Effects of transition on HIV and non-HIV services and health systems in Kenya: a mixed methods evaluation of donor transition

In Kenya, PEPFAR designated over 400 health facilities in Northeastern Kenya to be transitioned to government support, known as central support (CS). The seven CS counties in Northeastern Kenya were assigned to CS, accounting for 1% of Kenya's HIV burden. HIV prevalence in Kenya has been hovering around 5.6% in the general population, with higher rates among women, young people, and key populations. HIV care is widely available across health facilities, and patients are starting on anti-retroviral therapy (ART) earlier. However, there is considerable geographic variation in disease burden across Kenya, with estimates ranging from over 25% prevalence in Homa Bay to 0.2% in Wajir. Coverage of key HIV services in CS counties is considerably worse than elsewhere, with higher rates of mother-to-child transmission, increasing infections among children, lower ART rates, and high ratings on the HIV Stigma Index. PEPFAR IPs provided support to CS counties, including providing lay counselors for testing, integration with maternal, neonatal, and child health (MNCH) and tuberculosis programs, expert clients to promote treatment initiation and adherence, county-level planning and management, healthcare worker training and supervision, and laboratory strengthening and networking. IPs also provided support to MNCH, family planning, water and sanitation, and nutrition services. Transition to CS was expected to take place by mid-2016. The GP process took place in a context of two major policy changes in Kenya. The health system went through widespread devolution of responsibilities in 2013, with responsibilities for health facility ownership and service provision shifting to county governments. The national level retained stewardship responsibilities, such as policymaking and regulation. The seven CS counties are considered "marginalized" counties eligible for equalization funds under devolution. Among them, only Lamu, Garissa, and Isiolo allocated more than 20% of their budget to health in 2016/17, and across CS counties, more than 50% of health budgets are allocated to personnel costs. Doctors and nurses are not widely available in CS counties, with Mandera, Tana River, and Wajir reporting less than 0.5 health workers per 10,000 population, Marsabit 4.4 per 10,000 population, and Isiolo and Lamu 7.3 and 10.4 per 10,000 population, respectively. The National AIDS Control Council (NACC) and National AIDS/STD Control Programme (NASCOP) released the Kenya HIV Prevention Revolution Road Map in 2014, which outlined an approach focused on prioritization between counties based on HIV incidence. PEPFAR's allocation of counties to different categories mostly aligned with that of the Government of Kenya (GOK), with the exception of Isiolo, which was categorized as medium incidence in the GOK's Road Map but was flagged for CS by PEPFAR. The recent trend of donor transitions in global health has been the focus of evaluations and research around the world. Transition evaluations for immunization and HIV programs have described the effects and lessons learned from transitions, including on program beneficiaries, and have identified lessons and guidance for future transitions, including assessing readiness and improved transition planning. Studies of USG transitions have been conducted in Latin America and other regions, highlighting the importance of careful planning and coordination to ensure a smooth transition.