Uganda: transitioning from external health financing

1Uganda: transitioning from external health financing Key messages • In Uganda, the sustainability of health programmes and services following the withdrawal of external funding has varied. In areas where the Saving Mothers Giving Life initiative operated, which aimed to reduce maternal mortality, there were increases in facility births and in antenatal care attendance after the programme ended. For PEPFAR, which aimed to treat and prevent HIV/AIDS, HIV prevalence increased in some districts that were deprioritized by the programme. • The design of programmes shaped their ability to survive following transition. Key enabling factors included: taking an integrated systems approach rather than setting up targeted parallel services; aligning worker pay scales with the government system to facilitate the absorption of programme staff into the national system; and co-development and clear communication of transition plans at all levels. • The political salience of different health interventions both nationally and among funders is also a critical factor. National funds were prioritized for continuing maternal, newborn and child health (MNCH) services compared to other services. Similarly, there were multiple other external funders interested in continuing to support MNCH whereas no other funders picked up where PEPFAR left off. Overview of programmes and transition outcomes To understand how and why projects that have transitioned from external assistance have or have not been able to sustain intervention coverage in Uganda, two programmes were evaluated: • Saving Mothers Giving Life (SMGL) – USAID supported (2012–2016) The United States Agency for International Development (USAID) launched a public–private partnership with the Government of Uganda (GoU) to pilot a five-year intervention, Saving Mothers Giving Life (SMGL), which aimed to reduce maternal mortality by 50% and perinatal mortality by 30% in 10 districts in Western and Northern Uganda (2012–2016) using a health system strengthening approach (1,2). SMGL 2Uganda: transitioning from external health financing targeted high-volume health facilities with a record of high maternal and newborn deaths. 263 facilities in Western Uganda and 118 in Northern Uganda were included in the intervention, with a higher emphasis placed on district and subdistrict hospitals. The intervention included quality improvement teams within maternity units, coaching and mentorship of health workers, renovation of operating theaters, procurement of necessary equipment, and community outreach. The study revealed mostly positive outcomes post-transition. There was a sustained increase in facility births and antenatal care (ANC) attendance in the intervention districts. ANC attendance was 2.4 times higher post-transition compared to pre-transition. Newborn deaths, however, only fell in two out of the three districts post-transition. • PEPFAR National HIV/AIDS Response (PEPFAR) – supported by PEPFAR/ Government of the United States of America (2004–2017) The President’s Emergency Plan for AIDS Relief (PEPFAR) has been the leading source of international assistance for Uganda’s national HIV response since 2004. Funding was used to improve supervision of HIV services, strengthen antiretroviral therapy (ART) supply chains, support health workforce, fund community HIV outreach, and bolster behavioural and biomedical prevention strategies. Between 2015 and 2017, PEPFAR shifted its funding approach away from a generalized national HIV response to a targeted geographic prioritization strategy based on disease burden at subnational level (3). 731 low-volume facilities across Uganda and 10 low-burden districts in Uganda lost PEPFAR support because of this strategic shift. An earlier study conducted nine months after this strategic shift could only assess early effects of donor transition, so long-term outcomes could not be extracted (3). However, a recent study observed that HIV prevalence post-transition doubled in two districts, Luuka and Bulambuli (1% in 2015 to 2.2% in 2020). At the same time, there was increased HIV testing in districts where PEPFAR support was maintained. Country context of transition Uganda is a low-income country that relies heavily on donor funding. The National Health Accounts reflected that up to 46.2% of the total health budget was funded with donor support in 2020/21, of which 38% (of the 46.2%) was off-budget support (4,5). For the national HIV response, donor aid has been estimated to be as high as 85% (6). Uganda’s total budgetary allocation to health has been increasing over the years, but health spending is still only 7% of total government spending, less than half of the 15% Abuja target. The rapid growth in population at 3% per annum has contributed to health service coverage gaps and quality issues. Additionally, out-of-pocket (OOP) expenditure accounts for one the highest sources of health expenditure (37%), raising concern around access to services and financial protection against the cost of health care. However, there was a substantial drop in OOP expenditure from 42% of total health expenditure (THE) in 2019/20 to 29.9% of THE in 2020/21. It is difficult to know yet whether that number reflects the drop in services during COVID-19 (7). Facilitators and constraints to sustainability Various factors influenced Uganda’s transition from external funding in the two programmes. 