ensure that all functions are fulfilled and that “no one is left behind” in terms of representation.

c. Broadening the interests represented in CCMs or the successors

This may include representation from the Ministry of Finance, legislature, other locally relevant players, and the private sector. Representation could include the broader business community. If they are informed about the contributions HTM services make to improvements in the productivity and welfare of the workforce and the challenges they face, they may be willing to make corporate social responsibility contributions to funding and to become political supporters for greater domestic government resource allocation to HTM services.

d. Adapting governance estrangements for decentralized health systems

Decentralized governance should optimally connect and include the whole health sector, including HTM-related services and funding.

2. Financing

HTM services in EMR benefit substantially from external funding. In the context of transition, there is a need for greater, if not complete, reliance on domestic, public financing. Given this reality, the practice of off-budget financing of HTM activities, which is not aligned with public financial management (PFM) processes, creates a sustainability risk. Several actions can address this risk.

First, programmes may embed HTM participation in health financing strategy development (or revision). Second, they can advocate for equitable health coverage overall where HTM services are included and embedded in guaranteed benefits packages. Third, there is a need to ensure that HTM public health and preventive activities receive sustainable funding not only for diagnosis and treatment. Fourth, programmes should understand the PFM systems and work to understand and coordinate with reform efforts.

Careful analysis is needed to track and project overall health spending, estimate time to transition and analyse prospects for public, domestic health spending through a fiscal space calculation (11). Data from the analyses may be combined with information about the costs of HTM services, taking into account any efficiency improvements that could be made, and related systems to estimate: (a) the share of overall public spending on health that HTM services represent and (b) the broad timeframe that economic growth would allow the HTM costs to be covered. This would provide a general feasibility assessment related to the overall fiscal space for health projections. Close-to-transition countries should focus on ensuring funding for essential-to-transition components and, when applicable, pursue debt swaps to increase domestic resources for HTM programmes.

Overall, sustainability instruments proposed by WHO, the Global Fund and other donors should be used proactively, and not only with the narrow perspective of complying to the requirements of funding requests.

3. Service delivery

First, integrating and co-locating HTM services into the overall approaches to effective and efficient service delivery is the starting point to sustainability. Second, greater involvement of sector-level experts can better embed HTM services into system reform efforts, while also bringing a primary health care lens to funding request development, grantmaking, implementation, monitoring, and revision processes. Third, we need to support the delivery of an integrated primary health care essential services, including for HTM, to support a comprehensive strategy to optimally use all domestic and external assets to sustain HTM services in the context of overall efforts to advance towards UHC. Fourth, we need to include HTM services in any overall health system quality initiatives or quality assurance mechanisms to ensure that access to care is effective and efficient. Fifth, we need to consider opportunities to engage private sector service providers.  This could be pursued by connecting private providers to HTM services through training (in evidenced-based diagnosis and treatment), referrals, and access to attractively priced commodities for diagnosis and treatment in HTM programmes. Such engagement must be regulated and based on quality service, supportive supervision, and a requirement to report through the national health information system. Framed in this way, collaboration with private service providers could extend the reach and effectiveness of HTM services.

4. Health workforce

Some of the health workforce is specific to certain services, such as programme managers and those providing specialized services. However, service delivery personnel who are not specific to the programmes are part of the broader overall health system.

First, CCM or the successors (or HTM programme managers) should advocate for investment in addressing fundamental issues around healthcare workforce for the overall health system. Improved overall workforce management will enhance HTM sustainability. Second, domestic budgets must progressively assume the costs of service delivery human resources supported by the Global Fund and the costs of HTM programme management personnel as part of the sustainability agenda. Third, HTM programme management salaries and benefits must progressively align with the national scales. Fourth, leadership handover plans should be regularly updated for HTM programme management.

5. Health product and supply chain

The success and sustainability of the HTM services depend heavily on the reliable supply of physical resources or health products. The lack of access to pooled procurement processes, negotiated prices, and public procurement capacity to assure supplies of critical medicines and supplies are barriers to sustainability and transition.

