Graduation and Phase-Out in the Health Sector: What Have We Learned?

Graduation and phase-out are transition processes in the health sector that ultimately result in the closeout of external assistance. Graduation occurs when certain thresholds of development or intended results have been attained, while phase-out is the withdrawal of assistance over a finite time period due to resource constraints, instability, and economic or political considerations. Between 2008 and 2015, USAID graduated or phased out 27 countries in the health sector. More than 65 health sector element level funding ended across countries in the last five decades. A literature review was conducted to document USAID lessons learned in graduations and phase-out of programs. A total of 97 documents were found in the USAID Development Exchange Clearinghouse and in internal USAID files. In addition to the desk review, interviews were conducted with key informants. Four key factors for achieving sustainability of any health program have been identified. These factors include country-led financing, policy and regulatory reform, institutional strengthening, and leadership and stewardship. Country-led financing involves financing processes that are country-led and country-managed, whether the financing is public or private. Policy and regulatory reform promotes supportive policy and regulation to create an enabling environment for health programs. Institutional strengthening involves strengthening existing or new collaborations for leaving a lasting USAID legacy. Leadership and stewardship are critical for ensuring the sustainability of health programs. Five critical steps have been identified for phasing out of a health program. These steps include good coordination and clear communication with all stakeholders about close-out dates, development of a phase-out strategy with the host country's government and partners early in the process, strengthening of existing or new collaborations for leaving a lasting USAID legacy, communication and documentation of the program's successes over the entire period of USAID assistance in a country, and evaluation of the program or health sector element at the end of the assistance. Family planning (FP) graduations merit a special mention in USAID history of health sector transitions. Many of the graduated health programs have been in the area of family planning, and largely in the Latin American and Caribbean (LAC) region. FP graduations offer a model process for other health programs to follow. In 2003, Global Health/Population and Reproductive Health (GH/PRH) and Regional Bureau health teams, with endorsement from the Health Sector Council, developed a technical note that identified thresholds for achieving graduation. The common underlying goal in both graduation and phase-out processes is achieving sustainability of program goals and self-sufficiency. In the health sector, Missions and partners typically focused on the following four key pillars for achieving health program sustainability: country-led financing, policy and regulatory reform, institutional strengthening, and leadership and stewardship. These pillars are critical for ensuring the long-term impact of USAID assistance on the recipient country's health sector program. The five critical steps for phasing out of a health program are essential for deliberately closing out any program. Good coordination and clear communication with all stakeholders about close-out dates are critical for ensuring a smooth transition. Development of a phase-out strategy with the host country's government and partners early in the process is essential for ensuring that the program's goals are met. Strengthening of existing or new collaborations for leaving a lasting USAID legacy is critical for ensuring the long-term impact of USAID assistance. Communication and documentation of the program's successes over the entire period of USAID assistance in a country are essential for ensuring that the program's achievements are recognized. Evaluation of the program or health sector element at the end of the assistance is critical for ensuring that the program's goals were met and for identifying areas for improvement.