This blog was originally published in Health Affairs Blog on December 14, 2018. The original version can be found here.
Many middle-income countries are transitioning away from donor-funded health programs in a range of areas including immunization, maternal and child health, tuberculosis, malaria, and HIV. Unless these donor exits are managed well, they could imperil the sustainability of the remarkable gains that have been achieved over the past two decades in fighting killer infectious diseases and maternal and child health conditions.
Donor exits could particularly jeopardize gains in global HIV control. Countries and donors have spent more than $500 billion on HIV programs in low- and middle-income countries over the past two decades, but the gains from these investments are fragile. When donor funding for HIV programs ends, there is an especially acute risk of HIV re-emerging among “key populations”: vulnerable minority groups such as sex workers, men who have sex with men, people who inject drugs, transgender populations, and prisoners.
Too little attention has been paid to date to the needs of key populations during transition. This is a mistake. Unless departing donors and “graduating” countries address the risks that key populations face, these populations could suffer serious health setbacks, and the larger national achievements in fighting HIV/AIDS could easily be undermined or even reversed.
Key Populations Are At Higher Risk Of HIV Infection
Almost everywhere in the world, key populations have higher rates of HIV infection than the general population, often 10-20 times higher. They face stigma, discrimination, and persecution, which in some countries can be enshrined in local laws and perpetrated even by health professionals. These communities thus require specially-designed and targeted prevention, counseling, and treatment services, often best delivered by peer groups and non-governmental organizations (NGOs).
At the same time, circumstances in these countries make it highly uncertain whether HIV programs for key populations will continue after donors depart. Because key populations are highly marginalized and stigmatized, and because of the political “unpopularity” of helping these groups, programs for key populations tend to be heavily supported by outside donor organizationssuch as the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) and the US President’s Emergency Plan for AIDS Relief (PEPFAR). When these donors leave, it is unclear – in some cases doubtful – whether national governments will pick up the tab for services targeted at vulnerable communities. In addition, many of the most effective programs for key populations are carried out by local NGOs, and governments are often reluctant or legally unable to provide funds through “social contracting” to these NGOs once donor support ends.
What Happens When Donors Leave?
To understand the risks that key populations face as a result of transition, we conducted an in-depth study of HIV donor transitions and key populations. This study was one of the first to examine in depth the risks and challenges of HIV transitions for key populations, looking both backward and into the future. We examined the global literature and data on a set of over 20 middle-income countries that have just transitioned or are on the verge of transitioning from donor aid in the next few years.
We then selected six countries. Three had recently “graduated” from donor assistance for HIV (China, Mexico, Romania) and the other three (Nigeria, Malaysia, and Cambodia) are scheduled to transition soon. We read the published and gray literature on these countries and conducted more than 15 interviews with experts.
We sought to answer three questions:
- What has been the effect of past HIV donor transitions on key populations?
- What were the enabling factors for successful past transitions and what were the factors that contributed to unsuccessful transitions for these populations?
- What challenges are key populations in pre-transition countries likely to face, and what could be done to mitigate these problems based on past experience?
Several important findings emerged on the unique risks and challenges of sustaining, and where needed improving, HIV services for key populations in transitioning countries:
A Precipitous Transition Without Planning Can Have Serious Negative Consequences
This was the case in Romania, where the Global Fund pulled out rapidly as a result of a global policy shift. Special prevention and treatment programs for sex workers, men who have sex with men, and injecting drug users were not picked up by the government, and consequently rates of HIV infection spiked in just one to two years.
Government Ownership Can Smooth Transitions
When government already cares about and owns programs for key populations and dialogue on transition with donors is advanced, the transition and country takeover go more smoothly. This kind of seamless transition occurred in Mexico, where the head of the private foundation implementing programs for key populations with Global Fund support moved to the national Ministry of Health to run the government HIV/AIDS program.
Before Leaving, Donors Must Counteract Weak Political Support For Key Populations
Where political interest and support for key populations are weak, corresponding government budgeting for HIV prevention tends to be very low, often less than 10 percent of total public funding for HIV/AIDS. Before donors depart, they need to encourage the government to expand HIV prevention efforts. Such efforts include those for key populations (e.g., condom promotion, needle and syringe exchange, treatment “as prevention”) as well as those for the general population (e.g., sex education, HIV testing, and keeping the blood banks safe).
Preexisting Mechanisms For Government Social Contracting Can Be Crucial
Where mechanisms for government “social contracting” with local NGOs working with key populations already exist, it is much easier to see that the government takes over from the donors and continues to fund these NGOs. This was the experience in China and Mexico and creates a favorable environment for transition in Malaysia. However, there is still a risk that government funding for programs for key populations will fall following donor exit, with valuable activities conducted by NGOs being under-funded or neglected.
Donors Should Begin Preparing NGOs Well Before They Exit
In high-performing countries, governments that agree to fund NGOs for key populations also set targets and keep the NGOs accountable for results. Even though such NGOs have received training and advice from donor-backed programs, many NGOs still lack the organizational and business skills to operate with government budget support. In the final years of donor support, further efforts should be taken to build the capacity of these NGOs and put them on a strong business footing.
Protecting Services For Key Populations Within Broader Coverage Arrangements
Where the government pays for HIV testing and HIV/AIDS treatment as part of a larger package of services under “national health insurance” or universal health coverage, funding for services for key populations should be protected during transition. Thailand, for example, has largely transitioned from donor aid for HIV and guarantees HIV/AIDS treatment for all, including key populations, as part of its Universal Coverage Scheme.
Where Attitudes Toward Key Populations Are Most Negative, Donors Must Start The Hard Talk Early
In places like Nigeria where key populations face high levels of stigma and discrimination, it may be especially problematic to get the government to pick up financial responsibility for programs for these groups as donors wind down their support. Homophobia and condemnation of sex work and injection drug use are also common in parts of Eastern Europe, Latin America and the Caribbean, and elsewhere as well. In these settings, more liberal sub-national government units such as urban municipalities may be willing to fund services for key populations, but donors and human rights groups are likely to face a tough uphill battle to persuade the government to take over as donors transition out. The “hard talk” – about key populations and the duty of government policies and programs to support them – needs to start early after the donors begin to fund programs, and not in the final months when the donors are about to depart and their leverage and influence are low.
What Needs To Be Done?
Our findings suggest that donors and middle-income countries should together develop a more systematic approach to preparing for, designing, and implementing transition programs for key populations. Many new and effective transition risk assessment tools have been developed recently and need to be applied widely. Starting early with analysis and policy dialogue around transition – especially around the tough issues such as government willingness to pay for services for key populations and to contract with local NGOs – is essential.
Donors should use their remaining funds and influence to engage with local leaders about key populations, not shying away from difficult and sensitive discussions. Innovative approaches, such as having donors match government funding dollar for dollar for programs for key populations, urgently need to be tested.
The full technical report for the new study is available here.
Robert Hecht, Kelly Flanagan, Hanna Huffstetler, and Gavin Yamey
Kelly Flanagan, Hannah Rees, Hanna Huffstetler, Kaci Kennedy McDade, Gavin Yamey,
Diana Gonzalez, and Robert Hecht