Several options are available for countries to establish reliable physical resources. First, countries need to progressively increase domestic funding of HTM products. Second, they need to integrate HTM supply chains and supply infrastructure with those for the rest of the health system. Third, they may want to consider employing WAMBO (12) and the Global Drug Facility (13) as alternatives to national procurement of HTM products. This will allow them to make use of pooled procurement mechanisms for HIV supplies and TB medications, ensuring low prices and assured quality. Fourth, where appropriate, countries are encouraged to procure from national product suppliers when the suppliers can provide health products of acceptable quality, reliably and at competitive prices. Fifth, a strong linkage from quantification, to budgeting, to procurement, to execution is required. Sixth, countries may choose to apply the UNICEF supply chain assessment tool to identify weaknesses in their supply chain systems. Seventh, commodity supply managers could invest in building the capacity, skills, tools, and processes of national medical resources and products systems and use reference prices. Often, supply managers lack the ability to estimate and forecast order quantities with sufficient accuracy and then manage stocks and deliveries. Eighth, national regulatory authorities should streamline pharmaceutical registration and find ways to lighten processes and shorten lead times. National regulatory authorities may consider joining WHO’s Accelerated Registration of Prequalified FPPs (15) initiative. Streamlined registration will allow adoption of new products needed when medical knowledge and recommendations change, so that HTM and other services are not left behind. Ninth, a “do versus buy” analysis of potential efficiencies from outsourcing (contracting with private sources) for product-related programme functions such as specimen transportation, laboratory services, and commodity storage and distribution could allow efficiency. Tenth, for countries under sanctions, use of UN agencies as principal recipients will facilitate the purchase of needed medical products, even if, in the short term, using a UN agency for this purpose will tend to weaken national systems and raise overhead costs of the HTM services.

6. Key and vulnerable populations and human rights

Based on the WHO/EMRO context, the biggest effort needed is to change the legal environment regarding human rights. Several options are available. First, countries could base their work on eliminating barriers to legal human rights on the broader human rights initiatives. Second, countries may opt to employ the relevant Articles (3, 4 and 39) of the Arab Charter on Human Rights (14). Third, countries could include requests for support for work on the human rights agenda in Global Fund funding request. Countries could choose to work on changing attitudes and practices, beyond the legal context. Human rights of key and vulnerable populations will not be assured by legal and regulatory changes alone. There is a need to continue efforts on changing attitudes and practices of health workers and law enforcement personnel. This may entail working with medical councils (or equivalents) that oversee health workers to establish training on ethical practices complemented by sanctions for violations of patients’ rights. There should be planning for sustainable funding for these efforts [and collaboration or social contracting with civil society organizations (CSOs) to complement government efforts]. Fourth, national social contracting with the NGOs/CSOs may enhance the sustainability of services when NGOs or CSOs provide essential services to key and vulnerable populations. However, existing NGO/CSO work is often highly dependent on Global Fund support. An initial step may be to review the functions being performed by NGOs/CSOs currently supported by Global Fund grants, and to assess their fit for purpose including alternative approaches to attaining the same results. When the assessment is positive for the NGOs/CSOs in terms of fit, then social contracting can be pursued. This entails ensuring that the public financial management system accommodates social contracting, establishing systems to manage social contracts, progressively funding social contracting where possible, using competitive methods in the contracts with incentives for performance, and assisting CSOs (and/or NGOs) with their own sustainability.

Conclusion

EMR has and will continue to benefit from Global Fund support for HTM services. Although there has been a lot of accomplishments in the fight against HTM in the region, there is still much to do. We need to sustain the accomplishments with or without financial support from the Global Fund, and sustained results will not occur without taking proactive steps to progressively support national capabilities and increase resources for HTM. When economic growth and reduction in the burden of HTM diseases occur, EMR countries must be ready for transition from Global Fund support. Our work on sustainability and transition must include efforts to improve efficiency and ensure optimal use of available financial resources. Transition will enhance national self-reliance and autonomy and efforts to address HTM post-Global Fund support.

Acknowledgement

This report was developed with substantial support and guidance of Dr Susan Sparkes. We acknowledge the national and international partners who provided valuable inputs, comments and suggestions to validate the regional document summarized in this paper.

Funding: None

Competing interests: None declared.

Préparatifs pour la pérennisation et la transition en vue de s'affranchir de l'appui du Fonds mondial dans la Région de la Méditerranée orientale

Résumé

Contexte : Les services de lutte contre le VIH, la tuberculose et le paludisme bénéficient du soutien financier du Fonds mondial et doivent élaborer un plan pour assurer la pérennisation, et prévoir la transition en vue de s'affranchir du financement externe.

