Usaid/Uganda Family Planning Activity Quarterly Report

Home , Ankole, Buganda, Buliisa District, Kibaale District, Kiryandongo District, Kyankwanzi

USAID/UGANDA FAMILY PLANNING ACTIVITY

QUARTERLY REPORT

FY21Q1 (October - December 2020)

Submitted to: Rhobbinah Ssempebwa (AOR)

Table of Contents List of Tables ...... III List of Figures ...... IV Activity Overview/Summary ...... V Acronyms and Abbreviations ...... VI Executive Summary ...... IX 1.1 Introduction ...... 1 Result 1: Ugandan leadership and coordination strengthened to support voluntary family planning ...... 2 1.1: Commitment to and leadership for voluntary FP programs strengthened at all levels ...... 2 1.2: Management capacity developed and strengthened ...... 3 1.2.1 Collaboration Meetings with MoH FP/RHCS ...... 3 1.2.2 Supportive Performance Assessment and Recognition (SPARS) strategy implementation .. 4 1.2.3 Conduct quarterly action review on FP commodities ...... 4 1.2.4: RH web-based reporting and monitoring in 11 FPA districts ...... 5 1.2.5 One Facility, One Warehouse implementation ...... 5 1.3: Cross-sectoral coordination and institutionalization ...... 6 1.4: Use of data for program design, management, and decision making ...... 6 1.4.1: Support to NMS and MoH on FP procurement planning for public sector facilities ...... 9 1.4.2: Support procurement planning in FPA supported districts...... 10 1.4.3: Implementation of the FY20/21 procurement plan ...... 10 1.4.4: Support Health Information, Research and Innovation Technical Working Group...... 10 Result 2: Positive social norms and behaviors enhanced to improve healthy timing and spacing of pregnancies ...... 11 2.1: Knowledge and understanding of root causes of social norms and their distribution ...... 11 2.1.1.1 Engagement of community and national radio stations TV stations, to deliver key information on FP ...... 11 2.1.1.3: Review and development of resource training packages for resource persons ...... 11 2.2: Innovative solutions to address root causes of social norms at the household and community levels developed and scaled: 12 Result 3: Access to quality, voluntary family planning increased ...... 14 Family Planning Uptake Summary ...... 14 Number of Mothers receiving Post-partum FP services ...... 15 Contraceptive Method Mix ...... 16 Trends in Long Acting and Reversible Contraceptives (LARCs) ...... 17

3.1: Provider readiness to deliver quality voluntary family planning services ...... 18 3.1.1 Training of Health Workers and Village Health Teams (VHTs) on FP ...... 18 3.1.2 Support facilities to integrate FP service at different care entry points ...... 19 3.2: Innovative approaches to support implementation of targeted interventions ...... 19 4. Monitoring, Evaluation and Learning ...... 23 4.1 Implementation and Dissemination of Evaluative Survey Findings ...... 23 4.2 Improving Data Quality and Use ...... 23 4.3 Partnership, Collaboration and Stakeholder Engagement ...... 25 4.4 Collaboration, Learning and Adaption ...... 27 PROGRAM MANAGEMENT ...... 31 Staff Recruitment ...... 31 Stakeholder Engagement ...... 31 Office Support-IT ...... 31 Compliance Activities ...... 31 Challenges and recommendation ...... 32 Planned activities for next quarter (FY21 Q2) ...... 32 Annex 1: Success story...... 34 Annex 2: Overall assessment Results for Drug Shops ...... 35

LIST OF TABLES Table 1: FP commodities Available at assessed drug shops ...... 21 Table 2: List of Grantee by District and Subaward Amount ...... 26 Table 2- 1: Overall assessment results for eight drug shops per category assessed...... 35

