Transitioning financial responsibility for health programs from external donors to developing countries: Key issues and recommendations for policy and research

摘要

In this paper we explain why the transition of financing responsibility for health programs from external donors to domestic governments is picking up momentum; highlight the main challenges that countries and donors face in achieving smooth transitions that preserve health gains; point to the key strategies and tools that should be used in assessing, preparing, designing, and monitoring financial transitions; and finish by outlining a recommended agenda for priority research in this area. We argue that the drivers of transition include health program maturity, economic growth in aid-receiving countries, and slowing growth in levels of international donor assistance for health. We identify several factors that make successful transition especially challenging, such as establishing expectations among all key parties about levels of funding that are reasonable and fair, aligning local and international priorities, mobilizing adequate and sustained domestic funding, and improving efficiency of service delivery. We discuss several important tools available to address these challenges and improve the planning and implementation of financial transition, including robust resource tracking, policy modeling and financial forecasting, and analysis of the sustainability of increased domestic financial commitments. We conclude by highlighting key recommended areas for additional research and stakeholder engagement and avenues to pursue in these areas. THE GROWING IMPORTANCE OF FINANCIAL TRANSITIONS IN DEVELOPING COUNTRIES International support for health programs in the developing low- and middle-income countries has grown dramatically since the early 2000s, even though it has started to level off during the current decade. Philanthropic organizations such as the Bill and Melinda Gates Foundation (BMGF), bilateral programs like the US President’s Emergency Program for AIDS Relief (PEPFAR), and global health partnerships such as Gavi and the Global Fund to Fight AIDS, TB, and Malaria have become major players in the financing of disease control programs and health system strengthening. Since 2000, development assistance for health (DAH) has grown from about US$ 10 billion per year to over US$ 30 billion [ 1 ], reaching a cumulative total over US$ 350 billion. Over US$ 109 billion has gone to HIV programs [ 2 ], with US$ 24 billion invested in vaccination [ 3 ]. While these efforts have had a measure of success in achieving their stated mandates [ 4 , 5 ] their long-run sustainability and effectiveness are not guaranteed. The goal underlying most DAH is not to function as an emergency “band aid” or to operate as currently structured in perpetuity. Rather, it is to foster the widespread proliferation of effective scaled-up programs, integrated responsibly into functioning health systems which are owned, operated, and funded locally. Now, a decade and a half since the acceleration of DAH growth, we are seeing a first wave of programmatic transition with attention increasingly focused on shifting the financial burden of health programs from external donors to local stakeholders. While this trend can be viewed as consistent with long-run goals of development programs, it is not without risks. THE MAIN DRIVERS BEHIND COUNTRY TRANSITIONS Broadly, the factors contributing to this momentum toward financial transition can be grouped into three categories: Photo: By Medici con l’Africa Cuamm (Beira, Mozambico, World AIDS Day 2013 auf flickr) [CC BY-SA 2.0 ( https://creativecommons.org/licenses/by-sa/2.0 )], via Wikimedia Commons. First, some donor-supported health programs have met their initial goals for scaling-up and have matured into stable programs that may be ready for transitioning. In these circumstances, donors are increasingly eager to hand over these programs to reduce their long-term liabilities [ 6 ], as well as to concentrate aid in settings that most need it. BMGF’s Avahan HIV prevention program in India [ 7 ], Global Fund-backed AIDS treatment in Eastern Europe[ 8 ], Gavi’s support to introduction and widespread coverage of pentavalent, pneumococcal, and rotavirus vaccines, and USAID-assisted family planning programs in Latin America are some examples [ 9 ]. Second, most countries that have been recipients of health aid have experienced considerable economic growth and are losing eligibility for aid, or are perceived to be increasingly capable of financing health programs themselves [ 10 ]. For example, the 72 countries eligible for Gavi phase II from 2007 to 2010 achieved 50% higher GDP per capita by 2014. As a result, 21 of these countries have already transitioned or are moving toward it, with more to follow. Third, levels of donor assistance for health alone are unlikely to increase at rates needed to meet ambitious new targets as encapsulated in the Sustainable Development Goals for 2030. The growth in health aid temporarily plateaued after the global economic crisis of 2008. Despite rebounding in recent year