Transitioning from multilateral to domestic health financing: The looming challenge

Although good health is the foundation for individuals, communities, and countries to thrive, a 2015 study by the World Health Organization and the World Bank estimated that 400 million people worldwide lack access to at least one of seven essential health services, ranging from pregnancy care to clean water. Despite much progress under the Millennium Development Goals (MDGs), from 2000 to 2015, much more needs to be done to give all people equal access to health. This means removing identifiable barriers, mobilizing resources and creating the policy framework to enable universal health coverage, providing a healthy start for every child, and funding research and care for diseases like TB.

ACTION’s policy paper, Progress in Peril? The Changing Landscape of Global Health Financing, to be launched on the sidelines of the United Nations General Assembly today, examines the global health landscape in the face of imminent shifts in where and how global health funding is available to support low- and middle-income countries. 

With improved health as a major focus of the MDGs, new programs were created to fund improved standards and outcomes in low income countries. Official development assistance increased dramatically, and the Global Fund to Fight AIDS, TB, and Malaria and Gavi, the Vaccine Alliance, emerged out of that period. These funds mobilized billions of dollars to expand access to life-saving care. The increased funding resulted in dramatic health improvements in many countries.

Today, many sources of external financing are beginning to “transition” out of countries they had supported to achieve these health gains. Transition, if not executed well, poses serious risks: that recent gains could stagnate or progress could be reversed. What few have so far fully accounted for is the fact that for many countries—at least 24 by ACTION’s analysis—transition is likely to occur from multiple funders within the same time period. This heightens the risk of a poorly managed transition, a risk that could put people’s lives at stake.

In our policy paper, we looked at the policies of major multilateral funders, bilateral foreign assistance, and national governments’ health financing strategies. We took lessons from three countries at varying stages of transition in order to identify key recommendations for stakeholders across the global health community to effectively address the risks posed by simultaneous transition. 

The first, Côte d’Ivoire, has yet to transition from any mechanisms but anticipates increased co-financing payments and the beginning of the transition process from 2020. The health system’s fragility and low prioritization in the national budget pose additional risks during transition. It will be essential to have a strong, harmonized, and costed plan created by a partnership of all relevant stakeholders to address transition.

The second, Nigeria, currently faces accelerated transition from Gavi, as well as transition from the GPEI, roughly in the next five years. In order to maintain even the current low levels of health coverage, let alone to make new progress, a dramatic increase in health financing at both the federal and state level must occur in the next 5–10 years to replace reduced external support.

Finally, Vietnam is poised to undertake simultaneous transition effectively, having achieved middle-income status, reduced income poverty significantly, and achieved improvements in health outcomes. Nonetheless, limitations in health service delivery and governance could cause problems in the transition process, notably in protecting access for key populations served by donor-financed health programs.

Among a comprehensive list of recommendations, we are urging all stakeholders to review the transition process and prioritize health equity. Strategies to expand health access in the face of simultaneous transitions include greater coordination, comprehensive planning, political accountability, and prioritizing access to health for key populations.

Without such a review and rethinking of transition, an unnecessary crisis could unfold in the next decade—just when the world should be consolidating gains under the SDGs.

Read the full report here.