A responsible exit: Using theories of justice to inform donor practices of transitioning health programs to in-country partners

Global justice theories frequently raise the moral question of what rich nations owe poorer nations.  This question is important not only in determining when and how countries should engage in aid, but equally so in determining when and how to end a funding engagement.   As global health priorities shift from the achievement of short-term impacts to longer-term goals of sustainability and country ownership, global health practitioners are increasingly seeking to transition responsibilities for planning, implementing, managing and financing effective health programs to developing country governments and community partners.  While transitioning to in-country partners potentially offers a mechanism to sustain a program’s beneficial impacts, in practice, transition requires a challenging alignment of budgets, staffing, and technical capacity between donor-funded programs and the local health system, as well as a shared political interest in transition.  Without careful planning, transition may result in changes to the scope, quality, coverage, or overall character of the program that risk disrupting services, compromising care, and potentially halting or reversing health gains.  Yet, little guidance is available to determine what, if any, responsibility funding agencies hold in the context of making such transitions.  Drawing examples from an empirical case study of the transition of a large-scale HIV prevention program from donor funding and management to the government of India and community partners, this project explores specific challenges of transition and uses theoretical conceptions of global justice to inform practical recommendations for donors seeking to transition programs in an ethically responsible way.  By systematically considering donors' ethical obligations under different conceptions of global justice along a spectrum from nationalist to cosmopolitan, this work explores areas of convergence that may provide the foundation for practical, normatively informed policy recommendations.