Integrating NTD programs into national planning and budgeting processes
Lessons from Tanzania and Uganda
By Jose Luis Gonzalez, Edward Owino, Alemu Chekole
More than one billion people around the world are affected by neglected tropical diseases (NTDs) — including lymphatic filariasis, trachoma, onchocerciasis, schistosomiasis and soil-transmitted helminths — which can cause severe disability, stigma, and distress.
Though remarkable progress has been made in the countries most affected by NTDs over the past decade, there are still insufficient resources for the control, elimination, and eradication of these diseases at both the country and global levels. Many of these countries rely heavily on donor funding for their NTD programming, which may lead to a lack of integration with national systems and processes compared to other health services — this dependence makes them vulnerable to changes in donor priorities and resource allocation, competing with other health programs for limited funding.
To address this financing challenges, the World Health Organization (WHO) and donor organizations call for renewed attention to domestic investment in NTDs and building political will and sustainable financing for NTDs to deliver services needed to achieve the targets outlined in the WHO 2030 NTD road map and Sustainable Development Goals 3 (SDG3).
As previously outlined in our blog post “5 Lessons in Mobilizing Domestic Financing for NTDs,” NTD programs are more likely to be financed when they are:
- Integrated within national and sub-national health plans and strategies,
- Aligned with broader financing reforms, and
- Included in essential health service delivery platforms under universal health coverage.
This mainstreaming with local health systems approach, recommended by WHO, not only raises the visibility of NTDs in health resource allocation discussions at national and subnational levels but also increases the efficiency of health interventions by leveraging existing delivery platforms and related programmatic efforts, such as safe drinking-water, sanitation and hygiene (WASH), and vector control.
While government funding for the control and elimination of NTDs has been more clearly observed at the federal/national level, subnational efforts are also crucial for achieving our goal of ending or mitigating the negative impacts of NTDs. This is particularly important in decentralized settings where local governments have the authority to approve health plans and budgets and prioritize and allocate funds for health interventions during the annual planning and budgeting cycle. By prioritizing NTDs in subnational health plans and budgets, local governments can be held accountable for meeting their annual commitments to NTDs, thus increasing domestic financial ownership of NTD programming.
In this blog post, we present our experience working on domestic resource mobilization (DRM) for NTDs in the USAID’s Act to End NTDs | East program (Act | East) at subnational levels in Tanzania and Uganda, through their integration within health planning and budgeting processes.
What challenges do subnational levels face in mobilizing domestic resources for NTDs?
Experience from both countries has shown that decentralization has devolved financing and implementation responsibilities to subnational levels, leading to difficulties in securing adequate funding for NTD. This could be attributed to the following reasons:
- Dependence on central level for funding allocation: Even with decentralization/devolution of financing responsibilities, local governments such as districts are still largely dependent on the central level for their funding allocation and those amounts may not be increasing or entirely predictable, leading to difficulties in securing adequate planning and funding for NTD programming.
- Engaging subnational finance and administrative officials: Gaining the support of finance and administrative officials who control resource allocations at subnational levels can be a major challenge for NTD programing officers and hinder their efforts to secure adequate funding for control and elimination activities.
- Effective communication of NTD performance and financial needs: Subnational staff may not have the necessary skills, availability of or access to programmatic data, and confidence to effectively communicate NTD programming and financial needs to non-health actors who play a role in resource allocation during the budget cycle.
- Limited role of financial data: Subnational governments face challenges in including NTD resource needs and gaps in local budgets due to limited availability and use of expenditure data and inadequate capture of partner resources and programming information in planning processes.
- Limited role of programmatic data: Subnational governments also have insufficient access to NTD data in the District Health Information Software 2 (DHIS2) or other databases, which is what they need to inform their health plans. Without NTDs represented in national Health Management Information Systems (HMIS), national and subnational planners have limited capacity to include NTD data in their plans and budgets.
- Limited advocacy capacity: Subnational staff may lack experience with strategic, evidence-informed advocacy and NTD-specific financing information, hindering their efforts to secure adequate resources for NTD control efforts. This challenge links the ones on financial and programmatic data, as NTD financial and programmatic data are necessary to inform annual planning and advocacy strategies.