III

LIST OF FIGURES Figure 1: Trends in EM-SPARS Visits ...... 4 Figure 2: Trends in Monthly and Quarterly reporting rates ...... 7 Figure 3: Trend in proportion of HFs with complete FP reports ...... 8 Figure 4 Quarterly and Monthly Trends of DPMA stock Status ...... 9 Figure 5: DPMA stock status by District...... 9 Figure 7: Intersectional approach to gender ...... 13 Figure 6: Hart’s ladder of youth engagement ...... 13 Figure 8: FP uptake by Age group ...... 14 Figure 9: Quarter Trends of FP Uptake by user type ...... 14 Figure 10: FP users by Cluster ...... 15 Figure 11: FP Users by district ...... 15 Figure 12: Monthly trends of FP users (New and Revisits) ...... 15 Figure 13: Trends in PPFP uptake ...... 16 Figure 14: PPFP uptake by method and time service was received...... 16 Figure 15: Quarterly trends in Contraceptive mix (Jan-Dec 2020) ...... 16 Figure 16: Contraceptive method mix by age group (Oct-Dec 2020) ...... 17 Figure 17: Quarterly Trend of Implants and IUDs inserted (Oct’19-Dec’20) ...... 17 Figure 18: Monthly trend of Implant & IUD by age group (Jan-Dec’20) ...... 18 Figure 19: Overall performance of assessed drug shops ...... 20 Figure 20: Commodity availability in the assessed drug shops ...... 21 Figure 21:Table showing performance of record keeping and reporting ...... 22 Figure 22: Distribution of assorted HMIS tools quantified by tool category and district ...... 24 Figure 23: Sample screen shot of the FP Dashboard ...... 27

ACTIVITY OVERVIEW/SUMMARY

Activity Name: USIAD/Uganda Family Planning Activity Family Planning Project:

Activity Start Date and March 5, 2020 to March 4, 2025 End Date:

Name of Prime Implementing Partner: Pathfinder International

[Contract/Agreement] Cooperative Agreement Number 72061720CA00004 Number: Uganda Protestant Medical Bureau (UPMB) Name of Sub-awardees Uganda Youth Adolescent Health Forum (UYAHF) and Dollar Amounts: Samasha Medical Foundation (SMF)

Ministry of Health, Ministry of Finance and Planning, Ministry of Gender, Labor, and Social Development, Ministry of Education and Sports Uganda Family Planning Consortium National Planning Authority Major Counterpart National Population Council Organizations: Donor agencies DFID, United Nations Population Fund (UNFPA) IPs – Regional Health Integration to Enhance Services (RHITES), Uganda Health System Strengthening (UHSS), Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH), and the Social Behavior Change for Transformation (SBC4T), Uganda Learning Activity (ULA)

Bunyoro region: Kiryandongo, Kibale, and Bulisa Geographic Coverage Changes Rwenzori region: Kyegegwa, Kyenjojo, Ntoroko, and Bundibugyo (districts): Buganda region: Kyankwanzi, Butambala, Gomba and Rakai

October 1st, 2020 – December 31st, 2020 Reporting Period:

ACRONYMS AND ABBREVIATIONS 3FHI Faith for Family Health Initiative ACODEV Action for Community Development ADHO Assistant District Health Officer AMELP Activity Monitoring, Evaluation, and Learning Plan AOR Agreement Officer Representative BBBU Brick by Brick Uganda CAO Chief Administrative Officer CBS Central Broadcasting Service CDO Community Development Officer CHC Communication for Healthy Communities CIP Costed Implementation Plan CLA Collaborating, Learning, and Adapting CME Continuous Medical Education COC Combined Oral Contraceptives COVID-19 Coronavirus Disease 2019 CQI Continuous Quality Improvement CSO Civil Society Organization CSSA Civil Society Strengthening Activity DCDO District Community Development Officer DHIS2 District Health Management Information System 2 DHO District Health Officer DHT District Health Team DMPA Depot-medroxyprogesterone Acetate DMPA-IM Depot-medroxyprogesterone Acetate-Intramuscular DMPA-SC Depot-medroxyprogesterone Acetate-Subcutaneous DQA Data Quality Assessment EM-SPARS Essential Medicines-Supportive Performance Assessment and Recognition FAM Fertility Awareness Method FASBEC Family Strength for A Better Child FH Family Health FP Family Planning FP/RHCS Family Planning/Reproductive Health Commodity Security FPA Family Planning Activity FP-CIP Family Planning-Costed Implementation Plan FY Fiscal Year GBV Gender-based Violence GYSI Gender, Youth and Social Inclusion HAR Hope After Rape HC Health Centre HIA Health Information Assistant HMIS Health Management Information System HSD Health Sub-District HTSP healthy timing and spacing of pregnancy

