Designing a Payment-for-Results Modality for Mongolia's HIV Program
THE PROBLEM
Mongolia is a low HIV prevalence country, with an estimated incidence of less than 100 new cases in 2022 and a general population prevalence of less than 0.1%. However, there is a concentrated epidemic among key population groups (KPs). Among men who have sex with men (MSM) HIV prevalence is 5.6%, and among transgender people (TG) prevalence is 5.7%. The national HIV response is led by the National Center for Communicable Diseases (NCCD) of the Ministry of Health (MoH), but most services for KPs are implemented by Civil Society Organizations (CSOs), mainly Youth for Health for men who have sex with men (MSM) and Perfect Ladies for female sex workers (FSW).
The Global Fund has used input-based financing in its grants for HIV and Tuberculosis, in which a fixed amount is allocated to cover specific line items for a specific period, for CSOs that cater to KPs in Mongolia. These CSOs have consistently marched and exceeded their coverage targets for testing and prevention services.
For 2023-2026, the Mongolian government and The Global Fund agreed to shift to a payment-for-results (PFR) modality, with disbursements to the CSOs linked to accomplishing performance targets. By paying for outputs rather than inputs, PFR aims to increase the autonomy of CSOs, enhance the efficiency and accountability of CSOs and the MoH, and strengthen national systems and capacity in planning and fund management. It can also set the stage for an eventual handover of the PFR modality from external Global Fund financingto domestic financing, under a social contracting approach.
THE PHAROS SOLUTION
Pharos was engaged by The Global Fund in August 2023 to support the Mongolian National HIV program in defining a complete solution for a PFR modality to finance KP interventions implemented by CSOs under the new “GC7” 2024-2026 Global Fund HIV/TB grant. Pharos was select in part because of its earlier experience in developing an HIV/TB Sustainability and Transition Risk Assessment and Roadmap with Mongolia.
The project is organized into three phases:
- Phase 1: Examine the country context (HIV epidemiology and CSO involvement) and conduct trainings with stakeholders to familiarize them with payment-for-results.
- Phase 2: Conduct a programmatic design and analysis for the PFR solution, which includes defining objectives and criteria for success, results chain and implementation mapping, risk analysis, and identifying deliverables to confirm achievements.
- Phase 3: Assist the MoH and CSOs in crafting and agreeing on a contract for the PFR arrangement that includes pricing, payment structure, verification protocol, and disbursement triggers.
During a visit to Mongolia in October 2023, the Pharos team interviewed all stakeholders, trained them on PFR, and held a workshop in which broad agreement was reached on the detailed design of the PFR model and the contracts between MoH and the CSOs.
LOOKING AHEAD
The deliverables prepared by Pharos will help Mongolia implement an innovative model for HIV financing that will gives CSOs more autonomy and flexibility to optimize their budget and continue their impressive accomplishments to date.
Since the use of PFR for HIV CSOs is relatively new, Mongolia will need to monitor the experience closely and be ready to further adapt the model in 2024-25.
The Mongolia experience may also be relevant for other LMIC countries where PFR could help to improve the reach and effectiveness of CSOs working on HIV, TB, and malaria outreach services, especially to key and vulnerable populations.
Status: Ongoing, August 2023 – December 2023
Team Members Involved: Socci Santos, Joan Tallada, Munkhjargal Ayurzana, Jeremy Otridge, Robert Hecht
For more information, contact Socci Santos at [email protected].