The Global Fund eligibility and transition status of HIV and TB programs in Eastern Europe and Central Asia

Author:

Ivan Varentsov

Article Type:

Article Number: 9

In a follow up to an article in 2018 on the same topic, we provide an overview of the transition status of HIV and TB programs in the Eastern Europe and Central Asia region.

 

Introduction

 

Eastern Europe and Central Asia (EECA) is one of two regions, together with Latin America and the Caribbean, where planning for transitioning from Global Fund support is most advanced. In 2018, we summarized the status of transition planning in the region; this article provides an update on the situation, five years later.

 

Since 2014, the Global Fund has required that all grants contain a component on transition planning. In April 2016, the Board adopted a Sustainability, Transition and Co-Financing (STC) Policy outlining: (a) the principles for engaging with countries on the long-term sustainability of Global Fund–supported programs, as well as (b) a framework for ensuring successful transition from Global Fund financing.

 

Since then the EECA region has made significant steps in transition planning, including transition readiness assessments, broader sustainability planning, development of transition work plans, and implementation of transition grants. Currently, all EECA countries are at a certain stage of transition and within their grant programs are expected to plan for responsible transitioning, especially for those components of highest priority for key and vulnerable  populations (KVPs). However, the sustainability of such components in most EECA countries remains uncertain.

 

This article provides an overview of the transition status of HIV and TB programs in the region in 2023.

 

Global Fund’s Eligibility and STC Policies

 

According to the STC Policy, all countries, regardless of their economic capacity and disease burden, should be planning for sustainability and embedding sustainability considerations within national strategies, programs and grant design and implementation. For countries with high disease burdens and fewer resources, the STC Policy emphasizes the need for domestic investments to build resilient and sustainable systems for health and approach universal health coverage. As countries move along the development continuum – either by increasing economic resources or lowering disease burden – expectations are for greater transition planning, as well as for co-financing targeting specific transition challenges and KVP programming.

 

Country disease components eligibility for Global Fund allocation is defined by the Global Fund’s Eligibility Policy. The eligibility of each component is based on a country’s income classification and disease burden indicator for the relevant disease.

 

The Eligibility Policy allows for up to one allocation of Transition Funding following a country’s change in eligibility (although there can be exceptions). Transition Funding is intended solely to fund activities included in the country’s transition work-plan.

 

To support advanced planning and enhance the predictability of potential transition timelines, the Global Fund produces an annual list of country components that are most likely to transition from Global Fund financing in upcoming years. Such projections are only based on potential changes in income classification, and do not consider reductions expected in disease burden.

 

For the purposes of this overview, all EECA country components were divided into the following categories:

• • Components which have become ineligible, received Transition Funding and are expected to transition in 2024;
  • Components who received transition funding in the 2023–2025 allocation period or were eligible to receive it;
  • Components projected to become ineligible in the 2026-2028 period due to change in income status;
  • Components expected to focus on sustainability and transition preparedness in 2023-2025 (upper- and lower-middle income countries (UMICs/LMICs) with low disease burden);
  • Components which still have time for long-term sustainability and transition planning; and
  • Others.

 

Countries currently implementing transition funding and expected to transition in 2024.

 

Only one country falls within this category:

 

Albania (TB/HIV)

 

Albania’s HIV/TB programs moved to transition in 2015 when Albania was classified as an UMIC in the 2015 Eligibility List, with a ‘Low’ disease burden classification. Albania is still implementing its Transition TB/HIV grant from the 2017-2019 allocation period, which has now been extended until the end of 2024.

 

Components who received an allocation of transition funding in the 2023–2025 allocation period or were eligible to receive it

 

The following UMIC countries became ineligible due to having their HIV and\or TB disease burden classified as ‘Not High’, but were eligible to receive an allocation of transition funding for 2023–2025:

 

Armenia (HIV)

 

In 2018, Armenia was categorized as a UMIC and its HIV disease burden classification was ‘Not High’. As a result, its HIV component received a final allocation of Transition Funding for the 2020-2022 allocation period. In 2022 the Board exceptionally approved an additional period of eligibility for Transition Funding for the 2023-2025 period.

