Decentralising HIV and TB Control Through District Leadership: Insights From the Governance Graduation Model (GGM) in Central Uganda

ABSTRACT

The purpose of this study was to evaluate the effectiveness of the Governance Graduation Model (GGM), a district‐led governance strengthening approach designed to improve health system performance for HIV and tuberculosis (TB) control in Uganda. Despite substantial national progress in HIV and TB outcomes, persistent weaknesses in district‐level governance, planning, and coordination continue to constrain consistent service delivery and local sustainability. Using a longitudinal observational design, quantitative GGM scorecard data were collected from eight districts in the Mubende region at baseline, first follow‐up, and second follow‐up across eight governance and health system dimensions. Data were analysed in SPSS Version 26 using descriptive statistics and multivariate repeated‐measures analysis of variance (ANOVA). By the second follow‐up, seven of eight districts (87.5%) achieved the predefined graduation threshold (≥ 75%), indicating improved governance maturity and readiness for autonomous programme management. Mean governance and leadership scores increased from 64.3 at baseline to 93.9 at second follow‐up, while planning and coordination improved from 52.4 to 81.9 and finance from 57.4 to 84.4. Repeated‐measures ANOVA showed statistically significant improvements in governance and leadership ( p  < 0.001), planning and coordination ( p  = 0.005), and finance ( p  = 0.002). Supply chain management and health information management systems demonstrated positive but variable trends, while human resources for health and service delivery showed limited and inconsistent improvement. These findings indicate that district‐led governance strengthening can enhance accountability and operational readiness in decentralised HIV and TB programs, although sustained investment in workforce and service delivery capacities remains essential.