Supporting local ownership of transition processes: a key pathway to sustaining the HIV response

Abstract

Globally, an increasing number of countries have made progress towards HIV epidemic control, yet decreasing donor funding and insufficient domestic investments threaten these strides. Within this context, the global community is interested in how to successfully transition responsibility for HIV services from donor-funded programmes to local ownership within the broader healthcare system.

This analysis explores how to centre local leadership in transition processes to ensure long-term sustainability of HIV programmes, including moving from external to domestic financing. Existing frameworks show broad consensus on the core elements required to examine readiness and support transition processes; however, many of these frameworks do not address how to ensure that transitions are locally owned. An examination of HIV programmes in Vietnam and Zambia, supported by previous evidence, presented four specific lessons on promoting local ownership and local leadership of transition processes. First, sustainable transitions rely on strong locally led health systems and health system functions. Second, the prioritisation of HIV service and system integration must be locally led to ensure harmonisation with national health sector reforms and priorities. Third, capacity strengthening and consistent engagement with civil society, especially during decision-making processes, can strengthen the sustainability of transition efforts. Finally, decentralising planning and integration processes to regional platforms and actively involving subnational actors is essential in contexts with decentralised health systems. The global community can embrace these lessons to support locally led transitions and improve sustainable HIV services in the long term.

Summary box.

• As donor funding for HIV programmes decreases, significant attention is being paid to transitioning HIV services to local country ownership to ensure sustainability of the global HIV response.

• Past frameworks highlight essential steps for assessing readiness and successfully transitioning services yet provide little evidence concerning the extent these transition efforts have been locally led.

• Governments and donors must prioritise strengthening health system functions as they are the backbone of successful transitions and ensure the long-term sustainability of HIV programmes.

• Aligning transition efforts with local health sector priorities, including fostering political buy-in and engaging multisectoral actors, is essential to ensure that transitions can be locally owned and sustainable.

• Capacity strengthening and consistent engagement with local actors, especially during decision-making processes, can buttress the sustainability of transition processes.

• Decentralising planning and integration processes to regional platforms and actively involving subnational actors is essential in contexts with decentralised health systems.

Sustainability planning in the global HIV response

Over the past several decades, the global HIV/AIDS response, bolstered considerably through bilateral and multilateral international aid, has achieved significant progress towards ending the HIV epidemic.¹ In addition to expanding access to prevention tools and offering immediate care and treatment for people living with HIV (PLHIV), investments have strengthened health systems more broadly in their ability to detect and fight new threats, offer essential primary care and support better health outcomes beyond HIV.²

Despite this progress, funding for HIV programming through essential donors, such as the US president’s Emergency Plan for AIDS Relief (PEPFAR), has remained flat over the past decade and is under political pressure that indicates a severe funding reduction quicker than anticipated.^{3 4} Within a global context of inflation, the lingering effects of COVID-19 and competing priorities, the level of future donor commitments is uncertain and raises questions about how gains made thus far will be sustained. More countries will need to transition from primarily donor-supported HIV services to country-owned, country-run and country-financed services at a faster pace than planned. Thus, the conversation turns to the mechanics of smoothly transitioning from internationally funded and administered HIV programmes to locally implemented ones.

Having local ownership of transition processes is imperative to ensure that the shifts are accepted and appropriate for local actors, rather than simply reflecting donor preferences. It is not enough for local actors to be engaged in transition processes; rather, they should lead the process planning, implementation and monitoring with donor support. These elements are essential for effective integration of HIV services into the broader health system and for ensuring sustainability.⁵ The urgent question becomes: what strategies can ensure that the design, planning, execution and monitoring of transitions are locally led and locally owned?

Positioning government and local actors to lead the management and execution of health system and HIV programme functions now and in the future is a high priority for both donors and countries, not only due to uncertain funding, but also because locally led systems are more sustainable and resilient.⁶ Accordingly, Joint United Nations Programme on HIV/AIDS, PEPFAR and the Global Fund have launched a new approach to guide country planning for the long-term sustainability and transition of the HIV response.^{7 8} For example, PEPFAR has included ‘Sustaining the Response’ as one of the core pillars in their Strategic Direction to end the HIV/AIDS pandemic by 2030.⁸

The team reviewed existing frameworks and programmatic examples from two countries in different stages of transition—Zambia and Vietnam—to understand what strategies support local leadership during transitions. From these, we build on a core groundwork for transition to provide four principles to boost local ownership of transition processes: supporting strong locally led health system functions; alignment of transition processes with local health sector priorities and health systems; capacity strengthening and consistent engagement with civil society and decentralisation of planning and integration processes where appropriate.