 

However, Armenia’s HIV disease burden changed from “Not High” in 2022 to “High” on the 2023 Eligibility List, resulting in one determination of eligibility. Country components must be eligible for two consecutive eligibility determinations to be classified as eligible. This means that if the Eligibility Policy remains unchanged and nothing changes in Armenia’s eligibility criteria status in 2024, its HIV component could once again become eligible to receive an allocation for the 2026-2028 period

 

Kosovo (HIV, TB)

 

In 2019 Kosovo was newly classified as an UMIC. Kosovo’s HIV/AIDS and TB burden were (and still remain) ‘Not High’; as a result both HIV/TB components received Transition Funding for the 2020-2022 period. However, in 2022 the Board exceptionally approved Kosovo’s additional period of eligibility for Transition Funding for 2023-2025 for both disease components.

 

Romania (TB)

 

A TB grant of up to €10.3 million is being implemented throughout 2018-2023. In 2023 Romania’s TB burden classification changed from “High” to “Not high”, meaning Romania’s TB component is no longer eligible. As Romania has an existing TB grant, it was therefore eligible for Transition Funding in the 2023-2025 allocation period; however, it did not receive any funding.

 

Projected to become ineligible in the 2026-2028 allocation period due to change in income status

 

Applicable to only one EECA country:

 

Kazakhstan (HIV, TB)

 

There have been no changes in Kazakhstan’s HIV/TB components eligibility and its transition status since 2016, when its HIV disease burden classification was changed to high. According to the Global Fund’s 2023 projections of transition by components Kazakhstan is projected to move to high income (HI) status and become ineligible in the 2026-2028 allocation period.

 

Components expected to focus on sustainability and transition preparedness in 2023-2025 (UMICs and LMICs with low disease burden)

 

As countries move along the development continuum and into higher income categories, they are encouraged to put greater focus on preparing for transition. For UMICs regardless of disease burden and/or LMICs with ‘Not High’ disease burdens, the Global Fund encourages a national sustainability and transition planning process which would ideally be informed by a transition readiness assessment or equivalent analysis. It is therefore recommended that such countries should prioritize or build upon existing sustainability and transition planning during the 2023-2025 period. These countries and their relevant disease components fall under this category:

 

Armenia (TB)

 

This component was eligible in 2017 and received an allocation for the 2017-2019 period. It subsequently became ineligible in 2018; however, this did not impact its 2017-2019 allocation.

 

Armenia’s TB disease burden classification changed from ‘Moderate’ in 2018 to ‘High’ in the 2019 Eligibility List and after being eligible for two consecutive eligibility determinations Armenia’s TB component was classified as eligible on the 2020, 2021, 2022 and 2023 Eligibility Lists, becoming eligible and receiving funding for the 2020-2022 and 2023-2025 allocation.

 

Azerbaijan (HIV, TB), Belarus (HIV, TB), Georgia (HIV, TB)

 

There have been no changes in the HIV/TB eligibility of these countries and their transition status since 2016 (Georgia’s income category was changed from UMI in 2019 to Upper-LMI in 2020 and back to UMI in 2021).

 

Moldova (HIV, TB)

 

Moldova’s income category was changed from Lower-LMI in 2019 to Upper-LMI in 2020 and to UMI in 2022.

 

Montenegro (HIV)

 

In 2016, Montenegro’s HIV disease burden classification was changed to “High”, and its HIV component was classified as eligible again in the 2017 Eligibility List after meeting criteria for two consecutive eligibility determinations for the first time since 2009. Montenegro’s HIV component received funds within 2017-2019, 2020-2022 and 2023-2025.

 

Serbia (HIV)

 

Serbia’s HIV disease burden classification was changed to “High” in 2015. Its HIV/AIDS component was classified eligible again in the 2016 Eligibility List after meeting eligibility criteria for two consecutive eligibility determinations and received allocations within the three consecutive funding periods 2017 to 2025.

 

Turkmenistan (TB)

 

Turkmenistan’s TB component moved to transition in 2016 when Turkmenistan was classified as an UMI country and its TB disease burden category changed from ‘High’ in the 2015 Eligibility List to ‘Moderate’ in the 2016 Eligibility List and ‘Low’ in the 2017 Eligibility List. In 2016 Turkmenistan’s TB component was subsequently allocated $4 million in transition funding for 2017–2019. Then Turkmenistan’s TB disease burden classification changed from ‘Low’ in 2017 to ‘Moderate’ in 2018 and ‘High’ in 2019. After meeting eligibility criteria for two consecutive eligibility determinations Turkmenistan’s TB component was classified eligible in the 2020 list. The TB component received allocations within the two allocation periods of 2020-2022 and 2023-2025.

