On 15 September 2021, BACKUP Health, in collaboration with the Uganda Country Coordinating Mechanism (CCM) for the Global Fund, held a workshop to validate the findings of a needs assessment commissioned in June to identify the main areas for technical support. The stakeholders, including representatives of the Ministry of Health (MOH), the United Kingdom’s Foreign, Commonwealth & Development Office (FCDO), and the Global Fund, attended the workshop either physically or virtually.

Aidspan attended the workshop as an observer and this article highlights the key issues that were discussed.

BACKUP Health supports countries to efficiently use resources provided by global financing mechanisms

The German Federal Ministry for Economic Cooperation and Development (BMZ) commissioned BACKUP Health to support countries to efficiently plan and implement Global Fund-supported health programs. As well as the funding it receives from BMZ, BACKUP Health is supported by other donors to offer technical support to state and civil society organizations (CSOs). It has been co-financed by Switzerland’s Swiss Agency for Development and Cooperation (SDC) since 2013, the UK’s FCDO since 2020, and the French’s Expertise France since 2021. During the current phase (April 2020 – August 2023), BACKUP Health has expanded its mandate beyond the Global Fund to include GAVI, the Vaccine Alliance, and the Global Financing Facility for Women, Children, and Adolescents (GFF) health initiatives. With support from the FCDO, BACKUP Health has selected six countries to strengthen their health systems under the Global Fund Accelerator project. These are the Democratic Republic of the Congo (DRC), Mozambique, Nigeria, Tanzania, Uganda, and Zimbabwe, for which the Global Fund allocated a total of 28.5% ($4 billion) of the $14 billion raised during the Global Fund’s Sixth Replenishment.

In the workshop, BACKUP Health’s Team Leader explained that they support state and non-state actors in implementing global health financing for health system strengthening in four areas. The four focus areas are:

• governance and national coordination,
• institutional strengthening,
• integrating health services, and
• responding to the COVID-19 pandemic.

BACKUP Health has embedded components of human rights, gender, and equity in the four areas, and thus these issues are addressed in a cross-cutting manner. On governance and national coordination, BACKUP Health intends to ensure that programs supported by three global health initiatives (GHIs), the Global Fund, GAVI, and GFF, are better aligned to overall national coordination and dialogue. On institutional strengthening, BACKUP Health aims to enhance the capacity of state institutions and CSOs to better participate in strengthening the overall health system. On integrated health services, BACKUP Health is working to improve the integration of GHI-supported programs at the decentralized level (district and health facility) by disseminating learning from best practices. On COVID-19, BACKUP Health supports mitigating the impact of the pandemic on GHI-supported projects.

Figure 1: BACKUP Health’s 2020-2023 project phase

Source: Obtained from BACKUP Health

In April 2020, BACKUP Health launched the implementation preparation phase of the project. It has recruited staff and set up offices in the six countries, commissioned needs assessments, and organized workshops for stakeholders to validate the needs assessment findings. The preparation phase ends in September 2021 when BACKUP Health will begin to focus on providing technical support in the areas identified during the needs assessment and validated by stakeholders.

Figure 2: Timeline for the current BACKUP Health project

Source: Obtained from BACKUP Health

The findings of the appraisal mission in Uganda

The appraisal mission in Uganda, which took place between June and mid-July, determined the needs for technical assistance and Global Fund Accelerator project opportunities. The team undertaking the appraisal mission obtained information through desk reviews and interviews with various stakeholders such as government officials, CSOs, and representatives of bilateral and multilateral organizations. The appraisal team conducted a thematic analysis of the fundings as a basis for the development of recommendations for BACKUP Health’s technical assistance under the Global Fund Accelerator project.

Technical support required under leadership and governance

Coordination within the Ministry of Health

The appraisal found that the MOH had several challenges in coordinating Global Fund-supported activities. The MOH does not routinely conduct joint support supervision with the Funds Coordination Unit (FCU) of the Ministry of Finance, Planning and Economic Development, set up to monitor Global Fund-supported activities implemented by Sub-Recipients (SRs). The COVID-19 pandemic exacerbated the situation as coordination meetings shifted from physical to virtual via teleconferencing. The MOH could not absorb all the Global Fund’s allocated resources and had an overall absorption rate of 70% during the New Funding Model (NFM) II. Also, the MOH held off starting the implementation of Global Fund grants for between six to eight months and also delayed reporting program outcomes and expenditures to the Global Fund.

To improve coordination, BACKUP Health will strengthen the technical capacity of the Global Fund Coordinator and MOH technical staff to supervise SRs and CSOs. In addition, the appraisal recommended that BACKUP Health provide technical support to ensure the existing risk management tools and frameworks are tailored to the country context. To address COVID-19- created risk, technical capacity is required to enhance the MOH’s capacity to conduct physical and virtual joint supervision visits with FCU by improving video teleconferencing and virtual conferencing facilities.