Established frameworks provide groundwork for transition

Existing frameworks highlight the tools to assess readiness and support sustainable transitions. For background research, researchers conducted an article search which included context-specific keywords such as “PEPFAR”, “Global”, “Global Fund”, “HIV”, along with sustainability-related keywords such as “sustainability”, “sustain”, “transition”, “country ownership”, “locally led” and included articles published from 2011 to present. Researchers identified 56 articles through the initial search, conducted an initial review for relevancy, then included 33 articles in the detailed review.

Two researchers reviewed these articles to document the research methods and data used, donors involved in the transition, other actors involved in the transition, which functions were transitioned (ie, prevention, testing, treatment or above site services), core elements of focus (ie, donor coordination, local capacity, governance, readiness, technical and managerial alignment, policy priorities alignment, financing, timeline, communication/coordination, integration), along with key recommendations or lessons learnt.

When assessing readiness, Vogus and Graff highlight the need to understand local leadership and management capacity, political and economic factors, policy environments, alternative funding sources, integration of HIV programmes, institutionalised processes, procurement and supply chain management, staffing and training needs, and private sector and civil society engagement.⁹ Ongoing discussion of these factors with local partners can inform transition planning, timelines, areas in need of strengthening and ensure that countries are set up for success once transition plans are implemented.

Transition processes require active stakeholder engagement in planning; widespread communication of the plan; support for midterm plan evaluation and refinement; strengthening local stakeholders in financing, management and technical capacity; and supporting ongoing monitoring and evaluation of the transition.⁹ Co-created monitoring plans are essential to ensuring continued progress towards epidemic control when transferring from highly monitored donor services to local ownership. Early planning with government and local stakeholders ensures alignment, along with shared understanding of co-created timeline, milestones, monitoring plan and goals.

Evidence from Kenya showed that inconsistent communication, a short timeframe or top-down approaches during transition make it hard for local actors to meaningfully engage.¹⁰ During the geographic prioritisation transition for the PEPFAR programme, for example, the short timeframe was cited across multiple stakeholder groups as the largest barrier to successful transition. Lack of transition planning has made it harder for local health systems to rehire, replace or absorb informal staff into the health sector or re-establish services with continuity after restructuring. Conversely, the phased transition¹¹ of the Avahan programme by the Gates Foundation was seen as widely successful due to the longer timeline,¹² clear benchmarks and shared monitoring process; this was all bolstered through early and ongoing collaboration with local government in creating, funding, managing and refining the co-created transition strategy.¹³ Fast transition timelines and lapses in communication have been cited as barriers to effective transition and represent a major source of treatment disruption.⁹ Assessing readiness, co-creating transition and transition monitoring plans and analysing policy environments to ensure they are supportive for HIV service provision are established principles in sustaining services beyond donor support.

To explore these concepts in more depth, the team conducted programmatic reviews to understand the experiences of two countries in different stages of sustainability planning. Interview questions focused on the individual role in HIV transition of the interviewee, broad experience with sustainable transitions to date, reflection on core elements of sustainable transition frameworks and recommendations for future transitions. The team interviewed 7 stakeholders in English in Zambia, a country earlier in the transition process, and 10 in Vietnamese in Vietnam, a country further into their transition. Stakeholders represented a range of perspectives from both national and subnational levels, including donor organisations, local government, civil society, PLHIV, implementing partners, along with the private sector. Researchers obtained written consent which confirmed all names and organisations would be obscured in the final analysis. In addition to the core principles for transition listed above, the following findings lend insight into ensuring that transitions are locally led and owned.

Core principles to support local ownership of transition processes

Principle 1: country governments and donors must plan for and strengthen health system functions as they serve as the backbone to all successful transition efforts

Decades of experience have taught the global health community that stronger health systems lead to sustainable health outcomes.¹⁴ Therefore, when donors and national governments consider transitioning HIV programming, health system functions must be at the centre of the conversation. These health system functions are essential for sustaining a resilient health system that results in client satisfaction, financial risk protection and better health for all¹⁵ (see figure 1). Without robust, locally led and implemented health system functions such as integrated data systems, enabling policy environments or reliable supply chains, countries may struggle to provide quality HIV care and sustain treatment and prevention efforts previously supported through strong vertical programmes. Without reliable health systems, countries will be unable to integrate these services into primary healthcare for a person-centred approach to HIV that accounts for comorbidities and needs throughout the life cycle.

Figure 1. Health system functions.