3Uganda: transitioning from external health financing Governance The two programmes differed greatly in terms of political and technical leadership across all levels of the system from the start of the programmes. This contributed to differing outcomes for service coverage post-transition. For SMGL, national-level planning and programme design was carried out through protracted engagements with Ministry of Health (MoH) and other national- level platforms. At the subnational level, Baylor Uganda, USAID’s implementing partner, collaborated closely with the districts’ political and technical leadership. For instance, District Health Offices (DHOs) played a pivotal role in planning implementation, monitoring and evaluation of the intervention. Additionally, many leadership capacity functions were maintained post-transition. For PEPFAR, governance of the HIV response at subnational level is largely influenced by regional implementing partners who manage PEPFAR funds and implement PEPFAR programmatic targets in collaboration with district health teams. These various forms of governance for the programme made managing the multiple dimensions of donor transition difficult. Additionally, the current composition of district teams is inadequate with weak capacity. Financing SMGL garnered increased funding for maternal, newborn and child health (MNCH) services from the GoU through absorption of workforce, increased health worker salaries and upgrading services at facilities. Conversely for PEPFAR, which contributed up to 80% of HIV programming budgets at district level, the majority of the subnational workforce were not able to be absorbed on the GoU payroll. Additionally, the GoU did not provide extra funding to districts in Eastern Uganda to replace lost PEPFAR investments in HIV programming, forcing facilities to use their already constrained primary care budget. Continued external grant funding was critical to sustaining MNCH indicators post transition. On the other hand, there were no alternative external donors that supported HIV in the period between 2017–2020 in Eastern Uganda. Service delivery From inception, USAID funding for SMGL took a whole-of-system approach, where the intervention was largely integrated into the Ugandan health system (for example, community outreach was embedded in existing Village Health Teams). However, for PEPFAR, HIV service provision took precedence over health system strengthening. When districts transitioned, many critical functions for HIV services were disrupted, resulting in loss to follow-up cases, community HIV transmission, reduced laboratory samples handled, and reduced tuberculosis (TB) case notifications. Community outreach was vertical in nature and relied on PEPFAR funding, such as workforce field allowances, which ceased post-transition. Generation of physical capacity, human resources and inputs Salaried SMGL workforce were absorbed onto the GoU payroll in 2014, and from the beginning, health workforce salaries were consistent with the GoU salary scale. Salary enhancements, as well as coaching and mentorship, were used to strengthen capacity and enhance the quality of services. The sustained 4Uganda: transitioning from external health financing improvements MNCH indicators post-transition may be attributed, in part, to the integration of the workforce originally recruited by USAID into the national health system. However, PEPFAR’s geographic prioritization policy meant loss of support for refresher trainings of health workers in effected districts, including updates on HIV care and treatment. Additionally, there was a lower post-transition absorption rate of the additional workforce recruited by PEPFAR, especially among facility- level cadres such as data managers, counsellors and graduate laboratory technicians. Several cadres that were PEPFAR-supported were also not included in the GoU staffing norms at the time of the study, and high-grade PEPFAR cadres found the GoU salary scales uncompetitive. Relative to SMGL, physical infrastructure support was not a key feature of PEPFAR