Projected Health Financing Transitions: Timeline and Magnitude

In recent years, many global health institutions have adopted eligibility and transition frameworks for the countries they support, generating questions about how these frameworks apply in practice—and whether global health progress will be put at risk through premature or poorly planned transition processes. This paper builds on previous work in this space by mapping an indicative timeline of transition through 2040 across five global health financing mechanisms—Gavi, the Vaccine Alliance (Gavi); the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund); the World Bank’s International Development Association (IDA); the Global Polio Eradication Initiative (GPEI); and the US President’s Emergency Plan for AIDS Relief (PEPFAR)—with granularity by year and stage of transition. It contextualizes the magnitude of fiscal transition for each country with reference to overall government expenditure on health. Finally, it identifies countries and specific time periods of high transition risk based on cumulative fiscal impact. By 2040, it finds that Gavi and IDA will each see major transformations of their funding portfolios, while few large or aid-dependent countries will transition from Global Fund support. The countries in most fiscal jeopardy from anticipated transition are not those “transitioning” based on GDP per capita or disease burden, but instead those that are likely to be impacted by the near-term winddown of GPEI and reallocations of PEPFAR financing. A handful of countries face many major transitions within a very narrow time window—and the cumulative fiscal effect may be substantial, even if each individual transition should be manageable. Global health donors should build upon these results, working cooperatively at the country level, to ensure countries have a realistic understanding of transition processes to enable appropriate planning, budgeting, and prioritization.