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The German BACKUP Health Initiative

Learnings from 20 years of working for – and between – the Global Fund and recipient countries

Clemens Gros

Published by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH in October 2022.

Backup Health 2022

Key Learnings

Since 2002, the BACKUP Health initiative has been a key intermediary between the Global Fund and recipient countries. On BACKUP’s 20th anniversary, this review of experiences and learnings presents several insights into where and how providers of technical assistance and the Global Fund may wish to focus their efforts to achieve greater equity in health outcomes and health governance.

  • Agility, flexibility and recognising windows of opportunity are essential for impactful technical assistance (TA). BACKUP Health’s support to its partners has been most successful where the initiative was able to spot openings in political space or administrative process and was quick to deploy the right mix of subject matter expertise and knowledge of the local context. BACKUP has thus at times fulfilled the role of ‘honest broker’ between the Global Fund and recipient countries, for example, in their advocacy for stronger support to Country Coordinating Mechanisms (CCMs) – which ultimately contributed to setting up the Fund’s dedicated CCM Evolution project in 2018.
  • Several of the Global Fund’s core principles, such as civil society participation and accountability, still depend on external support by partners like BACKUP Health to be fully operationalised. This dependency will persist so long as the Global Fund does not internalise the necessary investments in technical support and capacity development for country partners. BACKUP has demonstrated that sustainable, inclusive solutions are possible. Its work with Supreme Audit Institutions in Africa has shown that the Fund’s accountability processes can be fully localised, signifying a strong move towards sustainability and alignment.  
  • Despite the Global Fund’s stated ambition to align itself with recipient country systems and priorities, concrete opportunities such as investing in a country’s pooled fund have been left unexploited. BACKUP Health has shown that it can deliver crucial preparatory work and prepare the way technically, though it cannot precipitate the requisite political will on the part of the Fund. 
  • The Global Fund and BACKUP Health were created to tackle inequities in global health outcomes. Today, twenty years later, they must tackle inequities in global health governance. Through more equitable distribution, the Fund’s resources have enabled remarkable successes in the fight against HIV, tuberculosis and malaria, particularly in the world’s poorer countries. But the Global Fund’s modus operandi has fallen short of the ambition expressed in its ‘partnership principle’, with CCMs maintained as structures parallel to countries’ existing health governance systems, with complex administrative procedures that are not harmonised with those of other Global Health Initiatives, and with the additional transaction costs that this entails. BACKUP Health can help by feeding its implementation experiences – via Germany’s representation on international boards – into the much-needed political discussion on the Global Fund and global health governance.

The challenge: Tackling inequities in health outcomes, global health funding raises issues of health governance

The Global Fund to Fight AIDS, Tuberculosis and Malaria (or simply Global Fund) was created in 2002 in response to what Kofi Annan called a ‘worldwide revolt of public opinion’. In the context of a growing global social justice movement, people demanded that governments deliver on health equity in the face of the raging epidemics of AIDS, TB and malaria that were killing an estimated 6 million people each year. The brunt of the suffering was borne by those who were too poor or too marginalised to access the effective treatment and care that were already available in affluent countries.

The Global Fund has become the world’s largest financier of prevention, treatment, and care for the three diseases and has begun to invest more broadly in overall health systems strengthening. Germany has been one of the largest contributors to the Global Fund from the start, with a pledge of €1 billion for the latest 2020–2022 funding round and €1.26 billion expected for the next phase.

Through its immense grant resources – around $4 billion annually – the Global Fund has become one of the most powerful actors in global health, alongside other Global Health Initiatives (GHIs). GHIs wield significant influence over health sector policies and programmes in many low- and lower middle-income countries.

In theory, the partnership principle espoused by the Global Fund aspires to ensure equity, not only in health outcomes but in health governance: i.e. that all those involved in the response to the three diseases have a voice in the Fund’s decision-making processes – including governments, civil society, communities affected by the diseases and technical partners. The Global Fund has also vowed to align itself with countries’ systems and priorities so that, at the least, accessing grant funding does not come at the expense of countries’ ownership over health policies and programmes and does not cause inordinate transaction costs.