support in Eastern Uganda. For SMGL, more durable physical infrastructure such as new maternity blocks across most subdistrict and general hospitals in mid-Western Uganda were provided, though maintenance was a challenge. There were disruptions in critical functions across districts that transitioned from PEPFAR funding, such as loss of PEPFAR-salaried supply chain management experts. This was perceived to have contributed to stockouts of antiretrovirals. Loss of community outreach undermined patient follow-up and monitoring systems. Additionally, loss of PEPFAR-supported facility-level data managers negatively impacted tracking of HIV indicators and broader health information systems and reporting. Enablers beyond programme content There are several factors outside of the programme or initiative design that influenced their sustainability. Context The GoU appeared to prioritize funding for MNCH when compared to HIV. This may be due to the higher political profile of maternal care, which affects nearly 20 million people in Uganda, compared to the 1.6 million living with HIV. Additionally, it appears that the GoU chose to use external assistance for the national HIV response relative to other health programmes, given the cost of HIV care and treatment. Additionally, PEPFAR support for HIV was more verticalized and frequently offered as parallel to general health services. Districts are heavily dependent on central government grants and unable to mount substantial transition responses on their own. There was also low civic competence among patients and communities to demand government action on replacing lost PEPFAR investments or remedial actions. Process factors In SMGL, district health teams and facility-level participants reported that they had ample notice of transition and that several meetings were held to prepare them for the end of support. While national-level actors such as MoH officials reported being informed about PEPFAR’s geographic prioritization, district 5Uganda: transitioning from external health financing health teams were not as engaged or aware of transition processes, as this was left to implementing partners at subnational level. Additionally, there were very clear timelines for aid and transition for SMGL. USAID/SMGL was a five-year project with no possibility of extension. With PEPFAR, support has been given continuously in five-year cycles since June 2004, with PEPFAR re-authorizations by the congress of the United States of America. As such, there has been an expectation of ongoing funding, and the timelines for transition have been ambiguous from both governments. Policy decisions were made at the global level for PEPFAR. The shift to a geographic prioritization was part of its strategic vision, dubbed PEPFAR 3.0, which was a global policy aimed at improving the allocative efficiency of PEPFAR aid to meet UNAIDS’s 90-90-90 targets in its 15 focus countries. This top-down approach was applied without consideration for individual country preferences and priorities. Actors The presence of internal MNCH programme champions at the subnational level emerged as a facilitator for sustaining programmatic gains post- transition in mid-Western Uganda. District-level local government political and technical actors appeared relatively committed to MNCH outcomes through budget commitments for items such as ambulance maintenance and recruitment of USAID supported personnel under SMGL. The implementing partner, Baylor Uganda, continued to provide MNCH service delivery support to select health facilities (such as Kyenjojo Hospital) even after transition. For PEPFAR, there was an imbalance of influence and authority between local and external actors in setting the agenda on transition – both with regard to criteria and timelines. A similar imbalance was noticed between central government and local government officials. Transition processes involved multiple actors ranging from PEPFAR global, PEPFAR-Uganda, subnational PEPFAR implementing partners, District Health Teams, district political and technical leadership, and facility-level officials. In relative terms, district government actors in Eastern Uganda did not appear to commit funds to PEPFAR transition. Lessons Political economy surrounding disease programmes play a critical role. MNCH attracted multiple successor external funders post-transition, such as the World Bank, Belgium’s ENABLE initiative and UNICEF. Key informants reported that Western Uganda appeared a fertile ground for MNCH interventions. For example, Norway wished to intervene via a mechanism like SMGL even before USAID, but USAID was quicker in mobilizing funding and in implementation. It appears that there is competition among donors for demonstrating public health