Initiating a new era in sustainable results-based AIDS responses (and achieving successful transitions ) Robert Hecht 8 April 2019 UNAIDS Sustainability Workshop Geneva
M ain messages to take away 1. “Sustainability” and “ Transition” are becoming the new watchwords of the AIDS response – for good reason 2. We are beyond the golden moment of donor funding – are countries ready to increasingly take over? 3. We have made huge strides on S&T in recent years – but we need to move faster and get real, about what needs to be done and about what won’t work, too 4. We need to extract and apply the key lessons from our efforts to date – our learning is too slow , e.g., a) Dominant S&T risks = key population programs and domestic financial expansion b) Start transition planning early, but imminent transition focuses the mind (Costa Rica, Algeria) c) National (multisectoral councils and MoH programs) and global players (UNAIDS, Global Fund, and PEPFAR) are not yet aligned – we are stepping on our toes 5. We need to work together urgently a) Better and standardized analytical tools b) Better processes, sequencing, dialogue c) Better data d) Translate analysis into action – a lot of studies but much few less impact 2
For today Review past investments and progress in the HIV 1 response Define sustainability and transition (S&T) in the 2 context of HIV and why it matters Discuss four key cross-cutting problems and 3 point to solutions Provide an overview of the Sustainability Meeting 4 agenda and objectives 3
Over $500 billion dollars has been spent on the HIV response in low- and middle-income countries -- leading to remarkable achievements AIDS response has given largest boost to increased life expectancy across Africa 21.7 million people on ART (2003-2016) New HIV infections down 47% since 1996 Systems strengthening: Enhanced utilization of SRH Improved infection control Task-shifting and health worker training Improved procurement, supply chain, and laboratory services Source: IHME, 2017; Global Burden of Disease database 2016; UNAIDS estimates, https://www.iasociety.org/Web/WebContent/File/ICAP%20Bellagio%20Report%20- %20Leveraging%20HIV%20Scale-up%20to%20Strengthen%20Health%20Systems%20in%20Africa.pdf 4 UNAIDS 2018, PCB slides
…however progress is fragile, and the epidemic is far from being controlled • 1.8 million new infections in 2017 • Incidence has increased in Eastern Europe (+29%) and the Middle East (+12%) since 2010 5
Global progress has been made towards the Fast Track targets, but is still short of 90-90-90 Source: https://www.avert.org/global-hiv-and-aids-statistics 6
Macro economic, sectoral, and political factors will also condition HIV responses and S&T efforts Macroeconomic Sectoral Political LMIC growth rates GGHE/GGE LMIC acceptance of KPs, human rights laws and practice Taxation policy and GGAE/GGHE LMIC priority to health and revenue collection effort HIV Emergent economies UHC policy and effort LMIC commitment to UHC (e.g., China) (e.g., SHI coverage) OECD economic growth OECD attitude toward aid outlook 7
Funding for HIV has been levelling off in recent years and the global response does not have the needed resources 30 Resource Availability by Funding Resource needs for fast-track 2020 target 25 Source (USD Billions) 20 15 10 5 0 2010 2011 2012 2013 2014 2015 2016 2017 Domestic USG GFATM Other donor Fast-track 2020 target 8 https://www.avert.org/professionals/hiv-around-world/global-response/funding
What do we mean by sustainability and transition? Programmatic Structural Financial sustainability Epidemiological sustainability sustainability sustainability Consideration of Political sustainability human rights 1 The global fund strategy 2017-2022 9 Components of sustainability: Oberth & Whiteside, 2016
Sustainability and transition are interlinked The process by which a country, or a country- component, moves towards fully funding and implementing its health programs independent of donor support while continuing to sustain the gains and scaling up programs as appropriate. 1 Transition A program is defined as sustainable when it is able to maintain service coverage at a level that will provide continuing control of a health problem even after the removal of external funding . 1 Sustainability 1 The global fund strategy 2017-2022 10 Components of sustainability: Oberth & Whiteside, 2016