 

Components still with time for long-term sustainability and transition planning (components from lower income countries (LICs) and those LMICs with high disease burden)

 

Although components from LICs (regardless of disease burden) and LMICs with high disease burden are not expected to transition imminently from Global Fund support, they are expected to focus on long-term sustainability planning by supporting the development of robust national health strategies, disease-specific strategic plans and health financing strategies.

 

There are no low-income countries in EECA region. The following LMI countries with high disease burden which fall under this category are Kyrgyzstan (HIV, TB), Tajikistan (HIV, TB), Ukraine (HIV, TB) and Uzbekistan (HIV, TB).

 

There have been no changes in the eligibility of these components and their transition status since 2016.

 

However, the sustainability of Ukraine’s HIV and TB responses is under major threat due to the war imposed by Russia on this country.

 

Others

 

There are three EECA countries which components do not fit the Global Fund’s STC concept and might be considered exceptions to the Eligibility Policy.

 

North Macedonia (HIV)

 

North Macedonia has no active Global Fund grants but is part of the Global Fund EECA multicounty HIV project. Macedonia’s HIV/AIDS disease burden classification changed from ‘Low’ in 2018 to ‘High’ on the 2019 Eligibility List, resulting in its first eligibility determination. After keeping this status for two consecutive eligibility determinations North Macedonia was classified as eligible on the 2020 Eligibility List. But eligibility does not guarantee an allocation and North Macedonia did not receive either a 2020-2022 or 2023-2025 allocation.

 

Romania (HIV)

 

Romania has no active Global Fund HIV grants. Since it has a high HIV disease burden but is not on the Organization for Economic Cooperation and Development (OECD) Development Assistance Committee (DAC) list of overseas development aid (ODA) recipients, Romania may be eligible for an allocation for HIV for non-governmental/civil society organizations (NGOs/CSOs) under Paragraph 9b of the Eligibility Policy if there are demonstrated barriers to providing funding for KVP interventions, as supported by the country’s epidemiology. In 2020 and 2022 the Secretariat’s assessments determined that Romania did not meet Paragraph 9b requirements. Thus it did not receive an allocation for the 2020-2022 allocation period and was also determined to be ineligible for 2023-2025.

 

Russian Federation (HIV)

 

Like Romania, the Russian Federation was not on the OECD DAC list of ODA recipients and could have been eligible for an HIV allocation for NGOs/CSOs if there were demonstrated obstacles for funding KVP interventions.

 

In 2022 the Global Fund Secretariat determined that the Russian Federation indeed met the requirements under the Eligibility Policy’s Paragraph 9b, entitling it to an HIV allocation of $10,010,167.

 

Russia is the only country in the world whose NGOs and CSOs receive funding directly from the Global Fund and not through the Government since the Russian Government is not involved in the implementation, coordination and oversight of the Global Fund HIV grant. This is because the country clearly demonstrates obstructions to providing funding for KVP interventions and therefore it is not expected that such interventions would transition from Global Fund to Government support and be sustained. The Country Coordinating Committee entirely comprises civil society and community representatives. Taking this into account, as well as the country’s current political situation and punitive environment for NGOs, including those working in HIV among KVPs, repressive laws against LGBTQ communities, Government denial of the harm reduction approach to HIV prevention among people who use drugs (PUD), very limited opportunities for advocacy without a risk of backlash and repression, as well as the relatively insignificant amount of Global Fund monies compared to the scale of Russia’s HIV epidemic, no significant impact is likely. Accordingly, it is difficult to expect or even plan any “transition” from Global Fund support to Government funding to sustain the HIV response among KVPs in the near future.

 

The following table summarizes the components in the various categories discussed above.

 

* If Armenia’s HIV disease burden status remains “High” in 2024, its HIV component could become eligible again to receive an allocation starting from 2025

** If Kazakhstan’s income status changes to “High” it will not be eligible for Transition Funding.

 

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*Ivan Varentsov is the Sustainability and Transition Advisor for the Eurasian Harm Reduction Association (EHRA).