FIJI’S TB PROGRAM ACHIEVES SUCCESSFUL TRANSITION FROM GLOBAL FUND GRANT TO DOMESTIC FUNDING
Elden ChamberlainArticle Type:
Article Number: 3
More than two years before grant closure, ‘improvement plan’ helped identify processes that would underpin transition
ABSTRACT Transition out of Global Fund support to a wholly domestically-funded TB program in Fiji was made possible by a three-year preparation process, using guidance from the Eurasian Harm Reduction Transition Preparedness Tool. Over 90% of the transition plan has now been implemented, covering eight key areas identified by the Fiji Country Coordinating Mechanism in collaboration with the Fiji Ministry of Health and Maternal Services. The last area still to be addressed is that of the role of the Country Coordinating Mechanism in providing oversight to all communicable disease programs in Fiji after transition.
The Republic of Fiji was the recipient of a Global Fund grant to support Fiji’s national tuberculosis plan from 2010 to 2018. A total of FJD21.3 million ($11.65 million) has been disbursed to the Ministry of Health and Medical Services (MoHMS) as the Principal Recipient (PR) and the National TB Program (NTP), Fiji Red Cross Society, Fiji Nursing Association, Fiji National University, and the World Health Organization, as Sub-Recipients (SRs) for Global Fund grants (see Global Fund Fiji Country Profile for further detail).
Fiji’s health services are delivered through approximately 900 village clinics, three major hospitals and 76 health centers. The country has made good progress in bringing tuberculosis under control through its National Tuberculosis Plan 2015-2020. Currently the country has registered and treated 89% of all TB cases, up from 67% in 2015, and has 100% coverage for prevention programs for children under 5 years of age. These rates are in line with the National TB Plan target of 90% successful treatment by 2020. The latest data can be found in the WHO Fiji TB Fact Sheet 2017.
In 2015, 49% of the national TB program was supported by donor funds, primarily from the Global Fund, with domestic government financing at 51%. However, in 2017 Fiji was no longer eligible for Global Fund support based on the Global Fund’s Eligibility Criteria. The criteria are designed to ensure that available resources are allocated to countries with the highest disease burden and lowest economic capacity. Eligibility is determined by a country’s income classification, as measured by Gross National Income (GNI) per capita (World Bank Atlas Method), and official disease burden categorization. This meant that the Fiji Government would become 100% responsible for the TB program at the end of the current grant and needed to investigate ways to fund the program, either from its own resources or from other donors.
The Fiji Country Coordinating Mechanism (FCCM) and the PR received the formal Grant closure notice in December 2017 but a no-cost extension was negotiated to expend funds not spent as a result of program implementation disruption caused by Cyclone Winston in February 2016. The grant extension meant that the formal closure of the grant happened on 30 September 2018, with remaining cash balances to be remitted to the Global Fund after that date. The Global Fund-supported TB program began its transition to a wholly domestically-supported TB program in October 2018.
The Global Fund encourages countries to plan proactively for transition, including addressing challenges and bottlenecks that may prevent a successful transition from Global Fund financing.
Whilst the Global Fund has no one-size-fits-all formal transition preparedness and implementation guide or model, it has supported the development of tools and guides to provide support to countries undergoing transition. The Eurasian Harm Reduction Network (EHRN) developed the Transition Readiness Assessment Tool in 2016 (its use has been documented in the Montenegro Transition Case Study and the Romania Transition Case Study). This tool has provided a useful basis for understanding the transition process and has underpinned transition planning and process for Fiji.
In February 2016, the FCCM undertook the Global Fund’s Eligibility Performance Assessment (EPA) which is required of all CCMs.The EPA, conducted by an external consultant, assessed the CCM against 4 performance areas identified by the Global Fund as necessary for CCM functioning; an improvement plan based on the results of the assessment is required to support the CCM achieve compliance with the performance areas.
The FCCM improvement plan that was developed by the consultant included consideration of the processes and structures needed to underpin the transition process. This ‘outcome’ was included as the assessment identified that no planning had been done to prepare for the ending of the grant and the potential transition away from Global Fund support. Implementation of the improvement plan began in April 2016. This was the formal beginning of Fiji’s Transition process and the development of the transition plan for Fiji.
