CSO Budget academy / Breaking the dependency cycle: Uganda’s drive for homegrown preparedness

Breaking the dependency cycle: Uganda's drive for homegrown preparedness

Civil Society Advocacy for Domestic Investment in Epidemic Preparedness

From 2018 to 2025, Resolve to Save Lives, the Global Health Advocacy Incubator and more than a dozen civil society organizations from nine countries—Ethiopia, Ghana, Kenya, Nigeria, Senegal, South Africa, Tanzania, Uganda and Zambia—partnered to increase domestic investment in epidemic preparedness.

Activities spanned coalition building and toolkit development, advocacy and media training and targeted engagement with political and financial leaders to make the case for investments in epidemic preparedness. The program is a testament to civil society’s potential to change policy, catalyze change, bolster domestic resources and safeguard communities.

Country context

In June 2019, a family became infected with Ebola while traveling in the Democratic Republic of Congo. As documented in Epidemics That Didn’t Happen, several family members died after returning home to Uganda. Yet Uganda’s effective epidemic preparations, which started when the Ebola outbreak began in DRC, prevented disease within its borders.

Mpox, Marburg, Ebola—we face these all the time because we are situated in the Congo Basin and are very prone to pathogens of pandemic potential.They are a clear and present danger. And we have to stay focused. We can’t tire of it. Unlike other countries, we are particularly exposed.
Justinian KateeraGHAI In-Country Coordinator for Uganda

Established in 2013, the Uganda National Institute of Public Health (NIPH), an entity under the Ministry of Health, is responsible for epidemic preparedness and response. Its Public Health Emergency Operations Center (PHEOC) operates under an emergency management model to coordinate day-to-day outbreak preparedness and response. Both are critical pieces of the country’s public health emergency architecture.

But while Uganda’s dedicated public health workforce, in partnership with technical and development partners, has made tremendous effort to improve epidemic preparedness, there is heavy reliance on external donor support. In fact, over half of Uganda’s health budget has been funded by foreign aid, including 85% of HIV funding and 90% of malaria funding.¹ Similarly, almost all NIPH and PHEOC activities and staff have been financed by external partners, threatening sustainability.² The U.S. Centers for Disease Control and Prevention (U.S. CDC), a core epidemic preparedness funder, began scaling back its support in 2023 and planned to end funding by 2025. While leaders in the public health space noted government readiness to finance outbreak response, they have cautioned that there is no similar interest in funding preparedness.

We had to create advocates around epidemic preparedness. All other kinds of burdens of disease have advocates – advocates for HIV, NTDs, cancer, etc. But there had never been an advocacy effort seeking the allocation of funding to epidemic preparedness, though it was an obvious cause that affects Uganda particularly badly. We probably have an epidemic every year of varying proportions. And the impact on the economy was quite significant even prior to COVID so there was a need to invest in epidemic preparedness.
Justinian KateeraGHAI In-Country Coordinator for Uganda

Pioneering a lighter touch model

In July 2023, this context informed Resolve to Save Lives and the Global Health Advocacy Incubator’s decision to support advocacy for more domestic funding for epidemic preparedness. Uganda’s efforts followed and benefited from extensive advocacy undertaken in Nigeria, Senegal, and Ghana, which began in 2018 and were captured in the Budget Advocacy Toolkit for Epidemic Preparedness, which is a blueprint for conducting effective advocacy.

The thing that helped us was the GHAI Budget Advocacy Toolkit. It had clear procedures and processes that we went through.
Mable KukundaAdvocacy and Networking Officer, UNHCO

There was an opportunity to pilot the Toolkit in Uganda under the leadership of the GHAI in-country coordinator and a CSO partner, the Uganda National Health Consumer Organization (UNHCO). UNHCO was selected through a targeted budget advocacy workshop aimed at identifying local partners in new geographies. While epidemic preparedness was not the organization’s primary specialty, UNHCO had a strong foundation in budget advocacy, credibility and a network that could could help champion health security efforts.

In Nigeria, epidemic preparedness funding work was entering its sixth year. Experienced campaigners were deployed to support skill building in Uganda, including Nigeria Health Watch which provided capacity building to UNHCO to amplify its media capabilities.

Timeline and successes

Jul 2023	Uganda campaign begins
Oct 2023	GHAI and UNHCO participate in Uganda’s 2nd JEE and form CSO Health Security Coalition
Dec 2023	High-level government and stakeholders meeting on epidemic preparedness
May 2024	Government allocates UGX 57.8 billion (US$15.4M) for COVID-19 response and emergency preparedness
Dec 2024	NAPHS II completed and launched

Nigeria, Senegal, and Ghana each had large project budgets ranging from US$ 200-300K for grants and staffing, making them unsustainable in the long term and hard to scale. In contrast, Uganda piloted a leaner model with a budget under $100k. This marked a strategic shift in budget advocacy campaigning. The goal was to test whether a focused plan built on a proven model could deliver impact with fewer resources.

