From emergency to sustainability: shifting objectives in the US Government's HIV response in Tanzania

The Impacts of Donor Transitions on Health Systems in Middle-Income Countries: A Scoping Review

As countries graduate from low-income to middle-income status, many face losses in development assistance for health and must ‘transition’ to greater domestic funding of their health response. If improperly managed, donor transitions in middle-income countries (MICs) could present significant challenges to global health progress. No prior knowledge synthesis has comprehensively surveyed how donor transitions can affect health systems in MICs. We conducted a scoping review using a structured search strategy across five academic databases and 37 global health donor and think tank websites for literature published between January 1990 and October 2018. We used the World Health Organization health system ‘building blocks’ framework to thematically synthesize and structure the analysis. Following independent screening, 89 publications out of 11 236 were included for data extraction and synthesis. Most of this evidence examines transitions related to human immunodeficiency virus/Acquired Immune Deficiency Syndrome (AIDS; n = 45, 50%) and immunization programmes (n = 14, 16%), with a focus on donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (n = 26, 29%) and Gavi, the Vaccine Alliance (n = 15, 17%). Donor transitions are influenced by the actions of both donors and country governments, with impacts on every component of the health system. Successful transition experiences show that leadership, planning, and pre-transition investments in a country’s financial, technical, and logistical capacity are vital to ensuring smooth transition. In the absence of such measures, shortages in financial resources, medical product and supply stock-outs, service disruptions, and shortages in human resources were common, with resulting implications not only for programme continuation, but also for population health. Donor transitions can affect different components of the health system in varying and interconnected ways. More rigorous evaluation of how donor transitions can affect health systems in MICs will create an improved understanding of the risks and opportunities posed by donor exits.

Pepfar 3.0's HIV testing policy in Côte d'Ivoire (2014 to 2018): fragmentation, acceleration and disconnection

INTRODUCTION

HIV Testing and Counselling (HTC) remains a key challenge in achieving control of the HIV epidemic by 2030. In the early 2010s, the President's Emergency Plan for AIDS Relief (Pepfar) adopted targeted HTC strategies for populations and geographical areas most affected by HIV. We examine how Pepfar defined targeted HTC in Côte d'Ivoire, a country with a mixed HIV epidemic, after a decade of expanding HTC services.

METHODS

We explored the evolution of HTC strategies through the Country Operational Plans (COP) of Pepfar during its phase 3.0, from COP 14 to COP 17 (October 2014 to September 2018) in Côte d'Ivoire. We conducted an analysis of the grey literature over the period 2014 to 2018 (Budget & Target Report, Strategic Direction Summary, Sustainability Index and Dashboard Summary, https://data.pepfar.gov). We also conducted a qualitative study in Côte d'Ivoire (2015 to 2018) using in-depth interviews with stakeholders in the AIDS public response: CDC/Pepfar (3), Ministry of Health (3), intermediary NGOs (7); and public meeting observations (14).

RESULTS

Since the COP 14, Pepfar's HIV testing strategies have been characterized by significant variations in terms of numerical, geographical and population targets. While the aim of COP 14 and COP 15 seemed to be the improvement of testing efficacy in general and testing yield in particular, COP 16 and COP 17 prioritized accelerating progress towards the "first 90" (i.e. reducing the proportion of people living with HIV who are unaware of their HIV). A shift was observed in the definition of testing targets, with less focus on the inclusion of programmatic data and feedback from field actors, and greater emphasis on the use of models to estimate and disaggregate the targets by geographical units and sub-populations (even if the availability of data by this disaggregation was limited or uncertain); increasingly leading to gaps between targets and results.

CONCLUSIONS

These trials and tribulations question the real and long-term effectiveness of annually-revised, fragmented strategies, which widen an increasing disparity between the realities of the actors on the ground and the objectives set in Washington.