What We Talk About When We Talk About Transitioning From Global Health Aid


What We Talk About When We Talk About Transitioning From Global Health Aid

The number of low-income countries has roughly halved in the past two decades, from 63 in 2000 to 29 in 2019, according to the World Bank. With such economic growth, many countries lose their eligibility for health aid from multilateral and bilateral donors. This phenomenon is often called “transition” or “graduation” from aid. However, donors use a wide variety of terms to describe this situation, each of which may mean different things to different donors. This imprecise and sometimes conflicting terminology can make it difficult to define the phenomenon and study it empirically, and it can impede countries in their planning process.

Transition, when done properly, has the potential to set countries up for prolonged success. But without appropriate guidance or planning, transition can lead to reversals in health gains, leaving citizens in transitioning countries worse off than they had been when the aid was in place. The absence of a clear understanding of transition presents an obstacle to achieving some of the principles of aid effectiveness, such as ensuring predictable, sustainable financing. When countries are left in the dark on the ways in which aid might change, and the schedule and timing of donor exits, it is hard for them to plan for the future. They need to be able to predict what support they will have, over what time frame, to know how best to prepare for a successful transition from aid.

We recently analyzed how seven major health donors describe the phenomenon of donor exits. This analysis was conducted as part of a broader project called “Driving health progress during disease, demographic, domestic finance, and donor transitions,” funded by the Bill & Melinda Gates Foundation. The project is examining the interplay of epidemiological, demographic, and health financing transitions in six middle-income countries (MICs) that are at different stages in their transition: Ghana, India, Kenya, Myanmar, Nigeria, and Sri Lanka. The seven donors that we examined provide most of the total health aid to these six MICs. These donors are the International Development Association (IDA); the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund); Gavi, the Vaccine Alliance (Gavi); the President’s Emergency Plan for AIDS Relief (PEPFAR), the US Agency for International Development (USAID); the UK Department for International Development (DFID, now part of the Foreign, Commonwealth and Development Office), and the Japan International Cooperation Agency (JICA). To understand more about how these donors describe transitions, we first conducted a desk-based review that included donor websites, strategy documents, grey literature, and academic literature. We then triangulated our findings from the desk review with findings from a series of semi-structured key informant interviews with personnel at each of the donor agencies.

The Variations In Terminology

Our analysis found that there is no consensus on the terminology used to describe the transition process. While several donors have clearly defined the terms that they use, others are reluctant to even use the word “transition,” believing it to be too sensitive or political because of the implication that the donor may be abandoning its partner countries. Exhibit 1 below shows the terminology donors themselves explicitly use to describe this phenomenon in their published policy documentation. These terms include transition, graduation, phase-out, self-reliance, exit, and country-ownership. In exhibit 1, we give an example of how selected donors use each of these terms (our working paper gives further examples).

Exhibit 1: Examples of terminology used to describe the transition process

Source: McDade KK, Schäferhoff M, Ogbuoji O, Bharali I, Dixit S, Mao W, et al. Transitioning away from donor funding for health: a cross cutting examination of donor approaches to transition. Durham (NC): Center for Policy Impact in Global Health; 2020 Apr. (Duke Global Working Paper Series No. 21).

Transition

The Global Fund uses this term in its formal transition policy, which outlines when a country should transition from the Fund’s support for particular “disease components” (that is, HIV, tuberculosis, or malaria—the Fund’s three focus diseases). The policy defines transition as “the mechanism by which a country, or a country disease component, moves towards fully funding and implementing its health programs independent of Global Fund support, while continuing to sustain gains and scaling up as appropriate.” 

Graduation

The JICA uses the term graduation to refer to countries losing their eligibility to receive official development assistance from the Organization for Economic Co-Operation and Development (OECD) Development Assistance Committee (DAC) donors—that is, countries “graduate” from JICA assistance when they have been removed from the OECD DAC list of eligible recipients. However, even these countries may be granted exempted status by Japan so that technical cooperation can continue.

Phase-Out

USAID’s Global Health Bureau uses this term for when its support is reduced over a finite period, “often as a consequence of resource constraints, instability, and economic or political considerations (i.e., a circumstance presented to a country partner).” Although phase-outs are still planned and sometimes guided by a similar rationale as that for USAID graduation (for example, a mission achieves its goals), there is not necessarily a comprehensive strategy governing the process.

Self-Reliance

USAID uses the term “self-reliance” in its Journey to Self-Reliance roadmap for countries (it also describes self-reliance as “ending the need for foreign assistance”). USAID does not consider self-reliance to be synonymous with donor exit; instead, it argues that self-reliance encourages both a change in the way USAID programs operate and a shift in the relationship that USAID has with the host country.

Exit

Prior to its merger with the Foreign Commonwealth Office, the DFID used “exit” to refer to the phasing out of its bilateral aid relationship with a country. An analysis by the Independent Commission for Aid Impact found that the DFID exited countries based on a variety of factors, including the country reaching middle-income status, the country reaching a particular gross national income (GNI) per capita, a shift in UK government priorities, or after determining that other donors are better placed to assist.

Country Ownership

While PEPFAR does not have clear and explicit terminology to describe transition, its most recent strategy (called PEPFAR 3.0) outlined a “Sustainability Action Agenda,” calling for more country ownership over health financing, management, and implementation.

