In 2015, the Global Fund commissioned the development of the Transition Preparedness Assessment (TPA) Framework. The tool assesses the readiness of various countries to carry out the transition of their HIV, TB and malaria programs from the Global Fund’s support to domestic funding. “The road to sustainability: transition preparedness assessment framework” has been developed by the Curatio International Foundation (CIF). The first article about this tool was published by GFO in February 2016, and can be found here.
The concept of the TPA framework
This framework relies on the principle that HIV, TB and Malaria programs are part of a complex health system, and takes into consideration most internal and external factors influencing disease programs in the country in question. These factors are:
- External - political and economic situations;
- Policy and legal framework;
- State budget allocations for health, both-overall and disease-specific;
- State commitments;
- Governance and stewardship;
- Program management capacity;
- Health information and M&E systems;
- Service provision;
- Prevention services;
- Treatment protocols;
- Prevention services;
- Procurement system’s capacity;
- CSO involvement in program implementation and government willingness and ability to contract CSOs for provision of prevention services.
Such a comprehensive approach allows users not only to capture the bigger picture of the transition process, but also to see how closely interlinked are the degree of preparedness to transition and programmatic sustainability.
The structure of the framework emphasizes that a country’s preparedness to transition does not depend only on financial commitments made by the state. Although the availability of funding is a crucial factor, sustainability of programs mainly depends on the overall functionality of the health system.
Actually, the tool helps not only in facilitating the assessment of each country’s situation, but also in guiding the countries through the process of transition planning, until sustainable environments for the management of HIV, TB and malaria epidemics are finally created. Dr. Ketevan Chkhatarashvili, President of CIF, explains: “This tool is not only for the process of assessment; it provides much more support for each national country teams, as they conduct their transition planning. The framework helps collect relevant information by listing possible sources and document types. It also helps identify weaknesses and gaps of the health system. It even stimulates thinking about possible solutions as well.” Although not a budgeting tool per se, the framework substantially assists the assessment of various funding contexts by making it easier to answer questions such as ‘What is the money needed for?’ ‘How much money is actually required?’ ‘How much was spent earlier on, and on what? ‘What changes should be made in allocations for the future?’
Rolling Out Process
Initially the tool was tested in four countries of the Eastern Europe and Central Asia region (EECA): Belarus, Bulgaria, Georgia and Ukraine. As the trial application of the first version proved so successful, the Global Fund decided to use an assessment methodology in other regions as well. The GF and UNAIDS are two funding partners financing the pilot initiative implemented by CIF to assess the countries across different regions. Up to date the countries assessed by TPA framework are: Armenia, Moldova, Uzbekistan and Kyrgyzstan (EECA), Jamaica (Latin America and Caribbean), Philippines (Asia Pacific) and Morocco (Middle East and North Africa MENA). CIF has adapted the tool to various contextual factors in other regions, which means that the second version, currently under final revision, has the capacity to assess all three diseases in the context of most Global Fund regions.
The tool gives flexibility to those wishing to organize an assessment process. CIF has performed assessments in seven countries; their consultancy assignment also includes development of recommendations and support in developing a transition plan. There are four cases when CIF has provided intensive training to preliminarily established country groups, which have performed an assessment independently with backstopping support provided by CIF team. Depending on the need, CIF provides guidance in developing the recommendations and transition planning as well. Decisions on how to assess each country depend on the locally existing analytical capacity, which is a matter considered by the donors in consultation with local representatives.
The development of a transition plan is just the start
“The most important thing for national stakeholders to understand is that transition planning is a continuous process, and it cannot end when the transition plan is developed. The development of the transition plan is only a starting point for moving towards sustainability”- added Dr. Chkhatarashvili.
Although the content of the three documents, the National Strategic Plans, the concept note and the transition plan may overlap, the TPA findings can help develop any of them. It is very important to understand the complexity and dynamics of the pathway towards achieving programmatic sustainability. In this process, clear communication from the Global Fund is needed to help countries manage the transition planning and their expectations.
Similar findings across the regions: what can other countries learn from this?
The transition preparedness assessment processes led by CIF have revealed a number of findings, which are substantially analogous across the various countries and regions. Therefore, other countries, even those that are not yet close to transitioning, can identify areas of concern, and decide what they can do now for the sustainable future of their programs.
In most countries, the first obstacle to a successful transition is the legal environment. Criminalization of drugs use, sexual work or homosexual contacts can impede provision of prevention services among key affected populations (KAPs), thus significantly diminishing the ability of the country to manage epidemics. Georgia is an illustrative case of the restrictive drug policy, but paradoxically the government has been contributing to opioid substitution therapy (OST) program financially since 2005, implying a tacit acknowledgement of the public health nature of drug use problem.
Another common challenge is that state agencies often cannot legally recruit or fund NGOs, who often deliver prevention services to KAPs within the Global Fund programs. Thus, without change in laws and regulations, after taking over from the Global Fund, countries cannot legally maintain services provided by donor funded NGOs. In other cases, countries have a legal framework in place and can formally sub-contract NGOs, but lack appropriate capacity to manage and administer tendering process; thus, states are unable to control the quality and efficiency of the services purchased from NGOs. Another aspect relates to the administrative procedures that discourage NGOs to participate in tenders, thus reducing the offer of services. For example, in Georgia, participation in tenders requires bank guarantee letter of a deposit of 1-2% of the announced program’s budget that most local service provider NGOs cannot obtain; in some countries, the procedure to regulate accreditation and licensing of medical services is very rigid and complicated.
The assessment showed that most countries’ health budgets do not provide the detailed information required to evaluate effectiveness of financial allocations. Also, the epidemiological data gathered by many countries is debatable as they originate from behavioral surveillance studies with questionable rigor in methodology.
When Aidspan asked Dr. Ketevan Chkhatarashvili to summarize the findings and observations and suggest solutions, she explained that many common issues revealed by the assessments are at health system level and unlikely to be resolved during the transition period. For example, the inappropriate capacity and availability of the human resources, which affects negatively the quality of services, also promotes stigma and discrimination against the patients who are KAPs. “It is recommended to address the health system level problems on the regional level. The countries which still receive donor funding should prioritize system level issues and resolve them long before they are qualified for the transition”- added Dr. Chkhatarashvili.