Objectif : Recommander des mesures visant à traiter les questions clés de pérennisation et de transition pour 15 pays qui reçoivent des subventions du Fonds mondial dans la Région OMS de la Méditerranée orientale.

Méthodes : Nous avons passé en revue des documents, interrogé des informateurs clés et mené des études de cas au Soudan et en Tunisie afin de mettre en évidence les principales considérations relatives à la pérennisation et à la transition en vue de s'affranchir du soutien du Fonds mondial, qui soient adaptées à la Région de la Méditerranée orientale et aux éléments constitutifs du système de santé. Les considérations relatives à la pérennisation devraient être conformes aux éléments constitutifs du système de santé, notamment la gouvernance, le financement, la prestation de services, les personnels et la gestion des produits de santé, en y ajoutant des considérations relatives aux populations clés et vulnérables en raison de leur importance particulière pour les services de lutte contre le VIH et la tuberculose.

Conclusion : Tout en espérant une croissance économique et une réduction de la charge du VIH, de la tuberculose et du paludisme, les pays de la Région de la Méditerranée orientale doivent se préparer à la transition en vue de s'affranchir de l'appui du Fonds mondial. Des mesures proactives adaptées aux éléments constitutifs du système de santé et répondant aux besoins des populations clés et vulnérables devraient progressivement renforcer les capacités nationales ainsi que les ressources consacrées à la lutte contre le VIH, la tuberculose et le paludisme.

التحضير للاستدامة والتحول عن الدعم المُقدَّم من الصندوق العالمي في إقليم شرق المتوسط

غادة محجازي، مارتي ماكينين، سميرة عبد الرحمن، أمل بن سعيد، أليكس إيرل، هدى عطا، إيفان هوتين

الخلاصة

الخلفية: تتلقى خدمات فيروس العوز المناعي البشري والسل والملاريا دعمًا ماليًّا من الصندوق العالمي، وتحتاج إلى التخطيط للاستدامة والتحول عن التمويل الخارجي.

الأهداف: هدفت هذه الدراسة إلى وضع قوائم الخطوات الاستباقية الواجب الانتقاء منها لمعالجة قضايا الاستدامة في 15 من بلدان إقليم شرق المتوسط ممن يتلقى الدعم من الصندق العالمي

طرق البحث: استعرضنا الوثائق ذات الصلة، وأجرينا مقابلات مع مصادر المعلومات الرئيسية، كما أجرينا دراسات حالة في السودان وتونس لتسليط الضوء على الاعتبارات الرئيسية للاستدامة والتحول عن الدعم المُقدَّم من الصندوق العالمي بما يناسب إقليم شرق المتوسط وأركان النظام الصحي.

النتائج: لم تعتمد البلدان التي تتلقى دعمًا من الصندوق العالمي في إقليم شرق المتوسط اعتمادًا كبيرًا على التمويل الخارجي للصحة. فقد تلقَّت أربعة من البلدان العشرة أكثر من 5% من إجمالي تمويلها من مصادر خارجية، بينما تلقَّت 5 بلدان 1% أو أقل. وينبغي أن تتواءم اعتبارات الاستدامة مع أركان النظام الصحي، ويشمل ذلك الحوكمة والتمويل وتقديم الخدمات والقوى العاملة وإدارة المنتجات الصحية، مع إضافة اعتبارات خاصة بالفئات السكانية الرئيسية والضعيفة بسبب أهميتها الخاصة في خدمات فيروس العوز المناعي البشري والسل.

الاستنتاجات: على الرغم من أن بلدان إقليم شرق المتوسط تأمل في النمو الاقتصادي والحد من عبء فيروس العوز المناعي البشري والسل والملاريا، فإنها بحاجة إلى الاستعداد للتحول عن الدعم المُقدَّم من الصندوق العالمي. وينبغي للخطوات الاستباقية المصممة بما يناسب أركان النظام الصحي، التي تلبي احتياجات الفئات السكانية الرئيسية والضعيفة أن تعزز تدريجيًا القدرات الوطنية والموارد المخصصة لخدمات فيروس العوز المناعي البشري والسل والملاريا.

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