impact, especially in resource-constrained settings such as Uganda. Therefore, the GoU appeared more responsive to MNCH in terms of funding commitments and transition responses. Uganda: transitioning from external health financing About The Alliance for Health Policy and Systems Research and the Department of Financing and Economics within the World Health Organization have embarked on a series of research studies aimed at understanding how and why countries have (or have not) been able to sustain or increase effective coverage of health interventions previously funded by donors. The studies also explore the enablers and barriers to this. Research teams have received funding for this analysis, and these briefs are informed by the extensive research reports produced by four countries: China, Georgia, Sri Lanka, Uganda. This briefing focuses on the context of Uganda. Acknowledgements This briefing was prepared based on research overseen by Henry Zakumumpa of Makerere University School of Public Health in Uganda. Additional writing and support was provided by Alexandra Earle. Uganda: transitioning from external health financing ISBN 978-92-4-008545-9 (electronic version) | ISBN 978-92-4-008546-6 (print version) © World Health Organization 2023 (acting as the host organization for, and secretariat of, the Alliance for Health Policy and Systems Research). Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The Alliance is able to conduct its work thanks to the commitment and support from a variety of funders. These include our long-term core contributors from national governments and international institutions, as well as designated funding for specific projects within our current priorities. For the full list of Alliance donors, please visit: https://ahpsr.who.int/about-us/funders. Collaborating with country teams to develop transition plans through direct consultation is important. Findings suggest a power imbalance between the GoU and health initiatives funded by the United States of America in Uganda in terms of setting the agenda for donor transition. Donor transition road maps for the two initiatives were almost exclusively externally determined. At the subnational level, district local governments were concerned about the amount of power of PEPFAR implementing partners, which can crowd out that of in-country actors. The SMGL programme was perceived as effective in communicating transition timelines. Whole-of-system approaches may be more effective than vertical ones, including reforms around staff norms. This was seen in SMGL’s strengthening of existing maternity services compared to PEPFAR’s more vertical approach. Especially for PEPFAR, reforms around the staffing norms in the Uganda public service may have enabled retention of cadres of health worker that are integral to HIV services delivery. References 1. Conlon CM, Serbanescu F, Marum L, Healey J, LaBrecque J, Hobson R, Levitt M, Kekitiinwa A, Picho B, Soud F, Spigel L. Saving Mothers, Giving Life: it takes a system to save a mother. Global Health: Science and Practice. 2019 Mar 11;7(Supplement 1):S6-26. (https://doi.org/10.9745/GHSP-D-19-00092, accessed 15 November 2023). 2. Serbanescu, F, et al. Impact of the Saving Mothers, Giving Life approach on decreasing maternal and perinatal deaths in Uganda and Zambia. Global Health: Science and Practice 7. Supplement 1 (2019): S27-S47. (https://doi. org/10.9745/GHSP-D-18-00428, accessed 15 November 2023). 3. Wilhelm JA, Qiu M, Paina L, Colantuoni E, Mukuru M, Ssengooba F, Bennett S. The impact of PEPFAR transition on HIV service delivery at health facilities in Uganda. PloS one. 2019 Oct 9;14(10):e0223426. (https://doi.org/10.1371/ journal.pone.0223426, accessed 15 November 2023). 4. Zakumumpa H, Paina L, Wilhelm J, Ssengooba F, Ssegujja E, Mukuru M, Bennett S. The impact of loss of PEPFAR support on HIV services at health facilities in low-burden districts in Uganda. BMC health services research. 2021 Dec;21(1):1-2. (https://doi.org/10.1186/s12913-021-06316-4, accessed 15 November 2023). 5. Uganda Ministry of Health. National Health Accounts 2020-2021. Kampala; 2023. 6. Lohman N, Hagopian A, Luboga SA, Stover B, Lim T, Makumbi F, Kiwanuka N, Lubega F, Ndizihiwe A, Mukooyo E, Barnhart S. District health officer perceptions of PEPFAR’s influence on the health system in Uganda, 2005–2011. International journal of health policy management. 2017 Feb;6(2):83. (https://doi. org/10.15171%2Fijhpm.2016.98, accessed 15 November 2023). 7. United Nations Children’s Fund (UNICEF) Uganda. Sustaining public investments in health sector: Uganda budget brief financial year 2023/24. Kampala; October 2023. (https://www.unicef.org/esa/media/13261/file/ UNICEF-Uganda-Health-Budget-Brief-2023-2024.pdf, accessed 19 February 2024).