Stakeholders in Vietnam highlighted that the strategic plan for HIV response centred on strengthening health system functions in anticipation of the transition, including policy development, health financing, health information and data management, and health workforce. To integrate the financing of HIV services into the national system, the transition plan mapped out processes for surveying and analysing operating costs and relevant financial policies. For example, the prime minister passed multiple policies, including those ensuring funding at the provincial and city level and reimbursement of centrally procured antiretrovirals.^{16 17}

A focus on policy also allowed for district health centre workforce strengthening to support both prevention and treatment services. To prevent disruption in the availability of health information and data for monitoring and decision-making, vertical data systems were intentionally adapted for integration into national health information systems. Not only did this allow for policymakers to easily access data, but it also allowed continual monitoring of care quality and access—a key component to ensure continuation of effective HIV services beyond donor support. An early focus on strengthening the capacity of the health workforce to provide HIV prevention and other services allowed the seamless and complete transition of the workforce from donor payrolls to the public sector.

In Zambia, USAID invested in Ministry of Health (MOH) and Ministry of Finance (MOF) public financial management capacities at the central and subnational levels to prepare the government to be a direct recipient of PEPFAR funds. Through this collaboration, they established an electronic management system which facilitated visibility of public financial management at the provincial and district health offices. Stakeholders commented that the institutionalisation of the electronic system was integral to the success of the project and eventual transition of responsibility in transferring funds to subnational entities. The changes required to implement the system contributed to the revision and strengthening of national regulations, such as the Public Financial Management Act (anonymous participant, interview, 2024).

Efficient procurement and supply chain management are critical for ensuring uninterrupted service delivery, underscoring the importance of building resilient systems and processes that can adapt to changing circumstances. This finding was highlighted in the Eastern Caribbean⁹ in preparation for transition and was identified as an ongoing challenge in Vietnam.

Stakeholders¹⁸ widely consider the transition in Vietnam a success, but they state that the procurement and supply of antiretrovirals continue to be problematic, primarily due to the unintended impact of internal policy changes. Although unrelated to the HIV programme, widespread anticorruption measures were put in place at the same time the transition was planned. While the measures themselves were needed, procurement processes were delayed and therefore impacted the programme’s ability to meet demand. Concerted efforts to ensure the supply chain functions well through systemic changes are essential for continued and effective service delivery.

Informants from Zambia listed a few barriers to integration efforts. Government employees are often transient within different departments, meaning that capacity-strengthening efforts often had to start again. The disparity in funding cycles and procurement procedures resulted in the donor recalling funds that had not been used within a specified timeframe. The challenges in Zambia and Vietnam highlight the necessity of alignment between donors and local stakeholders in investment into health system functions.

Practical steps for donors and country stakeholders: Established health system and transition readiness assessment tools can guide countries and donors in identifying which aspects of HIV programmes can be more easily transitioned to local ownership and which may require continued technical assistance and capacity strengthening.

Principle 2: successful transitions must align with country priorities, have political buy-in and engage across sectoral leaders

Gaining high-level political buy-in, along with interministerial engagement, is critical to building strong government ownership of transitions.⁹ To harness the political will of national and subnational leaders, sustainability plans should follow planned national health sector reforms and align services to broader systems to ensure sustainability of services as they become integrated and publicly owned.^{19 20} Support from multiple ministries, such as the MOH, MOF and Prime Minister’s Office, is vital to ensure that country policies, financing and health prioritisation support a successful transition. Donors can reinforce local leadership by providing dedicated technical assistance and funding throughout the transition and monitoring process. Providing multiyear transition funding can be particularly effective to support sustainable transition and transition monitoring plans.²¹ Countries should guide both the prioritisation of transition processes and the creation of monitoring plans to track progress towards the goals and desired results for their health sector.

In Vietnam, stakeholders reported that the decision-making authority of the MOH, backed by the Vice Prime Minister’s office, was a major factor in successfully integrating HIV services. Throughout this process, the Ministry leadership prioritised gathering input from donors and local organisations to ensure a comprehensive view of the transition and monitoring process. The MOH elected to start their process by transitioning antiretroviral treatment programmes and strengthening the capacity of healthcare workers in HIV prevention.

In this example, the Vietnamese government led the process, while international organisations provided technical assistance, funding and strategic guidance to align HIV services with global best practices while integrating services into the broader health systems. A donor representative echoes the importance of these roles, “We are committed to respecting the country’s desires and needs [and] aligning our efforts with their policies, politics, and financial and technical requirements. Our role is to support them in this endeavor.” Aligning transition planning with broader health system planning bolsters sustainability efforts, as well as awareness over the transition of services.²²

Practical steps for donors and country stakeholders: Analysing existing health sector strategies, priorities and plans and identifying and capitalising on opportunities to integrate or align HIV programme transition efforts with these processes is more likely to yield sustainable results. Clear sustainability roadmaps also ensure time to strengthen local organisation management, implementation and monitoring capacity. Certain long-held systems, such as monitoring data systems that were geared for reporting, may need to be retooled for decision-making by local leadership and burgeoning quality monitoring systems.