Devising a plan

The team followed the Toolkit’s roadmap to develop a focused campaign plan conducting a landscape analysis of the problem, context, and major players and mapping the budget cycle.

We organized the coalition on health security so that it comprised stakeholders who could gather and document evidence for our advocacy and create policy briefs while creating links to the committee in parliament. This ensured that these asks and recommendations were taken on.
Aziz AgabaHealth Policy Analyst, UNHCO

By October 2023, the team was moving quickly. UNHCO established the CSO Health Security Coalition, which convened key organizations and supported advocacy with technical expertise on budget and public health matters, government connections, and networks to amplify key messages. The coalition members–the Civil Society Budget Advocacy Group, the Coalition for Health Promotion and Social Development, the Infectious Diseases Institute (IDI) at the Makerere University School of Public Health (RTSL technical partner in Uganda), and Samasha Medical Foundation, among others—agreed on terms of reference, campaign goals to increase epidemic preparedness funding and accountability terms for fund usage.

At the same time, the GHAI in-country coordinator and UNHCO connected with national health leadership by participating in Uganda’s second Joint External Evaluation (JEE), which was supported by RTSL. The first JEE in 2017 noted that there were significant funding challenges—particularly for IHR implementation and outbreak response—and that there was an urgent need for advocacy within government citing ad hoc and insufficient funding for IHR implementation and outbreak response. Indeed, funding for outbreak management was one of the few areas where Uganda received a 1, the lowest JEE score.

The 2023 JEE showed Uganda to have “one of the best emergency preparedness and response systems in Africa,”³ yet gaps remained. Most notably, Uganda was heavily reliant on donor funding for its epidemic preparedness and response system. This highlighted the need for advocates to continue to push for better funding and accountability in spending.

The advocacy team engaged government officials on the need for increased funding while working closely with PHEOC leaders to refine and validate their ask. This engagement led the CSO Health Security Coalition to create a position paper advocating for USD 600k in domestic funding to the PHEOC to compensate for the outgoing US CDC support. When we spoke to the health committee and other departments of government, there had been no advocacy. And members of parliament were not aware that CDC was leaving and that emergency preparedness needed attention.
Robinah KaitiritimbaExecutive Director, UNHCO

As advocates made their case to parliamentarians, they encountered a significant challenge: the Ministry of Health had not budgeted for line items paid for with donor support. They also realized that parliamentarians were not aware of the need for increased epidemic preparedness funding and intensified their efforts, emphasizing the urgency of mobilizing domestic funding as external funding cuts loomed.

Advocates argued that amidst competing priorities, funding for epidemic preparedness would have a positive ripple effect. They emphasized that health security benefits the entire health system and that outbreaks disrupt all services. Using convincing evidence, they also argued that responding to outbreaks was far more expensive that preparing for and preventing them.

Wins and challenges

In May 2024, snowballing of enthusiasm following this advocacy led the Parliament to allocate UGX 57.8 billion (US$15.4M) for COVID-19 response and emergency preparedness. This major advocacy win also raised important questions. Would the allocation be backed up by actual tax revenue? Could the Ministry of Health absorb such a large sum over a short timeframe? What were the spending priorities for the funds? Because the costed National Action Plan for Health Security (NAPHS) for 2024-2029 had not been finalized, spending priorities had to be developed using the updated JEE assessment. And completion of the costed NAPHS was a precondition for release of the preparedness funds.

In the budget committee of parliament there was a recognition of this need for increased spending on epidemic preparedness. And they didn’t want impacts on trade and tourism. At the same time, we approached the office of the president. So going through all of those avenues we were able to move those levers. Our first level of ambition was to cover the PHEOC and it was commendable for the government to recognize that we need to focus on the bigger picture toward health security.
Justinian KateeraGHAI In-Country Coordinator for Uganda

Following the allocation, UNHCO organized meetings with high-level government stakeholders to galvanize effective use of the new funding. These efforts led to the creation of a working group with IDI to support MoH absorption capacity. The Office of the Prime Minister joined in helping advance the development of the NAPHS and soon after, CSO Samasha Medical Foundation joined the efforts in earnest to help finalize it. Representatives of Samasha Medical Foundation were participants in the newly launched CSO Budget Advocacy Academy, a project that brought together CSOs from 7 countries to strengthen domestic advocacy for epidemic preparedness funding. For its Academy capstone project, Samasha had intended to focus on budget accountability. However, as the incomplete NAPHS continued to be a barrier to release of the newly allocated funding, they focused their efforts on providing technical support to complete the document which was finally launched on December 12, 2024.

