A new project to establish a simulation-based training center in Surxondaryo exemplifies the close cooperation between KfW and GIZ in the health sector in Uzbekistan. What can be learned from this exceptional collaboration?

An ambitious vision is beginning to take shape in the ancient city of Termez, in southeastern Uzbekistan. There, in early April 2024, a kick-off meeting was held for a long-awaited project to establish a new medical training centre where doctors, nurses and midwives from the surrounding Surxondaryo Region will be able to practice their clinical skills using world-class simulation equipment. The project, which is being led by the Ministry of Health of Uzbekistan, will be realised with €19.5 million in financial and technical support from the German Federal Ministry for Economic Cooperation and Development (BMZ).

 In her opening remarks, Gulnara Yusupalieva, the deputy head of the Department of Science and Education at the Ministry of Health, welcomed the official start of this latest chapter in Uzbek-German cooperation in the health sector – a relationship which dates back more than 20 years. She noted that the project will make an important contribution to the Ministry of Health’s ongoing efforts to strengthen medical education: ‘Training programmes for nurses and midwives in Uzbekistan today should meet the practical professional requirements for providing high-quality services to patients,’ she said. ‘Currently, education and training is more theoretical in nature.’ The aim of the simulation centre in Termez is to create the conditions for more practical training.

Successfully translating this vision into reality will depend in no small part on close cooperation between the KfW Development Bank and the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) – two ‘pillars’ of German development cooperation which will implement the project on behalf of BMZ and in collaboration with the Ministry of Health and eight other Uzbek partner institutions. While each agency has its own commission – KfW will construct and equip the centre, and GIZ will work with Uzbek partners to revise curricula and prepare instructors to use simulation-based teaching methods – they are planning and implementing the project jointly, as part of a unified German approach. 

Given the very different timelines and delivery models of financial and technical cooperation (FC and TC) projects, this is no small task. However, it may be less daunting than it appears at first sight, since the two organisations already enjoy a close and constructive working relationship in the health sector in Uzbekistan. What does this look like in practice? And what helps to sustain it? This article takes a look at a robust FC-TC collaboration in the heart of Central Asia and asks what lessons can be derived for other countries.

Making FC-TC cooperation the norm in Uzbekistan

Germany is one of the leading development partners in the health sector in Uzbekistan, with a current portfolio of investments worth more than €220 million, according to Dr Michael Wimmer, Counsellor for Economic Cooperation and Development at the German Embassy in Tashkent. With the aim of improving the quality of public health services in the country, KfW focuses primarily on providing medical and laboratory equipment to hospitals, while GIZ works with partners to strengthen the skills and qualifications of health workers. 

While the mandates of the two organisations are complementary, the structure of German development cooperation can be hard for outsiders to grasp. It is not uncommon for partners to be confused about the respective roles of KfW and GIZ, how they work, and the scale of the resources at their disposal. This is not only an ‘external’ challenge: the different planning and implementation cycles for financial and technical cooperation projects can make it difficult to unlock synergies which are inherent in KfW and GIZ commissions in the same sector – even when the intention to do so is there.

 In Uzbekistan, the strategy for managing this well-known ‘FC-TC conundrum’ has been to make cooperation between KfW and GIZ the norm, rather than the exception. Dr Wimmer, the Counsellor at the Embassy, explains that he makes it a point to communicate with the KfW Portfolio Manager and GIZ Programme Manager jointly, so that both are aware at all times of developments in the sector. The country directors of the two organisations understand and support this approach. When there is a need to present German development cooperation at official events, this is generally done with the involvement of both organisations. Both KfW and GIZ take part in the health partners working group meetings which are organised by the Ministry of Health.

Because the country offices of KfW and GIZ neighbour one another in Tashkent, the staff of the two organisations have close contact. All of this helps to present a unified face for German development cooperation to the outside world. ‘The two organisations are perceived as cooperating, and the Ministry of Health has understood this,’ says Dr Wimmer. ‘I would see the situation here as a good example.’

Regular exchange facilitates easier, more meaningful cooperation  

For Vitalis Ritter, the Portfolio Manager for KfW in Uzbekistan, overlap with GIZ is ‘a given’ because the infrastructure and equipment which KfW finances ‘doesn’t work without people who know how to use it.’ GIZ’s expertise lies in the training and capacity development, policy advice, and systems strengthening work with partner institutions which is essential for KfW investments to generate sustainable results over time. But it is one thing to intend to work together, and another to actually do it.  ‘On a daily operational basis, everyone is busy with their own tasks,’ he says, adding that it requires a certain effort and discipline to establish and maintain productive collaboration. ‘Periodic institutional exchanges are important – we have both project- and policy-focused jour fixe – but there is also a constant flow of information on an everyday basis.’