ICOBI Integrated Community Based Initiatives ICYD Integrated Child and Youth Development IDI Infectious Diseases Institute IEC Information, Education, and Communication iHRIS International Human Resources Information System InPACT Innovation Program for Community Transformation IPC Interpersonal Communication IPS Implementing Partners IUD Intrauterine Device JMS Joint Medical Stores KIND UG KIND Initiative for Development-Uganda LACWADO Lake Albert Children Women Advocacy and Development Organization LARC Long-Acting Reversible Contraceptive LARCs Long Acting Reversible Contraceptives MCH Maternal and Child Health MCHN Maternal Child Health and Nutrition mCPR Modern Contraceptive Prevalence Rate MEC Medical Eligibility Criteria MEL Monitoring, Evaluation, and Learning MMS Medicines Management Supervisor MNCH Maternal Neonatal and Child Health MoGLSD Ministry of Gender Labour and Social Development MoH Ministry of Health NDA National Drug Authority NDP National Development Plan NGO Non-Government Organization NMS National Medical Stores NPA National Planning Authority NPC National Population Council OVC Orphans and Vulnerable Children PLGHA Protecting Life in Global Health Assistance PNFP Private-not-for-Profit PO Probation Officer PPFP Postpartum Family Planning PPFP Post-Partum Family Planning Q Quarter RBF Results-based financing RH Reproductive Health RHCS Reproductive Health Commodity Security RHITES Regional Health Integration to Enhance Services RHSP Rakai Health Sciences Program R&IH Reproductive & Infant Health SBC Social Behavior Change SBCA Social Behavior Change Activity SBCC Social and Behavior Change Communication VII

SCDO Subcounty Community Development Officer SCSA Strengthening Civil Society Activity SITES Strategic Information Technical Support SMF Samasha Medical Foundation SOP Standard Operating Procedure SPARS Supportive Performance Assessment and Recognition SRH Sexual and Reproductive Health SRHR Sexual and Reproductive Health and Rights SSCS Strengthening Supply Chain Systems TASO The AIDS Support Organization ToT Training of Trainers TWG Technical Working Group UFPC Uganda Family Planning Consortium UHSS Uganda Health Systems Strengthening UNFPA United Nations Population Fund UPMB Uganda Protestant Medical Bureau USAID United States Agency for International Development USG United States Government UYAHF Uganda Youth and Adolescent Health Forum VHT Village Health Teams WHO World Health Organization WUFBON Western Uganda Faith Based organization network Y1 Year 1 Y2 Year 2 YCC Young Child Clinic

VIII

EXECUTIVE SUMMARY The United States Agency for International Development (USAID)/Uganda Family Planning Activity (FPA) provides (i) above-site level technical assistance to national level government ministries and agencies, and site level technical assistance to 11 districts and 219 health facilities (HC II and above). The supported health facilities are classified into three regional clusters, namely: Albertine cluster (Buliisa, Kibaale, Kyangwanzi, and Kiryandongo districts); Central cluster (Butambala, Gomba, and Rakai districts); and lastly Rwenzori cluster (Bundibugyo, Kyegegwa, Kyenjojo, and Ntoroko districts). FPA applies evidence- based approaches that will be tested regularly to ensure efficiency of its interventions. Coordination, collaboration, and partnerships, for example, drive approaches to strengthen leadership and commitment to voluntary family planning (FP). Similarly, FPA promotes positive social norms and reproductive health (RH) practices through advocacy and social and behavior change communication (SBCC) via champions and influential leaders. Additionally, community-based organizations (CBOs) are supported to lead advocacy efforts at the national level and create demand for FP and establish linkages to care at the community level. Interventions by CBOs coupled with FPA’s direct engagement with health workers and District Health Teams leads to increased access to voluntary FP.

