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NOFO: USAID Strengthening Local Health Systems Activity (Uganda)

Deadline: 17-Apr-24

The United States Agency for International Development (USAID) Mission in Uganda (USAID/Uganda) is seeking applications for USAID Strengthening Local Health Systems activity to improve health outcomes and health security through increased availability of quality health services for all people in Uganda.

The purpose of the Activity is to strengthen key elements of the Ugandan health system: health care financing (HCF), human resources for health (HRH), health information systems (HIS), and community health systems. The Activity will provide tailored technical assistance (TA) to the Ministry of Health (MoH) to develop, update, test, and disseminate policies, strategies, tools, models, standards, guidelines, approaches, and evidence-based intervention packages that can be implemented by the central government, districts, health facilities, and communities to improve the performance of the health system.

The United States Agency for International Development (USAID)’s Mission in Uganda (hereinafter referred to as USAID/Uganda) invests more than $350 million annually in health area-specific programs, including Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), malaria, tuberculosis, maternal and child health, nutrition, family planning, and global health security. Health systems strengthening (HSS) remains critical to the achievement of USAID’s goals of preventing maternal and child deaths, controlling HIV/AIDS, and combating infectious disease.

Objectives
  • Objective 1: HCF and PFM Strengthened 
    • The desired outcomes under this objective are increased domestic resources mobilization for health, increased efficiency in the utilization of available resources, and improved accountability in the use of resources in the health sector. The Activity will support GoU’s efforts at the national level to explore sustainable domestic financing options.
    • Anticipated Outcomes: 
      • GOU health budget execution rate reaches at least 90% each year.
      • GOU health budget allocation formula revised to ensure equity and allocative efficiency.
      • Budget execution rate for major donor funded projects such as the Global fund and GAVI increased from about 41% in FY 2021/2022 to at least 80% annually.
      • PHC grant guidelines revised to include RBF.
      • Increased GOU budget for health as a proportion of national budget from 7.7 currently to at least 10% by the end of the project.
      • At least 90% of districts continue to have unqualified audit reports annually.
    • IR 1.1 Evidence Based Budget Advocacy Conducted
      • USAID/Uganda and the GoU remain committed to increasing domestic financing of the Ugandan health sector. Although the absolute amount of the health budget has been increasing since 2018/19, the percentage of the national budget allocated to health has not changed significantly.
    • IR 1.2 Budget Planning and Execution Strengthened
      • The MoH’s core strategic interventions in its health financing strategy include specific objectives on revenue collection, risk pooling, and strategic purchasing. Reducing or removing inefficiencies alone could have meaningful impacts on resource availability.
    • IR 1.3 PFM Strengthened
      • According to a study conducted by the World Bank, both MoH and Ministry of Finance, Planning, and Economic Development (MoFPED) estimated that Uganda loses at least $11 million annually, 36.7 billion Ugandan Shillings, due to waste and inefficiency. A more recent study by GIZ (German development agency) indicated that addressing corruption in the health sector in Uganda could result in annual savings of up to 25% of government spending on health.
    • IR 1.4 Innovative HCF Options Identified and Implemented
      • The Activity will work with MoFPED, Ministry of Local Government (MoLG), key parastatals, and other relevant ministries to advance health financing reform, including the anticipated national health insurance program. While the private sector has a significant presence, its potential, particularly in terms of financing health care, has not been fully explored and is less well understood.
  • Objective 2: HRH Strengthened
    • The Activity’s anticipated outcomes under this objective are increased availability of health workers in the public sector, improved skills, and increased productivity of the health workforce at all levels of the health systems. While the overall production of health professionals has increased in Uganda (except for a few cadres), the government has not been able to absorb substantial numbers of those that graduate and are available to work.
    • Anticipated Outcomes: 
      • Vacancy fill rate in the health sector increased from 78% currently to 90% at the end of the project.
      • Health staff absenteeism rate decreased from approximately 50% currently to less than 20%.
      • Annual wage analysis and recruitment drive supported nationwide to ensure timely recruitment of staff.
      • The new staffing structure adopted by the central MOH, all districts and health facilities nationwide with a 20% increase in staffing levels each year.
      • Proportion of staff who receive performance evaluation increased from 70% currently to 90%.
      • A virtual training platform created at the Mbale Institute of Human Resource Development and made accessible to all registered health professionals.
      • Proportion of HRH funded by PEPFAR reduced by at least 40%.
    • 2.1 Strategic Planning for HRH Improved
      • To implement changes to the health sector staffing structure, the MoH has reorganized the management of HRH under two departments: the Department of Human Resource Development (HRD) and the Department of Human Resources Management (HRM). The Activity will support the MoH to operationalize the 10-year HRH strategy and adopt a comprehensive approach to national HRH planning and implementation.
    • IR 2.2 Performance Management of Health Workers Strengthened 
      • Health worker performance continues to remain a key challenge for Uganda’s health sector. This could be improved by instituting proper staff performance management practices.
    • IR 2.3 the Capacity of the Health Workforce Improved 
      • Health workforce development/training plays a pivotal role in improving workforce capacity and performance to provide high quality services to the population. One of the objectives of the 10-year HRH strategic plan is to develop an adequate health workforce to meet the changing needs of the country, ensuring the right skills mix, and quality and integrated sector-wide training planning to match HRH supply to country needs.
  • Objective 3: HIS Strengthened
    • Timely and reliable data are essential to support implementation of other health system building blocks. The MoH in Uganda relies on data from multiple health facilities, population-based surveys, civil registration, and vital statistics systems to develop policies and improve service delivery. Since 2012, the MoH has been using standardized paper tools to collect routine data, which are eventually aggregated into the District Health Information Software (DHIS2), an open source, web-based platform used to manage health information.