 ‘Communication and regular contact are very important,’ agrees Cornelia Becker, who leads GIZ’s health projects in Uzbekistan. ‘We have invested a lot of time in learning about each other’s portfolios, because we find it is extremely helpful to know in detail what the other agency is doing.’ Representatives of the two organisations make joint duty trips, visit one another’s partner hospitals, attend one another’s events and debriefing meetings, and review and comment on key reports. This extensive contact deepens trust and understanding – also about difficulties each organisation may be facing.

The Embassy actively encourages KfW and GIZ to identify and act upon opportunities to align their activities for greater impact. New project phases are a natural time to exchange and identify synergies. For example, in some KfW-led projects, the partner has some flexibility in terms of where certain kinds of equipment is required. ‘We let them know that it would be preferable to provide equipment wherever GIZ is active,’ Dr Wimmer explains. ‘This dovetailing of activities we have here is something that BMZ is very much looking for.’

Embracing pragmatic solutions to advance shared aims

This close operational relationship has laid the foundation for the intensive collaboration in Termez which will unfold over the next three years. Beginning with the initial development of the concept for a simulation centre back in 2019, and continuing through joint appraisal missions, meetings with partners, the creation of an advisory committee, and the recent kick-off meeting, KfW and GIZ have been working side-by-side, even on tasks for which responsibility officially sits with one organisation or the other. 

The multi-stage planning process has provided representatives of partner organisations the opportunity to experience integrated German cooperation firsthand. After years of close cooperation with GIZ to develop specialised training programmes for nurses, Dr Lolakhon Musadjanova, the director of the Republican Medical Continuing Education and Specialisation Centre for Nurses and Pharmacists, has been participating in planning meetings for the simulation center and joined the KfW-led appraisal mission to Termez. ‘Our interaction with German development cooperation over the years has been predominantly with GIZ, but in the context of the project in Termez we see that the work of the two agencies complements each other well,’ she says. ‘Each is responsible for its own area and fulfils a specific mission in the larger project.’

As they shift from planning to implementation, KfW and GIZ are keeping a laser-like focus on what is actually needed for the project as a whole to succeed – and to think and work outside the box, where necessary, to best align their contributions. A prime example is the procurement of equipment. Rather than leaving this until the end of the project when the building is nearly complete, KfW will purchase certain essential equipment early on and install it at an interim training location at the Termez branch of the Tashkent Medical Academy. This will allow the GIZ team to begin introducing simulation-based education techniques to instructors from the medical training academies and technical colleges and to gradually build up the programme which will eventually be offered in the new facility.

‘By staging the procurement, we can start working with partners on new teaching methodologies and approaches to evaluating students’ practical skills. At first, we will focus on developing greater comfort using basic equipment in small group settings and then move on to more advanced simulation scenarios,’ explains Cord Versmold, who leads the Modernisation of medical education and training in Termez project on behalf of GIZ. ‘When the centre opens, the instructors will be ready to move in and begin working straight away.’ 

Both the Embassy and BMZ have endorsed this somewhat unusual arrangement, recognising the benefits of integrated planning and phased implementation. ‘It may not yet be so common to do it in this way, but it might be a good example for others,’ says Dr Wimmer, the Counsellor at the German Embassy. 

Focus on what partners need – and then find ways to deliver it

The health sector in Uzbekistan offers a positive example of a strong ‘internal’ partnership on the German side – between the two implementing agencies, the Embassy, and BMZ – wedded to clear and well-organised external coordination with partner institutions. It shows that harmonised designs and careful operational alignment can help to bridge some of the structural constraints which are inherent in Germany’s financial and technical cooperation model, but that doing so requires strong commitment and consistent effort. 

Another lesson is that the planning of development cooperation projects should begin by understanding the needs of partners, and only then consider how financial and technical cooperation can come together to make it happen. ‘The success of any development cooperation project should be closely tied to the benefit it brings to the partner,’ says KfW’s Vitalis Ritter. ‘When we combine our forces, our projects are more meaningful and are perceived as more meaningful by our partners. And this, in turn, benefits the very vision and objective of our development cooperation.’ 

Karen Birdsall
April 2024