This report describes FPA achievements in FY21 Q1 drawn from activities implemented between 1st October to 31st December 2020. In summary, FPA through participation in stakeholder consultative meetings, provided technical assistance to the multisectoral taskforce and consultants leading the development of the second Family Planning-Costed Implementation Plan (FP-CIP) and evaluation of the first FP-CIP. FPA also leveraged meeting platforms for the Family Planning/Reproductive Health Community Security (FP/RHCS) Technical Working Group (TWG) engage with FP stakeholders connected to the ongoing National Medical Stores (NMS)-led FY21/22 procurement planning exercise in order to ensure improvements in the method mix and FP commodities available in the districts.

Similarly, FPA developed a draft implementation plan for district-level implementation for the One Facility, One Warehouse guidelines. These will be useful for district, facility, and implementing partners’ (IPs) staff in identifying and coordinating operational issues among various actors. At the district level, FPA participated in district budget conferences in four districts (Kibaale, Kyenjojo, Kyegegwa, and Butambala). Such meetings not only contribute to integration of FP into other sector budgets, but also promote the allocation of resources to FP, which ultimately increases uptake.

Furthermore, FPA continued to engage in interventions that support data use for design, management, and data-driven decision making. For example, during this reporting period, FPA conducted a Gender, Youth and Social Inclusion (GYSI) analysis, FP data verification, and internally held a data feedback and performance review meeting to assess FPA’s Year 1 (Y1) performance. As a result, FPA saw improvement in the proportion of completed reports among the supported health facilities- from 5% in March to 20% by the end of December 2020. The improvement in the proportion of facilities submitting completed reports was mainly observed in the districts of Rakai, Butambala, and Buliisa. Additionally, the average FP commodity stock out rate dropped to 4.5% in FY21 Q1 from the 9.2% reported in FY20 Q4. This can be attributed to improved monitoring of FP stock and redistribution activities conducted by FPA during this reporting quarter.

Through FPA’s partnership with USAID/Social Behavior Change Activity (SBCA), the Activity contributed to the review of SBCC materials developed by Communication for Healthy Communities (CHC). These materials will be adopted to support communication activities in FPA-supported districts. FPA also worked with district health teams (DHTs) and community gate keepers to broadcast 18 radio talk shows across nine radio stations, including CBS, Buddu FM, Unique FM, Radio Kiboga, Kiryandongo broadcasting services, Biiso FM, Voice of Tooro, Bundibugyo development Radio, and Karuguza development radio. The talk shows aimed to address common barriers to FP uptake such as FP myths and misconceptions and raising awareness about Gender-Based Violence (GBV)

Building on the youth engagement meetings held in Y1, FPA worked closely with the District Community Development Officers (DCDOs) and Probation Officers (POs) to verify and identify influential young people willing to be champions for the Activity. A total of 110 champions (53 M, 57 F) were identified through this process.

By promoting quality access of FP services at health facilities, FPA has seen more community members accessing FP services. During FY21 Quarter 1 (Q1), a total of 86,222 FP users were served in the 11 FPA-supported districts, bringing the cumulative number of FP users served since inception of the Activity to 253,577. This represents a 1% increase from baseline. Of the users served in FY21 Q1, 43,765 (51%) were new users and 42,457 (49%) repeat users. More (52%) of adult FP users ages 25 years and above continue to access and use FP services compared to adolescents ages 10-19 years and youth ages 20-24 years who constitute 16.9% and 30.7%, respectively.

In November 2020, FPA successfully completed a pre-award assessment exercise of a select group of Civil Society Organizations (CSOs) and CBOs that applied for the subgrant opportunities. This led to the selection and USAID’s approval of the nine most highly qualified CSOs/CBOs. These include: Faith for Family Health Initiative (3FHI), Lake Albert Children Women Advocacy and Development Organization (LACWADO), Action for Community Development (ACODEV), Family Strength for A Better Child (FASBEC), Integrated Community Based Initiatives (ICOBI), Innovation Program for Community Transformation (InPACT), Hope After Rape (HAR), KIND Initiative for Development- Uganda (KIND UG), and Brick by Brick Uganda (BBBU). 3FHI will support above site interventions, while the rest will implement at the community level.

