In an increasingly complex and budget-strapped world, there is growing recognition that development cooperation can be more efficient and effective if development partners deliver their support in an aligned and harmonised fashion. The collaboration between GIZ and FCDO through BACKUP Health shows how this can be done.

‘I think that the way in which four like-minded development partners use BACKUP as vehicle for the delivery of technical support on the ground is quite unique and inspiring,’ says BACKUP Health Team Leader Huzeifa Bodal. ‘I am happy and proud to be a part of this process and to learn from it.’

In many low and lower-middle income countries, the development landscape in the health sector continues to be very fragmented with many different development partners and Global Health Initiatives providing technical support and funding that is often poorly aligned and not optimally coordinated. While, in theory, there is agreement between all partners that greater alignment and the breaking down of institutional ‘silos’ is needed, putting this into practice remains one of the biggest challenges in international development cooperation. 

Three years ago, the United Kingdom’s Foreign, Commonwealth and Development Office, FCDO, entered into a unique collaboration with BACKUP Health, a programme Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH (GIZ) implements on behalf of the Federal Ministry for Economic Cooperation and Development (BMZ). The British Government decided that its very large pledge to the Global Fund should be accompanied by technical support, some of which should be implemented by BACKUP Health on its behalf. This collaboration between Germany and the UK is remarkable because it is the largest co-financing of any German-supported health programme ever. For the first time in such a co-financing arrangement, it involves German and British colleagues working together in an advisory capacity in six partner countries: Democratic Republic of Congo, Mozambique, Nigeria, Zimbabwe, Tanzania and Uganda.

How and why did this partnership come about?  

Three months after the Global Fund to Fight AIDS, Tuberculosis and Malaria was established in 2002, the  BACKUP Health programme was set up specifically to provide technical support to state and civil society within partner countries and help them access and make best use of Global Fund resources. Over the last two decades BACKUP has been a key intermediary between the Global Fund and recipient countries. In recent years it has gained a lot of experience in providing technical support to four focus countries: Cameroon, Kyrgyzstan, Malawi and Nigeria. 

Three years ago, the UK’s FCDO decided it would like to work with BACKUP, using an already well-established programme to provide additional technical support to partner countries. BACKUP Health already has co-financing agreements with Switzerland (since 2013) and with Expertise France (since 2021). This means that over the past three years, four major stakeholders in global health – Germany, the UK, Switzerland and France – have been using BACKUP as a vehicle for enhancing the work of the Global Fund and, more recently, also exploring how BACKUP’s long experience providing technical support related to the Global Fund can be applied to other Global Health Initiatives.

How does the collaboration work and what are the advantages?

BACKUP is implementing UK funds in accordance with an agreed contract and jointly defined goals. In addition, in each of the six focus countries, a British secondee, formerly Department for International Development staff who are now FCDO staff, work very closely with BACKUP teams on the ground. ‘The secondees in the six countries and the FCDO colleagues we regularly interact with in the UK headquarters are real experts in their fields. They bring many years of experience,’ says Huzeifa Bodal.

Perhaps the biggest advantage from the collaboration between the UK and Germany, as well as the previous co-financing agreements with Switzerland and France, is that it provides a central point of contact for state and civil society partners on the ground.  According to Huzeifa Bodal, ‘BACKUP makes life easier for our partners in the countries. Germany, France, UK, and Switzerland all channel their resources via BACKUP.

Dr Joseph Bikuku is one of those partners. He works for the Ministry of Health in the Democratic Republic of Congo, coordinating one of the largest country allocations from the Global Fund to build resilient and sustainable health systems.

It has really simplified our work because it has helped a lot in terms of coordination. The joint funding means we only have to deal with and coordinate with one entity, the BACKUP Health team based in Kinshasa.

Dr Joseph Bikuku

Dr Joseph says that BACKUP funds have been used to enhance understanding and implementation of Global Fund programmes across several regions including some very remote areas, and draw up an action plan that will help the DRC to plan and monitor the implementation of future Global Fund grants more effectively – from the ground up rather than using a centralised approach, which had been the practise so far.

Fresh thinking

The collaboration has not been without challenges, says Huzeifa Bodal:

Having to change is always difficult. You think that what you are doing is great and suddenly you have a partner that is asking many critical questions about what you are doing.

Huzeifa Bodal

The FCDO collaboration has forced BACKUP to reflect on what it is doing and whether some of its interventions still make sense twenty years later. Even though the HIV pandemic and the global response to it have evolved considerably since the early emergency phase, many of the trainings and capacity development measures that partners request from BACKUP have remained largely unchanged. ‘So our UK colleagues asked us: Why do we continue to do the same things? Given that the Global Fund systems and structures have been in existence for 20 years, why is it still necessary to train CCMs (Country Coordinating Mechanisms) every few years? What can we do to support transitions in a more sustainable way that avoids the need for repeated training and workshops? And we had to recognise that they have a point.’

