Donor approaches to health aid transitions: Gavi and PEPFAR

Many former low-income countries are developing their economies and becoming capable of self financing their health systems. External donors are responding to this shift in varied ways: some have developed exit strategies based on reaching pre-determined milestones while others have shifted programmatic areas of focus and funding levels to respond to a country’s context specific needs. As countries continue to develop their capacity to become more self-reliant, how will donors respond in turn? Will these donor responses enable countries to sustainably continue to advance? Could such responses, if not properly prepared for, slow or even reverse progress?

To understand and build the knowledge base around this phenomenon, known as transitions from health aid, we are publishing a series on how seven major global health funders are approaching transition. The seven funders in our series are the World Bank; the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund); Gavi, the Vaccine Alliance (Gavi); the United States government—specifically, the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the US Agency for International Development (USAID); the United Kingdom government; and the Japanese government. For each of the seven “donor transition profiles,” we first conducted a desk-based review, which included donor websites, strategy documents, grey literature reports, and academic literature. To ensure our research reflected up to date approaches and thinking, we triangulated our findings from the desk review with findings from a series of key informant interviews with senior experts at these donor agencies. Our latest research in this series focuses on two donors, one bilateral (PEPFAR) and one multilateral (Gavi).

Gavi has an explicit policy outlining a clear path for countries to transition out of Gavi support. This transition pathway is primarily based on a country’s gross national income per capita (GNI p.c.). The goal in using GNI p.c. thresholds is to support countries based on a country’s ability to pay. As this ability to pay increases, Gavi’s support gradually reduces over a specific time period. PEPFAR behaves a bit differently: it does not have an explicit approach to leaving a country and, in fact, PEPFAR has stated that such graduations are not on the table. However, PEPFAR recognizes that countries are becoming increasingly able to pay for their own HIV programs. And PEPFAR itself has moved from supporting an emergency response (reflected in the name of the initiative) to supporting sustainable, long-term programming. These two realities mean that PEPFAR has begun shifting the type and level of support provided to countries as countries progress through the process of achieving, and ultimately sustaining, HIV epidemic control. While departure from any currently supported country is not imminent, says PEPFAR, PEPFAR is taking steps to sustainably shift responsibility to domestic players.

Although these two donors approach transitions in different ways, we discovered a striking point of convergence when speaking to key informants from each respective organization: focusing on financial sustainability alone is insufficient. Both organizations highlighted that building national programmatic responsibility and capacity is in some respects even more important than reaching financing milestones. The critical importance of such responsibility and capacity may be why Gavi is rethinking its current transition policy, which is primarily built around reaching financial milestones and shifting financial responsibility.

Next up in our donor transition series will be a focus on another key U.S. agency, USAID. After that, we will publish transition profiles on the World Bank, and then on the governments of the U.K. and Japan. To close out our series, we will launch a cross-cutting report comparing and contrasting donor approaches to country transitions.

About the Authors:

Kaci Kennedy McDade (tweets @Kennedy_Kaci) is a Policy Associate at the Center for Policy Impact in Global Health, Duke Global Health Institute.

Gavin Yamey (tweets @GYamey) is Director of the Center for Policy Impact in Global Health, Duke Global Health Institute.