Planning for how programs will be sustained after The Global Fund (or any other donor) has withdrawn from a country – or is anticipated to withdraw, sooner or later – must take into account more than just where the money will come from.
In a paper published in the African Journal of AIDS Research in January, Gemma Oberth and Alan Whiteside argue that financial considerations should be just one of six inter-related tenets of sustainability. The other five are epidemiological sustainability, political sustainability, structural sustainability, programmatic sustainability and considerations related to human rights.
The authors argue that stable or even increasing investments in HIV does not necessarily mean sustainable programs. “For instance, Malawi and Zambia have consistently achieved the Abuja target of allocating 15% of public expenditure to health, which is a measure of financial sustainability. ... However, key populations programs in these two countries cannot be said to be sustainable. Men who have sex with men, and sex workers, are criminalized by the government and struggle to access services.”
Oberth and Whiteside believe that epidemiological sustainability must consider the trends and outlook for HIV. They suggest that a possible measure of epidemiological sustainability is when the number of people on treatment is greater than the number of new infections.
Concerning political sustainability, the authors ask, “Will AIDS remain on the policy agenda? Is the legal and policy environment conducive for an effective response?” Without continued political leadership, they argue, the most promising programs will not be sustainable.
Oberth and Whiteside state that a sustainable response to HIV requires looking at structural barriers to access, such as gender-based violence, poverty and inequality. Further, they argue, “structural sustainability is needed in order to ensure that gains are not fragile, as factors such as gender-based violence and poverty could spark a resurgence in infection rates even after epidemics appear to be contained.”
With respect to programmatic sustainability, the authors state that sustainability necessitates a programmatic transition from an emergency response to a long-term main-streamed approach. “This raises questions about which programs should remain, which ones should go, and which ones should evolve,” they said.
The authors pose the following question: “How will the right to health be protected for populations who might be excluded from decision-making based on the five preceding factors?” They cite concerns about reaching key populations, such as men who have sex with men, sex workers and drug users, in contexts where the government would otherwise not provide services. The authors state that it will be difficult for funders to promote human rights while also encouraging country ownership in places where certain populations are criminalized.
Oberth and Whiteside argue that the human rights tenet must be considered an important factor for true sustainability. “It may also be necessary for certain key population interventions to continue to receive external investment, even after a country has transitioned away from donor support,” they said.
Assessing sustainability efforts
The authors state that assessing sustainability in practice is difficult because it is often a retrospective exercise. They said that based on an analysis of three noteworthy examples of attempts to achieve sustainability – PEPFAR in South Africa, the Global Fund in Eastern Europe, and the Bill and Melinda Gates Foundation in India (the Avahan Project) – “it is clear that transition had happened in very different ways and with varying degrees of success.”
The authors discuss each of these transitions and state that the Avahan Project was regarded as the most successful. It involved a handover from the Foundation to the Government of India over a five-year period. When the project was established, it had already been decided that it would eventually be handed over.
Regarding Global Fund transitions in the EECA region, Oberth and Whiteside note that the Fund has transitioned out of HIV programs in Romania, Bosnia and Herzegovina, Macedonia, Montenegro, and Serbia; and that Moldova is currently transitioning, set to be cut off from funding in 2017.
The authors state that the Serbia experience reveals a mixed bag of programmatic sustainability. Opioid substitution programs survived largely intact, but the government has not yet stepped in to fill the gap in needle exchange programs where The Global Fund had supported access to safe injecting equipment for more than 4,000 clients in four cities.
Romania is cited by Oberth and Whiteside as an example of poor epidemiological sustainability. A study by the Open Societies Foundations in 2014 found that there has been a spike in HIV infections among people who use drugs since the Global Fund departed in 2010. In 2013, about 30% of new HIV cases were linked to injection drug use compared with 3% in 2010. Another study found that a specific HIV outbreak among drug users in Romania in 2011 was directly linked to a significant decline in harm reduction services once Global Fund investments stopped. Finally, Oberth and Whiteside cite an article that asserted that Romania is now home to a growing epidemic, indicating that human rights and political will are not high on the agenda.
In their concluding section, Oberth and Whiteside argue that the six tenets – financial, epidemiological, political, programmatic, structural and human rights – should be regarded as prerequisites for donor transitions and domestic allocations. The authors state that the tenets should also be measured in a continuing manner, regardless of country readiness to move to a fully domestic response. “Importantly,” they said, “the human rights tenet means that key populations in many settings should continue to receive external money for programs, even in countries that have transitioned from donor funding.”
Gemma Oberth is an independent consultant and visiting academic at the Centre for Social Science Research, University of Cape Town, South Africa. She is also a correspondent for GFO. Alan Whiteside is a CIGI Chair in Global Health Policy at the Balsillie School of International Affairs, Waterloo, Canada, and is affiliated with the University of KwaZulu-Natal, South Africa. He is also on the Aidspan Board of Directors. If you would like a copy of the full journal article, please contact the corresponding author, Gemma Oberth, at email@example.com.