1.1 INTRODUCTION

The USAID/Uganda Family Planning Activity (FPA) is a five-year initiative funded under Cooperative Agreement number 72061720CA00004 by the United States Agency for International Development (USAID). This Activity is implemented by Pathfinder International as prime and its partners: Uganda Protestant Medical Bureau (UPMB), Samasha Medical Foundation (SMF), and the Uganda Youth and Adolescent Health Forum (UYAHF). The main implementing partners are government ministries and agencies, particularly the Ministry of Health (MoH), Ministry of Gender Labor and Social Development (MoGLSD), National Population Council (NPC), National Planning Authority (NPA), as well as 11 supported districts, local private organizations, individual private health providers, and other United States Government (USG) implementing partners (IPs).

The goal of USAID/Uganda FPA is to support Government of Uganda to increase adoption of positive reproductive health (RH) behaviors among Ugandan women, men, and young people and contribute to long-term shifts in Uganda’s modern contraceptive prevalence rate (mCPR) and fertility rate by 2025 in 11 focus districts of Bulisa, Kiryandongo, Kibale, Kyankwanzi, Kyegegwa, Kyenjojo, Ntoroko, Bundibugyo, Butambala, Gomba, and Rakai.

The USAID/Uganda FPA seeks to create a favorable policy and financing environment to increase access to family planning by strengthening leadership and coordination for a strong health system with accountable leadership, sustainable financing and innovations for demand generation, service delivery, capable health workforce, functional supply chains and information system management.

The Activity long-term objective is to ensure that Uganda attains and sustains increased contraceptive use for healthy timing and spacing of pregnancy (HTSP) and creates scalable nationwide interventions by the year 2025.

USAID/Uganda FPA contributes to achieve the following three major results;

1. Ugandan leadership and coordination strengthened to support voluntary Family Planning (FP); 2. Positive social norms and behaviors enhanced to improve HTSP; and 3. Access to quality, voluntary FP increased.

This report describes activities implemented by USAID/Uganda FPA from 1 October to 31 December 2020 and constitutes FPA’s FY21 Q1 report.

RESULT 1: UGANDAN LEADERSHIP AND COORDINATION STRENGTHENED TO SUPPORT VOLUNTARY FAMILY PLANNING

1.1: Commitment to and leadership for voluntary FP programs strengthened at all levels In FY21 Q1, as an above-site mechanism, FPA carried on with strengthening the established collaborations and support to the MoH’s Reproductive and Infant Health (R&IH) division through the FP/RHCS working group. One of the activities supported by FPA was the development of the second FP-CIP and evaluation of first FP-CIP. FPA provided technical assistance to the taskforce and consultants leading the exercise on behalf of the MoH. FPA participated in the initial stakeholder consultative meetings and contributed to discussions on framing the priority focus areas for the costed implementation plan (CIP). FPA further engaged the consultants on the approaches and strategic shifts that the FP-CIP should focus on. FPA’s support ensured that FP CIP 2 addresses challenges of FP CIP1 implementation and has subsequently aligned FPA activities to address the gaps., Together with USAID Strategic Information Technical Support (SITES), held meetings with MoH on the FP-CIP monitoring database to determine its relevance in monitoring the next CIP given the MoH new approach to strategic shifts. The FPA team received an orientation to the database led by MOH with a conclusion that with some adjustments the database is still relevant and can be used for monitoring the next CIP. In the next review period, FPA will continue to engage SITES, MoH, and the consultants leading the CIP development on how the database can be optimized, and, as necessary, continue providing support to the FP-CIP taskforce on the next steps including to provide data for the costing exercise.