Three Sources Of Confusion

When we look at the varying ways that donors define transition, we see three particular areas of imprecision and potential confusion. 

1.    Is Transition A Result Of A Change In A Recipient’s Or A Donor’s Circumstance?

Some donors, such as the Global Fund and Gavi, use explicit criteria to determine who is or is not eligible for their support. Criteria include a country’s GNI per capita, achievement of a certain level of health service coverage, disease burden, or a combination of these factors. A country’s progress (according to donor-assessed criteria) may make it ineligible for further support. Conversely, a donor itself may go through a change in policy, funding, or priorities that causes it to reevaluate its portfolio (for example, USAID and the DFID have undergone such reevaluations). In this latter scenario, although countries themselves may have not changed, the criteria by which the donor measures eligibility does.

While both of these scenarios ultimately lead to reduced or eliminated donor support, the method that a donor uses for transitioning countries away from the donor’s support can vary greatly. For example, a country knows it will enter Gavi’s accelerated transition phase once it reaches a certain GNI per capita threshold, and then it will (typically) have five years to transition itself to become fully self-financing. However, when a donor changes its priorities and sets thresholds for support eligibility, funding can rapidly decline with little time for preparation. For example, USAID has historically used two different terms to describe its reduced funding. The first term is graduation, which USAID uses to refer to a planned, gradual shift, during which countries have ample time to prepare for the funding decline. The second is phase-out, which USAID uses to mean reducing or removing funds due to abrupt policy shifts that are not necessarily guided by a comprehensive exit strategy. While both scenarios result in reduced or eliminated funding from a donor to a country, a planned, gradual shift in resources (graduation) versus a more abrupt termination of an aid program (phase-out) should not be viewed as the same phenomenon. The former enables a transition that at least in its intention aims to enable sustainable self-reliance while the latter is unlikely to enable a successful shift on a short timeline with ad-hoc planning measures. The two scenarios are apples and oranges.

2.    Does Transition Refer Primarily To Changes In Financing, Programming, Or Aid Instruments?

When we look at the way that different donors use different terms, we see that some may be using transition in a way that goes beyond financing to also reference programmatic shifts or aid instruments. For example, a donor such as PEPFAR may continue to provide funds to a country, but those funds may be for technical assistance rather than for specific drugs or interventions. Other donors, such as the JICA, may continue to support a country at the same total financial volume but shift from primarily grant-based support to concessional loans.

Although much of the transition discourse focuses on financing levels, a reduction in funding is not inherently a negative situation. The main concern with funding declines is whether or not a country is able to maintain programming despite external funding reductions. A country could maintain a program without fully replacing donor funds dollar -for dollar, say, if there were inefficiencies in the way donor-funded programs were run and countries found more efficient ways to deliver the same goods or services at a lower cost.

While reductions in funding levels can point to potential health financing vulnerabilities in a time of transition, focusing on financing alone may lead to missed areas of vulnerability, such as technical capacity or programmatic sustainability. If we look at funding level and not funding type, we may miss a shift in the way funds are provided and what accountability a country has for repayment. Transition should address all of these components. Analyses and planning should be sure to avoid overemphasis on funding alone, simply due to data availability.

3.    Is Transition A Process, Phase, Or Discrete Event?

Donors use various terms to refer to changes in their relationships with recipient countries. Some, such as Gavi and the IDA, view the changes that take place as a process or a phase that a country goes through before support ends, although the timeline for these varies greatly. Other donors, such as USAID, view transition as an event that happens based on changes in circumstances (for example, a change in donor priorities). Some donors (for example, Gavi) have specific names for the time period leading up to a change (for example, phase down or accelerated transition) whereas others do not explicitly refer to a phase at all. There is also varied use of planning and assessment tools to help determine whether or not a country is “ready” to transition, and variation in how the results of such assessments are used in transition decision making.

The term transition implies that there is a shift from the status quo to something different. Transition should be a process or a phase that enables ample preparation for a country to become self-reliant. While the donor alone cannot force a country to prepare, the donor can support best practices for transition success through more explicit articulation of policies, clearer planning and guidance measures, and ways for incentivizing gradual progress. Without sufficient planning, monitoring and evaluation, and explicit communication, the principles of the aid effectiveness agenda are unlikely to be achieved in transition countries. Without sustainable programs, how can donors claim to have had an impact if their departure leads to health reversals? Reversals in health progress would mean that donor aid did not help promote self-reliance, but dependence. 

Why This Confusion Matters And How It Could Be Addressed

Overall, there is no standardized definition of what constitutes a transition out of donor support for health. This variation is matched by other major differences among donors in how they view and approach transition, three of such issues are mentioned above. Greater definitional clarity and explicit transition approaches are needed if donors are to uphold their commitments to the aid effectiveness agenda. Without clarity in approaches, modalities, and timing, it is difficult for countries to adequately prepare for and be partners in the transition process. Predictable financing, and therefore, predictable transitions from financing, are a critical foundation for successful transition from aid.

Authors’ Note

The authors’ research on transition is funded by a grant from the Bill & Melinda Gates Foundation.


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