Header photo ©Unicef/Siegfried Modola
Published: 08 July 2025

Sustainability, Transition and Co-Financing

As low- and middle-income countries experience economic growth, they have greater capacity to invest in their health systems, progressively moving away from reliance on external and donor financing towards fully domestically funded and managed health systems. This is a welcome trend, but countries must be supported to gradually transition away from donor financing in order to achieve lasting impact in the fight against HIV, tuberculosis (TB) and malaria. An abrupt withdrawal of external support could lead to the reversal of hard-won gains, particularly in the lowest income countries with the highest disease burdens.

Working with countries to sustain hard-won gains and progress made against the three diseases is fundamental to the Global Fund’s approach. Strengthening sustainability requires both continued investments in reducing the burden of disease, while at the same time supporting countries to assume greater financing and responsibility for ending these diseases as epidemics as they move toward greater self-reliance. 

Ultimately, this will only be achieved with sustainable health systems that are fully funded by countries through their own resources. 

Guided by the Sustainability, Transition and Co-Financing Policydownload in English ] , which was revised in 2024, the Global Fund partnership takes a holistic approach to sustainability. We do this by supporting the scale-up of new technologies and service delivery, catalyzing better and more efficient use of domestic financing, increasing our alignment with and implementation through national systems, and supporting strong national sustainability and transition planning to gradually support countries to assume full leadership of the national responses. 

Key pillars of the Global Fund’s work on sustainability and transition include: 

  • Supporting countries to strengthen national planning to finance and manage their national responses, including country context-specific sustainability and transition plans. 
  • Supporting domestic resource mobilization and additional domestic investments in health systems and national responses, including by making a portion of Global Fund grants contingent on co-financing requirements. 
  • Supporting innovative ways to raise and leverage additional resources to support health systems, including through blended finance, Debt2Health and other financial mechanisms. 
  • Specific efforts to prepare for transition and support responsible transitions, particularly for higher income and lower burden countries. This includes setting transition timelines to strengthen predictability in our transition processes and allowing for one allocation of transition funding for country programs that are no longer eligible for Global Fund support to smooth the transition from Global Fund financing.
  • Supporting countries to address sustainability challenges related to key and vulnerable populations and structural barriers to health.
  • Advocating for programmatic and financial transformations that are key to long-term sustainability of national responses.
  • Strengthening alignment between Global Fund grants and country systems, including supporting countries to improve public financial management.
  • Supporting countries to identify efficiencies and optimize disease responses, with the intent to maximize the impact of existing resources. 

Strengthening Sustainability

The Global Fund defines sustainability as the ability of a health program or country to both maintain and scale up service coverage to a level in line with the epidemiological context. This provides for ongoing control of a public health problem and supports efforts for elimination of the three diseases, even after external funding by the Global Fund and other major external donors comes to an end. 

In practice, there are many factors that influence sustainability, which differ on a country-by-country basis and require country-tailored responses. Efforts to maintain sustainability gains and address challenges should consider financial, programmatic and political realities countries face. The Global Fund encourages and supports all countries to ensure sustainability is embedded into their national responses and grant design. 

Co-financing

The Global Fund’s co-financing approach encourages countries to commit additional domestic resources to health programs as a requirement to receive Global Fund grants. Co-financing fosters greater country ownership and accountability, incentivizes countries to strengthen financing of specific programmatic interventions critical to impact, and helps support better investments in health and community systems.

To support these goals, at least 15% of a country’s allocation – but in some cases more – becomes available if countries make sufficient co-financing commitments and fulfill those commitments during grant implementation.

Transition

The Global Fund is fully committed to the premise that countries must be self-reliant in financing and managing HIV, TB and malaria programs over time. Working hand in hand with countries, the Global Fund actively plans for transition away from Global Fund financing. 

The Global Fund defines transition as the mechanism by which a country, or a country component, moves towards fully funding and implementing its HIV, TB and malaria programs independent of Global Fund support. A successful transition is one in which previous gains against HIV, TB and malaria are maintained and scaled up, as appropriate, even after external support has come to an end. 

Disease components fully transition from Global Fund support when they are no longer eligible for funding, voluntarily transition, and/or have received their final allocation. Preparations for transition may also be affected by changes in the size of Global Fund allocations and/or the investments of other funding partners, which may require countries to progressively assume key parts of the national response well before they stop receiving Global Fund financing. For this reason, the Global Fund encourages countries to plan well in advance of expected transitions. 

Lessons learned suggest that successful transitions take time and require resources. Early and proactive planning is a key part of transition preparedness. The Global Fund supports countries to incorporate transition considerations into funding request development, grant design, grant implementation, national planning processes – including, where relevant, transition planning and assessments – and the overall management of national responses. 

The Global Fund proactively supports countries to undertake transition planning, and may provide transition funding to countries who become ineligible in order to help smooth the transition from Global Fund support. The Global Fund may also set transition timelines for eligible countries to ensure predictability in our funding. The Global Fund regularly publishes a listdownload in English ] of the disease components projected to transition from Global Fund support due to potential income classification changes.

Innovative Finance Mechanisms

The Global Fund connects countries with diverse partners – development and health funders, multilateral donors, private sector investors, philanthropists and civil society organizations – to develop and implement practical, innovative finance mechanisms to strengthen resource mobilization and increase our impact against the three diseases. These solutions complement Global Fund grants and domestic spending, in line with the Global Fund Strategy

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Blended financing

At the Global Fund, blended financing refers to combining grant funds with funding from multilateral banks and other financial institutions. Blended financing can strengthen alignment among development partners. It can also help countries build stronger, more resilient health systems that are better equipped to fight the three diseases through critical health interventions – such as expanding treatment, reforming social health insurance schemes and reaching vulnerable populations. Blended financing complements traditional Global Fund grant financing and is part of the Global Fund’s overall approach to raising additional resources for health and for HIV, TB and malaria. 

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Debt swaps (Debt2Health)

Launched in 2007, Debt2Health allows creditor and debtor countries to convert – or swap – part of their debt into lifesaving health investments. Currently focused on the conversion of official bilateral debt, all swaps are flexibly and independently negotiated in partnership with the Global Fund and are designed to meet the needs of creditor and debtor countries alike.

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