Monitoring the implementation of the commitments will be challenging
The WTP policy was effective at leveraging additional commitments from governments
Aidspan has published a report on how The Global Fund's willingness-to-pay (WTP) policy is being operationalized at country level. The report is based on an analysis of case studies which Aidspan conducted in 13 countries, plus information provided by The Global Fund Secretariat.
The report, entitled "The 'Fair Share' of Shared Responsibility," is available here.
The aim of the study is to increase transparency around the application of The Global Fund's WTP policy (now called "additional counterpart financing"), since very little is known about it. Under the WTP policy, 15% of a country's allocation can only be unlocked if it commits to increasing domestic funding beyond what is already required under the Fund's counterpart financing policy. Countries must also specify how this domestic funding will be spent.
The study and the preparation of the report were funded by Open Society Foundations. The study was conducted for Aidspan by Gemma Oberth, an independent consultant and a correspondent for GFO.
The 13 countries included in the study are Belize, Botswana, Bulgaria, Costa Rica, Fiji, Iran, Jamaica, Mauritius, Romania, South Africa, Suriname, Thailand, and Ukraine. All are upper-middle-income countries, except for Ukraine, which is an upper lower-middle-income country. Mainly UMI countries were selected because one of the objectives of the study is to gain a better understanding of how the WTP policy is linked with sustainability and transition.
The report provides quantitative and qualitative data for each case study, detailing how much money countries committed under the WTP policy, and what they committed to spend that money on. The report also describes how these commitments were obtained, including who participated in the process and any challenges that were encountered. Finally, the report describes how the WTP policy has contributed to spending on key populations, and how it impacted transition processes in some UMI countries.
The study found that in the countries sampled, the WTP policy was effective at leveraging additional funding from government. All but one country in the study not only met the WTP requirements, but also exceeded those requirements by a significant margin. South Africa, which was required to commit $140 million under the WTP policy actually committed just over $1 billion. Iran, which was required to commit $6.1 million, committed $77.4 million, 1275% higher than what was required. Only one country, Suriname, committed less than its minimum WTP requirement. See Table 1 for information on the commitments of all 13 countries.
In all, the 13 countries sampled committed $1.88 billion more for 2015-2017 than they did in 2012-2014. It remains to be seen, however, whether these commitments will translate into actual expenditures.
The 13 countries indicated in what general areas they would invest their WTP funds (see Table 2). Botswana has prioritized ART for all sex workers living with HIV. Iran will invest in training programs in prisons. Bulgaria aims to fund health system reform.
Of particular interest is the $1.5 million of Costa Rica's $11.2 million WTP commitment which will go to the Social Projection Board (JPS), a government funding mechanism which ensures local HIV NGOs are able to access public money. This is something that civil society in Costa Rica fought for. Globally, civil society advocates have called on The Global Fund to support the development of strong national mechanisms to fund civil society in countries that have not yet transitioned, as a way of ensuring that programs for key populations are sustainable.
Table 2 shows that nine countries indicated that they would invest at least some of the WTP monies into programs for key populations. Table 3 provides a breakdown by key population targeted in these nine countries.
How will the commitments be monitored?
The Global Fund intends to create an online database of counterpart financing and WTP commitments. If this database is public, it would make the WTP more transparent and could help in-country stakeholders and watchdogs (like Aidspan) monitor the commitments.
The report says that monitoring the commitments will be challenging:
"It is very difficult to track whether or not countries actually fulfil their side of deal. As one Global Fund staffer said: 'The overall financing for health picture is unclear - budget amounts go up and down with no meaningful trend. However, a larger problem is that budgets are very rarely matched by disbursements - what is budgeted for at the beginning of the year seems to have very little bearing on the amount of funding actually received by a ministry or disease program.' "
Another reason why monitoring may be difficult is that many WTP commitments are not very detailed or specific. Globally, among countries that have signed grant agreements under the NFM, only a few agreements contain specific conditions related to their WTP commitments.
The report says that there should be appropriate investment in watchdog activities, especially as key informants from several counties in the sample expressed uncertainty about their country's ability to deliver the promised funding in practice.
The grants for four of the countries in the study - Costa Rica, Bulgaria, Romania, and Thailand - were labelled "transition grants" because they are on their last cycle of funding from The Global Fund. As Table 3 illustrates, all four countries are prioritizing key populations in its WTP commitments. (See separate GFO article on this topic.)