In practice, the Fund’s insistence on parallel coordination mechanisms at country level in the form of CCMs, its complex administrative procedures and the power dynamics of grant governance, which determine who gets to sit at the decision-making table, run counter to its partnership principle. The Global Fund’s own reviews have diagnosed its limited alignment with national priorities, high transaction costs for recipient countries and shortcomings in adequately and consistently engaging and representing civil society and key populations in the pivotal CCMs (The Global Fund, 2016a, 2019a; The Global Fund/World Bank Group, 2020). Unsurprisingly, recipient countries have often found it difficult to navigate the Global Fund’s complex processes and requirements to access and implement grant funding. The demand for technical assistance (TA) has been immense from the start.

The response: Technical assistance to access funding and strengthen capacity, participation, accountability and alignment

To meet this need, in 2002, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH set up the BACKUP Health initiative. With a funding volume of €30 million for three years, it constituted a major commitment for the organisation. The overarching objective was to help countries access and use Global Fund resources effectively in the fight against the three diseases. In 2005, recognising the early successes and added value of the project, the Federal Ministry for Economic Cooperation and Development (BMZ) decided to invest in BACKUP Health. Over time, BACKUP has increasingly focused on helping its partners operationalise meaningful civil society participation, localise and strengthen the ownership of the Global Fund’s accountability mechanisms, and work towards greater alignment of the Fund with national priorities and systems.

Over the past 20 years, BACKUP Health has financed over 800 TA measures in around 90 countries. It has become an integral part of the Global Fund’s support ecosystem, also thanks to the significant contributions of its donor partners. Since 2013, BACKUP has been co-financed by the Swiss Agency for Development and Cooperation (SDC). In 2020, both Expertise France and the UK Foreign, Commonwealth and Development Office (FCDO) signed a co-financing agreement.

What has been achieved?

The mainstay business of BACKUP Health has been to use its relatively limited project resources to help recipient countries access and implement disproportionately larger Global Fund grants. Its support to countries in making funding requests to the Global Fund embedded in the national dialogue, generally with the assistance of experienced consultants hired for this task, has led to hundreds of successful grant applications over the past 20 years, ranging from funding for health systems strengthening in Angola, to combined HIV/TB programming in Uzbekistan, to accessing the COVID-19 response mechanism in Sierra Leone, to name but a few. A recent Global Fund audit report on capacity building and technical assistance recognises BACKUP’s approach as good practice, emphasising its fully transparent communication with the Global Fund, from the initiation of in-country technical assistance to assessing impact and reporting results.

Beyond access to funding, BACKUP Health has strengthened the capacity of governments and civil society to implement grant-funded interventions and to participate in the governance of Global Fund programmes at country level. Such effects have been multiplied by BACKUP’s support to regional knowledge hubs in Eastern Europe and in Eastern and Southern Africa. Between 2017 and 2019, BACKUP developed a new modular approach called Strategic Technical Assistance for Grant Excellence (STAGE), combining specific TA for grant management with organisational development support. Initial reports from the selected countries where STAGE has been deployed are promising.

Other capacity development efforts by BACKUP have focused specifically on enabling and empowering civil society organisations (CSO) and key populations to engage in CCMs, the main governance arena of the Global Fund at country level. This support has contributed to making Global Fund processes more inclusive and anchored in a practical human rights-based approach. Through its work with a broad range of partners, from grassroots community organisations to national Supreme Audit Institutions, BACKUP has helped to demonstrate how the Fund’s accountability mechanisms can be grounded in local ownership, instead of continuing to rely on multinational accounting firms.

But BACKUP’s experiences also reveal that several of the Fund’s core principles and functions, from partnership to civil society engagement and accountability, appear to be dependent on external support to be fully operational, raising crucial questions regarding their sustainability and alignment. The parallel structure of CCMs and the administrative procedures of the Fund, which are not harmonised with those of other GHIs, limit the Fund’s integration with national systems and impose significant transaction costs on recipient countries. 

For BACKUP Health it is important to consider where their efforts to strengthen GHI coordination and alignment are likely to be impactful. Certain country examples give promising signs that inroads can be made at country level. However, a sustainable solution – making alignment the norm rather than the exception – is likely to require structural changes at a central, policy level of the Global Fund.

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