Health development aid in Uganda
The government of Uganda stated its preference for donor funding to be channelled through the general or sectoral budgets (instead of project support) on the basis that these should be more efficient, equitable and should allow them greater ownership [35]. Introduced in Uganda in 1998, budget support occurred in two different forms: general contributions to the budget of the government and earmarked contributions to the Poverty Action Fund (PAF)-equivalent to a Poverty Reduction Strategy Paper (PRSP). The number of donors contributing to budget support increased from five in 2000/01 [36] to 12 in 2002/2003 [37]. Sectoral budget support to the health sector in Uganda was launched in 2000 in the form of a SWAp (Sector Wide Approach), under which donors and government pooled resources, and jointly agreed the National Health Policy (NHP) and the Health Sector Strategic Plan (HSSP) and exercised oversight over their implementation. The proportion of funding for the health sector financed through projects decreased from 45% in 1999/00 to 34% in 2002/03 in relation to the overall resource envelope for the health sector [38].
However, project funding started to increase once again from 2003 onwards as Uganda became a recipient of large volumes of funds from GHIs, mainly focused on HIV/AIDS. Over the period covered by this research (from 2003 to 2004), the total approved budget by the Global Fund to Uganda totalled US$160.6 million1[39]. PEPFAR's budget for Uganda in 2004 was US$94 million [40]. By February of that year, 40% of the PEPFAR budget had been disbursed [41], indicating fast disbursement. In comparison the government budget for the entire health sector in financial year 2004/2005 was US$136.5 million [42]. This amount included budget support contributions.
Structural features of the two GHIs
PEPFAR funds could not be provided directly to the government, only to non-governmental and private sector organizations (legal requirements established through the US Congress). In contrast the Global Fund operated as a financial instrument based on proposals being led by the government of Uganda. The Global Fund mechanisms for fund disbursement are somewhat flexible and in countries like Mozambique it used a common basket of pooled funds contributed by various donors and managed by the government [43].
In Uganda, both PEPFAR and the Global Fund opted to create parallel systems of management. Neither of these were seen to have contributed to the health Sector Wide Approach (SWAp), a mechanism which would have earmarked their funds for the health sector, but otherwise left the financial control in the hands of the government, overseen by a collective of bilateral and multilateral agencies. The Global Fund in Uganda used a separate project management unit within the Ministry of Health (MoH), their own monitoring tools (rather than the common mechanisms adopted through the Joint Review Missions, a performance review mechanism under the SWAp) and a parallel system for procurement (although the Global Fund guidelines made provision for the use of a common working arrangement).
Therefore neither Global Fund nor PEPFAR participated in the common technical mechanism of aid coordination among health sector stakeholders. Their proposals were not scrutinized by the Sector Working Group, set up by the Ministry of Finance Planning and Economic Development (MoFPED) and MoH to assess projects for value for money and alignment with government policies and plans. PEPFAR also followed their own funding and audit timetable instead of the national schedules for planning and budgeting.
Another special requirement set up by the Global Fund was the conditionality of additionality: the funds it provided had to be additional to those budgeted nationally and should not be treated as fungible. However, this condition came into conflict with macroeconomic budget ceilings set by the MoFPED. If these ceilings had been reached, the offer of resources from the Global Fund should in principle have been rejected. While there were discussions to apply the ceiling to Global Fund Round four, these did not materialise in the end [44, 45].
During interviews some respondents explained that the rationale that drove GHIs like PEPFAR and the Global Fund to set up these parallel mechanisms were related to the weak capacity of government-particularly in relation to timely disbursement of funds, procurement and monitoring and evaluation. If they had decided to work through the existing government structures, this would have delayed the implementation schedule of their activities. Interviewees also said that separate management structures were used as a mechanism to reduce fiduciary risks. The latter was substantiated to some extent when in 2005, the Global Fund identified serious mismanagement problems in five of its grants to Uganda leading to their suspension [46]. However the suspension was lifted later in the year highlighting some of the complexities related to this issue-further explored elsewhere [47].
Behaviour of GHIs and incentives
PEPFAR was argued by a number of key informants and government officials to be detrimentally affecting the health system. Competition for human resources was a particular concern. Often mentioned was the loss of highly qualified staff to PEPFAR funded projects in the face of higher salaries and benefits. This problem was said not to be restricted to government units but also to affect the private not-for-profit sector (which receives financial subsidy and seconded health workers from the government).
Staff were said to be moving primarily to two specific organizations receiving support from PEPFAR. One of them received 300 applications for clinical positions advertised in early 2004. Salaries paid by this organization were reported to be three times those paid by the private not-for-profit sector. The view of an interviewee from one of these organizations was that:
"We are not poaching staff; applicants are not from government units. But on the other hand, it's a free world". (Private sector representative)
It was reported that the targets set by the US government for PEPFAR were not chosen in consultation with local government partners. Furthermore, in contrast to the disclaimer in the Memorandum of Understanding between the government of Uganda and Health donors that "as provided in the Constitution of Uganda, [both parties should] ensure that other marginalized groups of society such as the poor, the displaced and the disabled are specifically addressed"[48], PEPFAR did not outline a clear strategy on how it would reach these particular groups. It did not explicitly mention a focus on the poor, only on orphans. A common critique made in various meetings of health sector stakeholders was that the agencies implementing PEPFAR projects were reaching their targets by focusing on 'easy to reach' population groups such as health workers, teachers, police officers in large urban areas as opposed to the poor and vulnerable in rural parts of the country.
Conflicting motives of parties
The Global Fund system requires the recipient country to apply for funding. Uganda applied for, and was successful in securing funding in all four rounds within the period of fieldwork. The justification used by those leading the application process in the MoH was the under-funding of the sector. The volume of funding made available by the Global Fund, and its perceived accessibility seemed to make certain members of the government more flexible about its rules and mechanisms leading them to interfere with the existing integrated budgeting processes, it was argued.