At the launch of the new NAPHS, Dr Daniel Kyabayinze, Director of Public Health at the Ministry of Health, noted that the first plan developed after the 2017 JEE had suffered from poor funding. He hoped the new one presented an opportunity to prepare and plan for outbreaks with adequate financial support.

The timing gap between the budget allocation and NAPHS completion, along with the inherent challenges of managing large influx of money, caused difficulties. For instance, lack of absorption in early periods led to reduced releases of funds by the Ministry of Finance in later quarters. And most of the money remained unused. Still, significant funds – US$ 2M – were spent on Mpox response, and plans were drawn up to improve infrastructure including oxygen plants and laboratories, along with purchase of ambulances. Funding also went to the PHEOC to replace monies withdrawn by the United States, which was the original goal of the campaign. The delays did lead to an extension of the funding to mid-2025. In a healthy sign for sustainability, the Government of Uganda has mandated that in preparing for the next budget cycle all ministries, departments, and agencies must allocate funds for epidemic preparedness.

The campaign has been justified now that the Trump administration is pulling out of financing the mechanisms. The national allocations have become very important. We were raising those arguments and now it has become true.
Moses TalibitaLegal Compliance Officer, UNHCO

While the US$ 5.4M was a massive win for the advocates and for epidemic preparedness, the United States drastically reduced its support early 2025.⁴ Tens of millions of aid dollars covered HIV, TB, and malaria programs, including healthcare worker salaries, and much else, leaving a massive hole in Uganda’s health budget in the short run, and hard decisions in the mid term as Uganda enters in a new bilateral partnership with the US.

Government is coming to us and saying, “You are right that we should be more invested in our own system because we can’t suffer such abrupt terminations.” The point has been brought home strongly. The disruption is huge.
Justinian KateeraGHAI In-Country Coordinator for Uganda

Lessons learned and legacy

A template and the support of advocates experienced in epidemic preparedness budget advocacy can jump start a campaign. The Uganda efforts marked the first full use of the newly devised Budget Advocacy Toolkit for Epidemic Preparedness. Nigerian counterparts and technical experts supported capacity building for the Uganda team. Applying skills gained through the CSO Budget Advocacy Academy, Samasha Medical Foundation helped complete the NAPHS and monitored disbursement of the new allocation. Capturing and passing on lessons from past work enabled success in Uganda.
While multiple government sectors are involved in health security, often with international support, domestic self-reliance mandates that the whole-of-government recognize the need for epidemic preparedness. In Uganda, many critical functions funded by donors were off-budget, which meant MPs and officials lacked visibility into actual needs; as a result,some viewed preparedness as a foreign priority rather than a national one, leaving the country vulnerable.
Working closely with government stakeholders to understand their needs and challenges is key. Throughout the campaign, advocates pushed for greater investment in epidemic preparedness and deliberately aligned their requests with government priorities. The team also engaged in conversations with parlimentarians about the difficulties of balancing competing needs. Conversations were not just focused on top decision-makers; advocates also engaged technical staff and others who advise and guide leaders, preparing memos and setting schedules.
Successful budget advocacy requires a thorough understanding of the barriers to epidemic preparedness Advocates recognized the need for effective plans to manage an influx of funds, backed up by transparency and accountability frameworks, showing that the money was being well used. From the start, the campaign prioritized these goals, including the development of the NAPHS as a roadmap for prioritizing spending.
Timing is everything, but advocates cannot control the schedule of events. While Uganda experienced a welcome and dramatic increase in funding, it came before the NAPHS finalization and in advance of an accountability framework. As a result, delays kept the full allocation from being utilized. Understanding and aligning with the proper sequencing of policy, planning, and funding is the only way to ensure that resources translate into effective action. In Uganda, advocates were adaptive; they worked to extend the new funding so it could be properly utilized once a framework was in place.

We had high level discussions and partners at MoH who gave us a lot of information and push. We were able to discuss with the commissioners and PHEOC who were threatened by the US withdrawal the experiences they’ve had on epidemics in southwestern Uganda. And the MPs were moved by this information directed from the Ministry of Health.
Robinah KaitiritimbaExecutive Director, UNHCO

Conclusion

Formal work in Uganda has ended, but because many CSOs were trained on health security and received capacity building from experienced campaigners, progress continues. Numerous government officials and parliamentarians are now aware of the critical need for epidemic preparedness. There is a strong foundation for a more resilient health system—one that is better prepared to protect lives in the face of future outbreaks.

Much of the capacity of those who have worked in different parts of the health sectors have gone and moved to other jobs. Some people are looking for opportunities outside of Uganda so in the future the Ministry may have to rebuild capacity for new people.
Sylveria AlwochProgram Officer, UNHCO

As the United States government reshapes its bilateral assistance, the knowledgeable budget advocates who facilitated epidemic preparedness success will play an invaluable role in supporting policymakers as they mobilize and prioritize resources for health security.