Act | East experience in Tanzania
In 2022, the Tanzania NTD Control Program (NTDCP), in partnership with the President’s Office for Regional and Local Government (PO-RALG) and Act | East, implemented a capacity building approach to increase DRM for NTDs and promote local ownership of NTD programming. This government-led effort has been applied to 15 selected councils and has demonstrated promising results.
The NTDCP conducted a series of advocacy meetings with high-level stakeholders and technical workshops with councils to equip local government officials with the data and tools necessary to effectively advocate for greater prioritization of NTDs during the preparation of the Comprehensive Council Health Plans (CCHPs) and influence budget allocation for NTD programming.
The councils also received technical assistance to negotiate fund allocation during the budget cycle and build their capacity to track funds approval, allocation, and disbursement using the national PlanRep tool through PO-RALG. The NTDCP, PO-RALG and Act | East developed an operational manual, now referred to a “pocket guide,” for planning and budgeting of NTD interventions at the subnational level. The manual provides simplified guidance for NTD planning and budgeting at the subnational level, developed from the National CCHP guide. The development of the manual, along with advocacy and capacity building activities, creates an opportunity to support additional councils to prioritize NTDs during the comprehensive council health planning and budgeting.
As a result of the first iteration of the capacity building activities, all 15 councils increased budget allocation for NTDs from previous years. The CCHP interventions supported include a wide range of activities such as case detection and management, early diagnosis, health promotion and prevention, medicine, medical equipment, medical supply and diagnostic supplies, preventive chemotherapy, vector control, safe healthcare waste management and practices.
In January 2023, the NTDCP and PO-RALG, with support from Act | East, organized a Pause and Reflect meeting with the 15 supported councils to review the lessons learned, best practices, and discuss what worked well, what did not, and what could be improved in the next iteration of the activity. Building on these findings, the NTDCP and PO-RALG are working to identify improvements for the next budgeting and planning cycle.
Act | East experience in Uganda
In Uganda, districts play a crucial role in allocating funds for health. The District Executive Committee and the District Technical Planning Committee are key decision-making spaces for approving annual workplans and budgets, and prioritizing health interventions according to local needs. However, domestic allocation for NTDs has decreased in recent years due to competing priorities and overall health budget reductions. To address these gaps, in 2022, the Uganda NTD Control Program (NTDCP), in partnership with Act | East provided technical support to five trachoma-endemic districts to meet with district health and administrative officials and to advocate and build capacity for adding NTDs to the district’s annual budget.
To make this process routine, the NTDCP and Act | East developed an NTD budgeting and planning guide to assist district authorities in incorporating NTD programming into routine health sector budgeting and planning. The guide outlines the steps and information needed to ensure that NTDs are considered during budgeting and that sufficient funds are allocated to support NTD control and elimination efforts.
In 2023, the NTDCP and Act | East will continue to support trachoma-endemic districts to prioritize NTD activities, identify funding needs and potential sources, and provide technical and financial assistance to strengthen their capacity for planning, budgeting, and advocacy during the budget cycle. Additionally, the NTDCP will conduct training sessions to teach districts how to effectively use epidemiological, programmatic, and financial data to advocate for increased prioritization of NTDs in district budgets.
The Path Forward: Sustaining local ownership and financing for NTD control and elimination
Addressing the control and elimination of NTDs requires commitment and resources from national and subnational levels of government, particularly in decentralized countries where local governments play a crucial role in decision-making and implementation of health programs.
The work conducted through Act | East support in Tanzania and Uganda demonstrates that by incorporating NTDs into subnational health planning and budgeting processes, governments can make provision for and be held accountable for meeting their commitments to NTDs, thereby increasing domestic financial ownership of NTD programming.
Thus, to achieve control and elimination goals, it is essential to continue investing in NTDs and building political will and sustainable financing for NTD programming. In this way, a targeted advocacy and capacity building approach can lead to sustainable and locally-led NTD programming.
Cross-posted with Act | East partners R4D.