The process of transition from donor support to country ownership of an HIV response is a daunting challenge for development partners, organizations and countries. If managed well, it can be an opportunity for countries to strengthen their HIV response and improve health system performance. Across the globe, governments, private-sector health care providers, civil society, communities, and development partners are making the transition to a more sustainable HIV approach. The global health community knows the well documented components of a sustainable HIV response. The President's Emergency Plan for AIDS Relief's (PEPFAR) Sustainability Index Dashboard defines them according to the following themes: Governance, Leadership, and Accountability; National Health System and Service Delivery; Strategic Investments, Efficiency, and Sustainable Financing; and Strategic Information.
We have learned by experience that if some of the ingredients of sustainability are missing or inadequate, then the whole response will suffer. Like a cake that falls flat because you forgot to add the eggs, for example, donor transition can fail without a sufficiently robust and engaged civil society.
But a recipe is more than a list of ingredients. The actual amounts, timing and (baking) techniques are vitally important. Technical assistance (TA) could address all the right ingredients and still be ineffective if some are provided too late in the process. As in the example, if you add eggs too late in the process, then the cake could sink later. Similarly, development partners and local stakeholders should address as soon as possible foundational elements that secure the HIV response into full country ownership, such as financing, governance, and institutionalized engagement of non-government actors. Even civil society organizations (CSOs) that provide quality HIV services will flounder without donor funding in the absence of domestic funding, a supportive policy environment, performance-monitoring and management capacity. What’s critical is managing the process with a long-term time horizon, political and programmatic engagement and communications, and monitoring and evaluation of the transition’s impact. All of this will help hold the shape of the HIV response together and continue to reduce the incidence of new infections and HIV deaths during the process.
Barbados is in the midst of what looks to be a successful transition from PEPFAR support. The country has already graduated from Global Fund support and has been increasing its ownership of the response to HIV over the last 10 years. I have had the (unbelievably) good fortune of working on PEPFAR-funded programs in Barbados and in nine other Caribbean countries during their transition processes. I marvel at the bumpy but doggedly determined process by which Barbados and its development partners have strengthened the country’s HIV response while increasing country ownership with strengthened health financing, multi-sectoral capacity building and engagement, and collaborative stewardship. The TA ingredients came together at roughly the right time and in the right measure to:
- Strengthen CSO capacity
- Build private sector engagement and contracting capacity
- Emphasize a health financing approach
- Coordinate development assistance
- Promote regional cross-learning and shared resources
- Support internal champions in the Government of Barbados
- Draft a sustainability strategy that reflects a health systems approach
Drawing from the lessons of countries in the Caribbean, here are seven ways that development partners and country stakeholders can ensure this happens:
- Develop a clearly communicated long-term transition strategy, with political signaling of the transition by international and national parties and a plan for gradual, planned withdrawal.
- Stakeholders and development partners need to coordinate, collaborate and be strategic, avoiding duplication. Country stakeholders should be engaged in this process.
- Take a systems approach as early as possible in the transition process. The HIV response needs to be integrated into a wider, well-functioning system to be sustainable.
- Build capacity for institutionalized multi-sectoral engagement. CSOs and the private sector must have a sustainable role within the broader system.
- Develop country strategies to sustain the HIV response beyond donor support that are realistic with successful transition as one objective.
- Strengthen governance to ensure inclusivity and access. We need a clear-eyed approach to this crucial issue. Development partner-established mechanisms rarely survive. What will be the new or adapted governance structure?
- Implement domestic resource mobilization strategies. Start with data, build capacity for collecting it, obtain adequate funding, and allocate it effectively and efficiently.
Transitioning from donor support is not as easy as baking a cake. Innumerable factors impact whether a transition process succeeds. Development partners can mitigate risks with well-designed and delivered TA: the right ingredients, in the right amount, at the right time, put together and delivered with care.