The message that FCDO came in with, says Caroline Mtaita, who manages BACKUP’s work in Uganda, was that BACKUP Health needed to ensure that Global Fund financing is invested more strategically to achieve longer-term systems strengthening. According to her, this message has very much landed with all BACKUP advisors. All partner requests that come in are now assessed with a view to the strategic impact that can be achieved through them. In Uganda, for example, where BACKUP works with the Central Health Laboratory, FCDO financing is now invested in analysing how to improve and simplify the transportation of samples from over 3,000 facilities across the country to Kampala where they are processed and analysed – a major logistical undertaking and an important element of Uganda’s healthcare system.

The challenges of working together

Bringing two organisations with different cultures and ways of working together has not been easy. Both GIZ and FCDO have their own specific way of interacting with partners, of designing and implementing programmes as well as their particular reporting mechanisms and indicator frameworks. Working together requires more communication and coordination to ensure that both organisations are on the same page. The German financial year, for example, runs from January to December and the UK financial year goes from April to March. Many of BACKUP’s financial management and planning tools had to be redesigned to accommodate the differences between the two organisations’ processes and instruments.  

There are also differences between GIZ and FCDO, on for example how to approach the prevention of sexual exploitation abuse and harassment. ‘We both see this as a very important part of our work, but we approach it in a different way,’ says Huzeifa Bodal. FCDO requires all its partners to have in place a comprehensive approach to preventing sexual exploitation and harassment (PSEAH) and implement it. The UK funding has enabled BACKUP to set up a new process to assess a partner’s capacities in this area, identify gaps and provide additional guidance where necessary.  This meant that partners who were set to receive grant agreements from BACKUP had to first develop an action plan to strengthen their organisation’s PSEAH capacities and commit to put into implementation the action plan before entering into a cooperation with BACKUP.

‘FCDO’s critical questions have helped us to sharpen our strategy’

Reflecting on the first three years of the collaboration, Jean-Olivier Schmidt, Head of Programme BACKUP Health, says that it has greatly impacted on the overall quality of BACKUP’s work. ‘The critical questions that FCDO asked us helped us to refine and sharpen our strategy. In all our focus countries we are now honing in on providing deep impact, system-strengthening technical support.’

Harriet Ludwig, Senior Policy Officer at BMZ, states:

Having the UK on board is a real asset. The FCDO colleagues are strong partners when it comes to the need to invest Global Fund finance in the strengthening of countries’ health systems. BACKUP Health allows us, together with our Swiss and French partners, to jointly work towards this goal.

Harriet Ludwig

Building good working relations

An important factor in the collaboration has been building good working relations, communication and trust between German and British colleagues, says Huzeifa Bodal. However, the FCDO secondees and senior advisers remain FCDO staff and have a remit which extends beyond BACKUP. This can lead to complexities in managing the teams within the project, he says.

Despite the bureaucratic challenges and cultural and organisational complexities, he explains that throughout the part three-year test phase he’s always tried to keep the shared goal in view, ‘because then I understand what it is that we are working towards.’ He believes that the outcome of BACKUP’s work is much higher quality because of that and hopes that the collaboration with the UK can be strengthened and deepened in the future.

At an event to celebrate 20 years of BACKUP Health at the World Health Summit 2022 in Berlin, Claire Moran, Director Global Health at FCDO, stated ‘We put six of our best people in the BACKUP country teams to support all of the large health initiatives to deliver more coherently and to focus on supporting health systems, and added:

We love the fact that BACKUP support is truly demand-led; the quality and the skill of their grant management; and its focus on the most marginalized and vulnerable.

Claire Moran

An exciting new phase is ahead

BACKUP is currently preparing the next phase of its work, and for the first time ever BMZ and the three contributors – the UK, France and Switzerland – are all involved in defining what it is going to look like. ‘Normally it doesn’t happen like that,’ says Huzeifa Bodal. ‘Normally it is a process between GIZ and BMZ, and there’s less opportunity for contributing partners to come in at the design phase.’ It can make the process more cumbersome, and requires more effort, he says, but the advantages clearly outweigh the disadvantages: ‘We gain more ownership by doing it this way. We are reducing future transactional costs and by doing it now, by getting everybody on the same frequency and buying into the same concept.’

He believes that this ground-breaking collaboration between FCDO and GIZ’s BACKUP should pave the way for other integrated partnerships in development:

I think there is a really a lot we can learn from this. We know that responding to some of the big global challenges requires a much more concerted way to work together and this could be one good example of doing just that.

Huzeifa Bodal

Back in Kinshasa, Dr Joseph Bikuku also hopes the FCDO-BACKUP collaboration will continue in the future, especially as the DRC’s Ministry of Health prepares its application for the new Global Fund grant cycle next year. ‘It has really helped with our work in implementing the current grant,’ says Dr Joseph. ‘My wish is that this collaboration between the four development partners will continue.’

Ruth Evans,
May 2023