Uganda’s CCM requires strengthening

The governance and leadership of Uganda’s Country Coordinating Mechanism (CCM) have been adversely affected by high staff turnover, which contributed to late proposal writing and submission. However, the appointment of a new Executive Secretary has stabilized the situation. The COVID-19 pandemic has made it difficult for the CCM to conduct field visits to oversee the Principal Recipients (PRs) due to a lack of technical capacity to hold virtual site visits and for communication purposes. The PRs were late in submitting their progress and financial reports to the Global Fund Secretariat as they were unable to deal with the overly long and complicated templates developed for this purpose. The appraisal noted that the CCM failed to adequately engage its constituency members due to limited financial resources, and there was a need to strengthen in-country capacity for resource mobilization.

To address these challenges, BACKUP Health will enhance the capacity of the CCM to address oversight and coordinate grant application processes. There is a need for technical assistance (TA) for the CCM to help them to effectively involve and communicate with constituent members, and to enable them to conduct a funding landscaping exercise on a regular basis. In addition, BACKUP Health has the opportunity to support the development of a dashboard to track the progress of GHI-supported activities.

Opportunities for civil society strengthening

The appraisal found that most CSOs lack strategies for advocacy and resource mobilization and community structures are not only weak but sometimes non-existent. Also, CSOs have few human resources, cannot attract the best people in the market, and have a high turnover rate due to low pay. To address these challenges, the appraisal recommends that BACKUP Health provide technical support to enhance the capacity of umbrella CSOs in leadership, governance, and financial management. Also, BACKUP Health could assist Uganda to improve the management of community-based health services by strengthening the community monitoring system and developing digital tools.

Technical support required under institutional strengthening

Support required for human resources for health

According to the appraisal findings, the MOH had several challenges in providing human resources for health at the sub-national level. Health workers lacked capacity in leadership as it was not covered as part of their formal training, were not skilled in financial management and monitoring and evaluation, and there was a high degree of absenteeism fueled by the lack of housing facilities. Thus, the appraisal recommended that BACKUP Health should provide TA to enhance staff capacity in financial management, policy development and implementation, and governance and leadership skills. It should also provide technical assistance on strengthening the existing monitoring and evaluation system.

Implementing partners’ technical support

The appraisal findings identified several challenges for Global Fund grants’ implementers. They fail to exercise an adequate governance and leadership role regarding managing CSOs and community-based organizations; they take longer to bring SRs on board; have low fund absorption, and their community data management and reporting are weak. In addition, implementing partners require more financial support to meet their management costs and take longer to procure and deliver commodities and equipment, thereby delaying implementation. To remedy these challenges, the appraisal recommended that BACKUP Health provide TA to support the mapping of leadership structures to improve implementers’ skills in leadership and governance, improve the non-state PR’s hiring process, and enhance the capacity of implementing partners in financial management.

CSOs’ institutional strengthening

The appraisal revealed that CSOs had lengthy and cumbersome registration processes. Their governance, planning, and financial management capacities are inadequate, and they have limited technical capacity to prepare complex funding proposals. Consequently, the appraisal recommended that BACKUP Health provide TA to address these issues.

Technical support required at the decentralized level

Opportunities identified at the regional and district level

The regional and district levels were found to lack technical skills in governance, leadership, coordination, planning, and capacity for programmatic and financial accountability. Furthermore, there are delays in fund transfers at the district level due to high bureaucracy. Moreover, health facilities (HFs) reported late and demonstrated poor data management skills. To address these challenges, BACKUP Health should provide TA to strengthen capacity in governance, leadership, coordination, and planning, and to improve technical supervision and reporting at the sub-national level.

Opportunities for community-based activities

There were limited human and financial resources in the districts to effectively provide services at the village level. Furthermore, the district and village staff had poor data management capacity and were unable to effectively conduct community-based surveillance for HIV, TB, and malaria. The appraisal recommended that BACKUP Health provide technical support for community-based surveillance for the three diseases and COVID-19, and systems for home-based care for COVID-19. Also, interventions should be put in place to modify the existing village health teams’ guidelines and map out community structures to support social and behavior change communication activities.

COVID-19 and mitigation opportunities

The pandemic has overwhelmed national and district coordination systems and constrained the provision of centralized support to districts. Also, risk management and community management support had been inadequate to deal with the pandemic, while some HFs lacked personal protective equipment (PPE). HFs faced a severe shortage of oxygen due to the inadequate procurement and distribution of oxygen cylinders. The areas identified for BACKUP Health support include technical support to the Government’s COVID-19 resurgence plan, and strengthening logistical systems for the provision of PPE, oxygen cylinders, and oxygen. BACKUP Health was recommended to support the development and maintenance of a system to help track COVID-19 testing, vaccination, and surveillance. In partnership with other stakeholders, BACKUP Health should support the MOH to develop and implement a post-COVID-19 transition intervention