Three key focus areas
In developing a transition plan the MoHMS and the FCCM determined that three key focus areas would underpin the transition process: first, the wider health context which would be addressed to ensure that health system strengthening and other gains made possible by Global Fund grants are not lost; second, direct transition of activities currently funded under the grant to domestic or other funding, which would address how activities funded by the Global Fund would be integrated/supported by the MoHMS; and third, transition of the CCM which would explore the potential role for a “CCM-type” body to support and oversee programs post-transition from Global Fund support.
These three key focus areas were further developed into nine thematic areas that each needed to be addressed to ensure successful transition; 1) Legal Framework, 2) Financial Framework, 3) Health Systems Strengthening – Infrastructure including surveys, M&E and Service Delivery, 4) Community Systems Strengthening – Decentralization of primary health care-related activities and Community DOT, 5) Procurement Supply Chain Management, 6) Public Private Mix, 7) HR Capital, 8) Future prospects of the Grant Management Unit, and 9) Transitioning the Fiji Country Coordinating Mechanism (CCM).
Between February and August 2017, the Grant Management Unit of the MoHMS took the lead on developing Fiji’s transition, with support from the FCCM and input from all stakeholders who attended an initial retreat in February 2017.
The transition plan was divided into two main sections: 1, “Background & Current policy/funding environment”, which provides background to the current situation regarding the National TB plan, current targets/gaps, impact of the GF support and donor/funding environment. The second section, “Thematic Areas to be Addressed”, provides details of the 9 thematic areas identified with key issues to be addressed for successful integration.
The transition plan was formally agreed to and signed off by the FCCM and the MoHMS in July 2018.
Eight out of the nine thematic areas defined by the transition plan have been fully completed/ implemented with all aspects of the Global Fund-supported TB program now fully integrated and supported by the national program.
The outstanding thematic area is the transitioning of the FCCM. Several potential roles have been discussed for a CCM-type body to provide oversight and support to communicable disease programs in the country, beyond the Global Fund grant. The FCCM is in discussion with the MoHMS and the Permanent Secretary of Health investigating what type of entity would be the best fit. Potential roles that have been discussed include a body focussed on TB/HIV, a wider communicable disease remit or potentially oversight of all externally funded projects within the MoHMS. It is anticipated these discussions will be concluded in the first quarter of 2019.
Main transition challenges
The main challenge for the FCCM and the MoHMS in developing the transition process has been the lack of formal guidance on how to approach transition. This was because the transition began during the same time as the Global Fund was developing its transition processes at headquarters level. Guidance available to countries from the Secretariat was, at that stage, minimal, leaving the FCCM and the MoHMS to develop a process of their own that tried to meet the overarching goals of the Global Fund’s transition aims as well as the needs of the country.
Coordination was less than ideal during the transition process, with the FCCM and the Ministry never formally agreeing on who was going to lead and coordinate. This was further hampered by a lack of continuity within the MoHMS, due to changes in senior personnel, which meant that agreements made with one senior staff member were not necessarily automatically followed up by their replacement.
Determining a role for the FCCM post-Global Fund has also been challenging. Whilst there is acknowledgement from the MoHMS that there is a role for an oversight-type mechanism for communicable disease programs, issues such the nature of the new mechanism are not yet resolved – for example, whether the FCCM morphs directly into a new organization, or whether it is scrapped and another type of entity is created, have yet to be agreed upon.
The development and implementation of the transition plan necessitated placing the Global Fund-supported TB program within the larger context of the Fiji National Health Strategy and the National TB program, whereas previously it had largely been considered a standalone program. It has also led to a plan that has been fully costed, agreed to by all key stakeholders, and has been 90% implemented.
In reviewing the process, the FCCM identified key lessons learned that others going through transition should keep in mind, primarily that transition planning takes time and cannot be rushed. For Fiji, the transition process took three years, and it would not have been possible to have achieved the designated ‘outcomes’ of the transition plan more quickly. Inputs for the transition process, in Fiji’s case, needed to come from the MoHMS, Ministry of Finance, FCCM, WHO, and others; in other countries, too, coordination will be essential to ensure that everyone involved is on the same page and all working to the same end. The ERHN tool was useful in underpinning the process and provided guidance for its implementation.
The cooperation and good-will that existed between Fiji’s government and civil society ensured that the transition process could be implemented. This did not occur overnight but came about by the building of strong relationships, and the existence of open dialogue and a willingness to work together for the common goal of ensuring that a comprehensive TB program would continue to be implemented post-Global Fund support.