"People rushed off around the Global Fund but collectively the rest of us [budget support donors] have more money that we are providing to the budget[49]2. But that is not seen to be accessible in the same way ... somehow the idea of the Global Fund money even if it's relatively small, excited much more political interest. I don't know ...it's seen as an opportunity that anybody can get something out of it and somehow with budget support money that isn't [the case]". (Donor representative)
Various donors reported that they had been willing to increase their contributions via general budget support to the government (and consequently to the health sector) but had been prevented from doing so by the MoFPED on the basis of the country's macroeconomic budget ceilings.
Hence it would appear that some members of the government went to considerable lengths to attract additional funding from a source not operating through the mechanism which the government had stated it preferred, while other members rejected funding from sources operating through that mechanism. An explanation of this apparently perverse behaviour was offered:
"The Ministry of Finance encourages the use of SWAp, but currently the approach of the Ministry of Finance [with]... sectoral budget ceilings results in threats to the sector, not only because there is insufficient funding to the sector at the moment, but also because it encourages the sector to seek funds elsewhere, off budget. If the sector was getting sufficient or a lot more funds through the budget it would be easier to argue against the GF and other GHIs". (Technical assistant)
When disagreements occurred between the government and GHIs, for example because of the lack of alignment with sector plans, the government did not always operate as a single entity. The PEPFAR program was agreed directly with the President's office without much scope for inputs from health sector stakeholders.
"If the president has said yes, then [a senior health sector official] saying hang on, not like that, isn't going to get us anywhere, he can't even be confident that his ministers are saying the same thing as him". (Donor representative)
The application to Global Fund round four was another indication of non-alignment of motives within government but also between government and different donors. The budget support and SWAp donors criticized government for applying to the Global Fund yet when donors were consulted during a monthly coordination meeting at the time of round four there had been general agreement in favour of the government applying (though no discussion took place at the time of the meeting as to how the funds should be channelled-via the SWAp or through a project management unit).
Weak institutional environment
A number of institutional issues represented an added layer of complexity in the relationship between the GHIs and the government, most prominently with regard to changes in authority and leadership as well rules and regulation which came into conflict.
The problem of lack of alignment with the stated goals of government was said to be related to lack of authority within government combined with a perceived low level of commitment by senior management [which was seen to be detached from the routine management of the technical programmes, lacking knowledge of their activities and not showing ownership (key informants)] and a lack of strong institutions-which instead made the system rely on key individuals. The waning commitment to SWAp and general budget processes and objectives over the period of the fieldwork seems to exemplify these arguments.
Some members of government argued that the rules and regulations of the public bureau would be sufficient to align incentives in this environment. The perception was that because government was a bureaucracy, the policies and rules it had effected would be adhered to.
"We have clearly said that our preferred mode of financing is budget support, and over the years, budget support has been on an increasing trend and even to provide more incentives for ministries, the issue of integrating projects into the budget is meant to be a trade off. If you have more projects then you have less budget support-as government we are not very much in control of projects so need to think twice if they are worth it....the way government works, [is that] it's a bureaucracy, so there, are no power struggles in that sense". (Government official)
However, it seemed that rules and regulations (e.g. the SWAp related structures like the Sector Working Group) put in place by government have not been able to curb project expansion and ensure that technical programs adhered to the budget system.
The SWAp appeared to be a major objective of the majority of development agencies during its introduction and first years of implementation in Uganda (between 2000 and 2002/03).
"The range of individuals motivated by the SWAp made the realization of the SWAp benefits easier...which was strengthened by the continuity of committed individuals in key donor agencies and posts..." (Donor representative)
This cohesion was reported to have subsided by late 2003 with the introduction of the large GHIs (PEPFAR and Global Fund) which were more strongly driven by disease-specific goals.
"In 2001 the overall balance was towards integration and coordination and two years further down the road and the arrival of alternatives in the form of the Global Fund and other projects has actually deepened the conflict and thrown that balance off." (Technical assistant)
Within the structure of the MoH in Uganda there were two directorates. The technical programs fell under the Directorate of Clinical and Community Services while Directorate of Planning and Development was in charge of coordination. In line with its role, the Directorate of Clinical and Community Services was said to follow a more vertical, disease-specific approach, often preferring the project mode (technical assistant). Consequently, there had been some level of tension which the leadership of the MoH was said to have managed to balance during some periods. The previous Minister (at the time of fieldwork) seemed to have played a major role in aligning staff motives within government through his vision, authority and charisma as a political leader.
"He was really engaged with the sector and he would get everybody [to] line up in one direction". (Government official)
"I have seen people listening to [the previous minister's] ideas about health sector reforms until 9 o'clock at night". (Donor representative)
However as there was a change of Minister, there was perceived to be a change in which directorate had more authority in the conflict, explaining changing support levels for SWAp vis-à-vis GHIs. Some key informants observed that at the outset the technical programs were the ones seeking or accepting project funding (including from the Global Fund), but after late 2003 it was said that senior management of the Ministry were more actively involved as well. One government official said: "some of the new people seem not to value the [SWAp] partnership to the same extent". Those who remained supportive of the SWAp principles and structures were said to be few by the time of field work.
To a certain degree, the observed shift away from the SWAp and towards projects was related to new leaders taking charge in the MoH. However these changes took place not only at the higher political level, but also at the technical level, on the government side. And the on donors' side, there were also changes of staff at different levels (leadership and technical) due to their rotation policies. These changes highlight the volatility of the institutional aid environment where changes in persons (with their different personalities and motives) may impinge on the goals and strategies adopted.