Principle 3: capacity strengthening and consistent engagement with civil society, especially during decision-making processes, can strengthen the sustainability of transition processes

Indigenous and local organisations are critical to effective and efficient HIV prevention and response activities.²³ Civil society organisations (CSOs) maintain accountability to the communities that they serve, unlike government entities where priorities may shift depending on the current administration or official. They are well positioned to inform policy, monitor access and quality, and hold governments accountable for policy implementation and achievement of targets. Not only do they support service provision and facilitate community engagement, but their relationships and networks are essential for tailored outreach with key populations to ensure consistent access and quality for those who experience barriers to care.²⁴

For countries earlier in transition, such as Zambia, significant emphasis can be placed on capacity strengthening for local organisations in terms of planning, service provision, monitoring and programme management. Prioritising local organisations in service provision is an important step to ensuring that local actors are equipped with the tools they need to sustain consistent services apart from donor assistance. This capacity can translate over to post-transition success stories, as seen in Vietnam, where CSOs successfully identified and filled funding gaps that resulted from the transition. Community organisations created social enterprises or business models to continue HIV-related community activities that would no longer receive donor funding. However, in Zambia, more than one interviewee noted that while donors had increased funding for local organisations, this does not always translate to increased decision-making power.

CSOs should be seen as partners for larger systemic decisions, especially in sustainability planning. In Zambia, stakeholders reported that the engagement of indigenous and local organisations to date has mostly focused on consultative processes at the national level, but they were not engaged in the design or execution of the transition or current HIV programming. Similar observations were reported in Ghana, where stakeholders highlighted the need to include CSOs, policymakers, healthcare workforce and donors in sustainability planning.²⁵ In Vietnam, some CSOs stated they were part of the consultative process but under-represented in decision-making spaces. Involving and empowering community actors to design and decide programming priorities consistently ensures shared understanding of the transition plan across sectors and also allows for proactive involvement in transition planning from civil society.

Practical steps for donors and country stakeholders: Systems and processes for engaging civil society, communities of people living with HIV and other non-state actors, including faith-based organisations and private sector, should be established for each stage of transition planning, implementation and monitoring, and supported by targeted efforts to strengthen capacity as needed.

Principle 4: decentralised planning and integration processes and active engagement of subnational actors are essential in contexts with decentralised health systems

Effective national leadership is essential for a successful transition of HIV services, but decentralisation can also play a significant role in ensuring that these services are effectively adapted for the regions and populations that need them most.^{26 27} The opportunity for innovation comes from any level of healthcare and often results from an in-depth knowledge of the needs of facilities, clients and providers. To only plan, execute and monitor the transition in the central level of government is to limit the adaptability and effectiveness of services in the future by side-lining people with extensive knowledge of challenges and opportunities. By decentralising innovation, health systems will be better integrated, available and effective. Donors and central governments must recognise that regional health authorities may play a key role in service integration, especially in countries with decentralised healthcare systems.

Provincial health authorities in Vietnam, for example, demonstrated significant leadership to meet regional needs. Provincial authorities in Ho Chi Minh City, which accounts for 35% of all PLHIV in Vietnam, spearheaded awareness campaigns to inform clients about service changes, such as insurance requirements and location updates, that might affect them. Recognising a potential gap in financing, the city government also planned a transition process for health insurance fees over several years for PLHIV in the province while they became aware of the insurance system. These successes echo calls from prior transitions,⁵ such as Rwanda and Ghana, which called for decentralisation to centre frontline worker and regional expertise in transition planning.²⁵

Practical steps for donors and country stakeholders: While transition and sustainability planning will be led at the national level and requires political will and cross-ministerial commitment, subnational actors should be actively engaged in defining and leading locally appropriate transition activities based on epidemiological and programmatic context. Local solutions are more likely to address specific needs, leverage existing assets and strengths, and generate sustainable system changes.

Conclusions

To transition from donor-supported HIV programming to a nationally funded and managed HIV response, the transition process must rely on established principles to ensure readiness and sustainability for the transition—beyond this, it must be locally led. Local leaders must guide transition planning and processes, even those initiated and funded by donors, to ensure alignment with local health sector priorities and integration into local health systems. Continued support for locally led health system functions, alignment with country priorities, capacity strengthening and continuous engagement with local actors, and decentralised processes and decision-making will support a transition with more local leadership at the helm, resulting in more sustainable HIV programming and integrated health systems.

The article’s contents are solely the responsibility of Brandeis University and do not necessarily represent the official views of the Bill & Melinda Gates Foundation. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Data availability statement

All data relevant to the study are included in the article.