    • Anticipated Outcome: 
      • Shift from using manual data reporting to digital platforms with approximately 600 facilities using the EMRs.
      • At least 95% of all HMIS reports submitted on time.
      • Capacity to conduct further analysis using routine and survey data built within the Department of Health Information.
      • Health Information Exchange developed to enable interoperability between approved MOH EMRs and other systems including but not limited to logistics and laboratory in at least 600 facilities.
      • The eCHIS scaled up for use with at least 30% of community health workers reporting through the system.
      • Increased data quality score to at least 70% on key indicators.
    • IR 3.1 Digital Health Platforms Harmonized and Strengthened 
      • Implementation of and investment in digital health platforms has largely been led by donors. In addition, other structural challenges such as poor internet access, limited electricity supply, and low ICT skills have made it difficult for MoH to fully operationalize digital health platforms. The MoH and collaborating partners must work together to harmonize and ensure integration of systems.
    • IR 3.2 Coordination of HIS Governance Streamlined and Strengthened
      • MoH has formal structures to manage HIS. The Activity should develop and strengthen synergies between the key HIS stakeholders to set standards and ensure coordination in data management, use, and dissemination.
    • IR 3.3 Health Information Planning and Management Strengthened 
      • The sources of health information include individuals, facilities, and population-based surveys. According to WHO, a functional HIS should be able to generate data from these sources. In addition, it should have the capacity to detect, investigate, communicate, and contain events that threaten public health security at the place they occur, and as soon as they occur.
  • Objective 4: Community Health Systems Strengthened 
    • Preventable communicable diseases drive the largest proportion of Uganda’s disease burden, though non-communicable diseases are rising. Disease prevention and health promotion cannot be done by health facilities and medical staff alone. With that in mind, the GoU introduced the VHT program in 2001 to mobilize communities for health programs and strengthen health service delivery at household levels. Since then, the VHT program has faced many challenges related to the VHTs’ voluntary status.
    • Anticipated Outcomes:
      • Community Health Extension Workers adopted as a formal health worker cadre by the
      • Ministry of Public Service.
      • Training and supervision of community health workers (CHEWs, VHTs, etc.) is standardized.
      • Reporting tools are created for the various cadres of community health workers.
      • Standard community package for integrated service delivery by community health workers developed.
    • IR 4.1 Key Aspects of the NCHS Prioritized and Operationalized 
      • The NCHS aims to empower households and communities to take greater control of their health. The strategy highlights the following priorities:
        • Revitalize community service delivery through community involvement and integration of services.
        • Introduce CHEWs as a new health cadre.
        • Strengthen community HIS.
        • Improve the community health supply chain and increase community health financing.
        • Strengthen leadership and governance of community health systems at all levels.
    • IR 4.2 Community Health Workforce Strengthened 
      • If the CHEWs pilot produces positive results, and the MoH decides to move forward with the implementation, the Activity will provide support to institutionalize this new cadre. Should the MoH decide against scaling up the pilot activities, then the Activity will, in consultation with USAID/Uganda and the MoH, jointly develop a plan to strengthen the VHT program and other community-based health workers and their interventions.
Funding Information
  • USAID intends to award one (1) Cooperative Agreement pursuant to this Notice of Funding Opportunity. Subject to funding availability and at the discretion of the Agency, USAID intends to provide up to $40,000,000 million in total funding over a five-year period. USAID reserves the right to fund any one or none of the applications submitted.
  • The period of performance for the Cooperative Agreement is five (5) years.
Outcomes and Results 
  • The Activity will provide tailored TA to the GoU to develop, test, refine, and disseminate policies, strategies, tools, models, standards, guidelines, approaches, and evidence-based interventions that can be implemented by the central government, districts, health facilities, and communities across Uganda to improve the health system performance. The overall goal of the Activity is to strengthen the Ugandan health systems to improve the quality of services and health outcomes for all Ugandans, thereby contributing to increased health security.
Eligibility Criteria
  • Eligible Applicants 
    • Eligibility for this NOFO is not restricted. In response to this NOFO, any U.S. or non-U.S. organization, non-profit, or for-profit entity is eligible to apply. Organizations may submit applications individually or in partnership with other international or local organizations.
    • USAID welcomes applications from organizations that have not previously received financial assistance from USAID. USAID assistance instruments do not require prior USAID experience. Faith-based organizations are eligible to apply for federal financial assistance on the same basis as any other organization and are subject to the protections and requirements of Federal law.
    • To be eligible for award of a Cooperative Agreement, in addition to other conditions of this NOFO, organizations must have a politically neutral humanitarian mandate, a commitment to non-discrimination with respect to beneficiaries and adherence to equal opportunity employment practices. Nondiscrimination includes equal treatment without regard to race, religion, ethnicity, gender, and political affiliation.
    • Applicants must have established financial management, monitoring and evaluation processes, internal control systems, policies, and procedures that comply with established U.S. Government standards, laws, and regulations. The successful Applicant(s) will be subject to a responsibility determination by the Agreement Officer (AO). The AO may determine that a pre-award survey might be necessary to assist in establishing the responsibility of the Recipient to receive U.S. Government funding.
  • Cost Sharing or Matching 
    • USAID has established a cost share of 5% of the projected award amount for the Recipient of the award. Such funds should be provided directly by the Recipient to contribute financially and/or in-kind to implementation of activities at the country level. This may include contribution of staff level of effort, office space, or other facilities or equipment which may be used for the program, provided by the Recipient.

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