Four overarching challenges related to sustainability and transition of the HIV response that must be urgently recognized and resolved for success Problem Solution S&T responses must be tailored so they are Country needs, capabilities and risks specific and relevant to varying country 1 are different typologies. One size does not fit all Programs for key and vulnerable Implementing social contracting to ensure the populations are heavily donor-funded sustainability of CSOs and their ability to reach 2 and run major risks during S&T key populations Rapidly and dramatically increasing domestic Donor funds are flat or falling but financing and improving efficiency; 3 domestic funding is not increasing fast maintain global solidarity and support to enough country-led programs of sustainability Coordinating key actors and developing better Poor transition coordination and 4 tools at global and country levels – we urgently planning among donors and countries need new rules of engagement and they must is undermining S&T be followed 11
Solution 1. Tailoring S&T responses so they are specific and relevant to varying country typologies. One size does not fit all 12
Challenge 1 Countries vary in their level of domestic financing and type of epidemic, with huge implications for S&T Share of Domestic Concentrated epidemic Generalized epidemic Financing among key populations • Latin America • Eastern Europe and High (>80%) Central Asia • North Africa • Asia Pacific • SA, Namibia, Medium (50-80%) • Middle East and North Botswana Africa • East Africa Low (0-50%) • West/Central Africa UNAIDS, 2018 AVERT, 2019 13
Challenge 1 In these two country groupings, the emphasis of S&T actions are different Predominant Sustainability and Country Type Transition Actions • Substituting for external funding for KP programs 1. Concentrated • Contracting and funding CSOs Epidemic (mostly • Political economy of KP activities • Integrating HIV into health systems MIC) • Developing targeted technical capacity • Mobilizing more domestic resources • Political economy of health and HIV generally 2. Generalized • Increasing efficiency Epidemic (LMIC) • Developing broad national technical and managerial capacity UNAIDS, 2018 AVERT, 2019 14
Challenge 1 Donors differ in the criteria used by donors to assess S&T readiness and risks – we need to unify our methods Transition Readiness SID Categories Assessment Modules Institutional, Health Human Rights, Financing and and Gender Transition Governance, National Health Environment Leadership and System and Service Accountability Service Delivery Delivery, Summary of Procurement, GF Support HRH, and Infrastructure Strategic Investments, Strategic Efficiency, and Epidemiological Information Civil Society Situation and Sustainable Organizations Programmatic Financing Context PEPFAR SID Guidelines; Global Fund Sustainability Tools, Aceso/APMG 2017 15
Solution 2. Implementing social contracting to ensure the sustainability of CSOs and their ability to reach key populations 16
Challenge 2 CSOs are essential to reaching key populations who are often the most marginalized and hard-to-reach, with limited access to HIV Community Adapted Advocates - KP representatives - Support human rights - Tied to communities - Advocate for access to services - Well-equipped to tailor services for KP Enhancers of Testing and Partners in Prevention Treatment Effectiveness - Peer connections - Can find missing cases - Independent - Improve adherence to treatment - Trusted - Reduce loss to follow-up 17
Challenge 2 In most LMICs key population programs through CSOs are financed primarily by PEPFAR and the GF El Salvador Honduras Guatemala 6% 9% PEPFAR 11% 13% 22% GF 20% 69% Country 85% 65% Panama Nicaragua 4% Key populations are at-risk if countries do not own these donor- 25% financed programs 48% 48% following transition 75% 18 Source: COP Central America, PEPFAR (2017)
Challenge 2 The (famous) case of Romania Pre-transition Post-transition 2010 Funding : Funding : • 1% of domestic expenditure • No domestic funding for CSO for HIV prevention services harm reduction programs collapse • Prevention funded by Global Fund and UNODC • Obtaining substitute funding from European countries in 2015 HIV prevalence among PWID : HIV prevalence among PWID : • 1% (2009) • 53% (2013), 29% (2017) Key lessons: • Government commitment to KP and HIV prevention services • Domestic budget for CSOs, HIV prevention and KP • Social contracting mechanisms and plans in place early before transition 19 Donor transitions form HIV programs: What is the impact on vulnerable populations?, 2018
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