The Sustainability, Transition and Co-financing policy follows the Global Fund’s principle of additionality – the GF adds to local resources to fight the three diseases, it does not replace them. It spells out the domestic funding requirements from government in countries where the GF invests. Some conditions apply to all countries where the GF invests. Others are differentiated by disease burden and income categories as per the World Bank categorization (Low-income countries (LIC), Lower middle income (LMIC) and upper middle-income countries (UPIC)). High income countries are not eligible.
Figure 1: Income level, disease burden, focus of application and co-financing
Are there requirements that apply to all countries?
Two requirements apply to all: countries should increase their governments’ health expenditures with time and should increase their investments in HIV, TB and malaria program with time.
What are the requirements for low- income categories?
Low-income countries (the majority in Africa) face no restrictions in where to invest their co-financing, as the Figure A shows. Thus, they can use all their co-financing into building their health systems.
What expenses count towards health system strengthening?
All expenses for health care can count as health system strengthening. Some countries like Uganda have considered government expenditures in running health facilities (utilities, maintenance, personnel) as part of co-financing. Uganda used National Health Accounts.
What are the requirements for lower middle- income categories?
The lower middle-income countries are divided into two groups from the middle point of the category: The lower LMIC and the upper LMIC income countries
The lower LMIC countries must invest 50% of their resources in interventions targeting key and vulnerable populations and at least 50% of their co-financing in disease programs. The upper-middle-income countries have to spend at least 75% on disease programs.
Upper middle-income countries (only four in Africa – Botswana, Gabon, Namibia, and South Africa) focus on preparing for transitions. They should spend at least 50% of the co-financing on key and vulnerable populations.
Is there an incentive to meet those requirements?
Yes. A country that does not meet its co-financing requirement may lose 15% of its allocation.
What is the experience of countries in our constituencies?
Most African countries comply with the requirements. There were a few published cases of countries of countries–Nigeria, —who failed to meet the requirements and lost 15% of the allocation.
Some countries, even low-income countries ones, commit to purchase health commodities like anti-retroviral (ARV) medications for HIV grants or other health intrants for their TB or malaria grants. Some, like Malawi even got loans to meet their co-financing requirements. This is contrary to the letter and the spirit of the policy. Some countries fail to disburse the funds for those medicines timely (if at all), causing stockout of the medication. The case of Guinea was documented both by MSF and Aidspan. Such experiences are not only in the past. For the current cycle, Niger, a low income country, challenging operating environment committed to spending 6.3 million USD to purchase ARVs, medications for TB and malaria. This is a country where less than half of the population have access to a health facility in a radius of 0-5 km. Such commitment of LIC is not an isolated case.
What should our countries do?
We should commit to “more money for health and more health for the money” i.e., invest more money in the health sector but do so more efficiently. For instance, use the co-financing for health systems in low income countries; negotiate with the Global Fund that the co-financing be used in line with the Health Sector Development Plan. So if a country is pursuing a Universal Health Coverage (UHC) for instance, can the co-financing be used to cover persons living with HIV or affected by TB or malaria? Can we use the co-financing to fund primary health facilities in countries that waive user fees for some categories like children under 5 as in Burkina or Togo? Or pay the community health workers? Can we use the Public Financial Management to approve the co-financing like in Ethiopia or National Health Accounts as in Uganda?
In middle-income countries where a percentage of the co-financing has to go towards disease programs, it is important to strengthen the supply-chain and the distribution of commodities along with purchasing those commodities for instance.