Building on Y1 interventions to support drug shops to provide modern contraceptives, FPA worked with the MoH drug shops taskforce committee to secure approval by the National Drug Authority (NDA) to scale-up provision of injectable contraceptives by drug shops. Technical assistance included preparation of documents, presentations, and recommendations in response to queries from NDA. In November 2020, a presentation led by the MoH, with support from FPA, was provided to the board and approval was issued to the MoH for the national scale-up of provision of injectable contraceptives in drug shops. FPA both contributed to drafting the submissions to NDA and the development of operational documents and standard operating procedures. Next quarter, FPA will focus on building the capacity of other partners and supported districts to scale-up the intervention. Support will include orientation on drug shops distribution of FP as a promising High Impact Practice; considerations for assessment and selection of drug shops; logistics and supply chain to enable access through drug shops, etc.

FPA further supported work initiated in Y1 to revise the National FP training curriculum and to harmonize the different training approaches. FPA, as a member of the task team, participated in the United Nations Population Fund (UNFPA)-led workshop in December 2020 to review the FP training curriculum. Moving forward FPA will support consolidating the findings from the workshop and ensure completion of the task.

Following the release of the World Health Organization’s (WHO) selfcare guidelines for Sexual and Reproductive Health and Rights (SRHR), MoH embarked on the development of Uganda’s self-care guidelines. FPA, as a member of the MoH self-care expert group, provided technical assistance to this process, providing input into the process of drafting the guidelines which are near completion. The guidelines cover multiple SRHR areas such as FP, sexually transmitted infections, antenatal care, among

others. In the next quarter, FPA will continue to support the processes until the guidelines are approved for implementation.

To strengthen coordination and efficiency and leverage resources across the USAID above-site mechanisms, FPA joined other USAID above-site mechanisms (USAID SITES, Uganda Health Systems Strengthening [UHSS] Activity, Strengthening Supply Chain Systems [SSCS] Activity, SBCA, Strengthening Civil Society Activity (SCSA, and the Maternal Child Health and Nutrition [MCHN] Activity) to develop a statement of purpose for collaboration among the USAID partners and MoH as well as a joint work plan. Engagement in this mechanism also led to the development of a joint presentation to USAID on the next steps in strengthening the collaboration and to MoH to highlight the scope of USAID’s support. In this reporting period, FPA planned to identify, train and/or orient FP champions on the importance of FP, barriers and key strategies for improving uptake. With USAID approval, this activity will take place in Q2. Similarly, development of FP2030 commitments could not be initiated in this quarter since the global and national processes were planned to start in January 2021.

1.2: Management capacity developed and strengthened

1.2.1 Collaboration Meetings with MoH FP/RHCS USAID/Uganda FPA provided ongoing technical support for strategic engagement with FP stakeholders through the FP/RHCS working group. FPA participated in all three meetings for the quarter that were organized by MoH and supported the secretariat to report back to the Maternal and Child Health (MCH) Cluster.

FPA also ensured ongoing technical engagement with the supply chain function at the MoH Pharmacy Department and supported the preparation and presentation of the stock status and supply chain updates as a standing agenda item for the FP/RHCS TWG and MCH Cluster meetings. The monthly discussions addressed the risk of expiry of condoms and Combined Oral Contraceptives (COCs) and coordinated with FP IPs to ensure increased distribution especially at the community level. FPA also leveraged the meeting platforms to reach out to FP stakeholders to engage with the ongoing NMS-led FY21/22 procurement planning exercise to ensure improved method mix and FP commodities in the respective districts. The Activity continues to use available data to drive key decisions among the TWG to support implementation of the FP high impact practices (HIPs) across service delivery programs.

Through the FP/RHCS working group, FPA supported coordination of the rollout of the RH web-based reporting, as well as implementation of the One Facility, One Warehouse guidelines this quarter. Additional details are outlined in 1.2.4 and 1.2.5 below.

1.2.2 Supportive Performance Assessment and Recognition (SPARS) strategy implementation Building on the experience of implementation of supervision, performance assessment, and recognition strategy (SPARS) for building capacity for logistics management at the sub-national level, FPA proposed to adapt the same to support RH/FP areas. In this quarter, FPA undertook initial engagements with MoH and the USAID SSCS Activity to develop the draft concept and tool for implementation of RH-SPARS as a model for supporting FP logistics management at the facility level, leveraging the network of Medicines Management Supervisors (MMSs) in the districts. This will be finalized for rollout in the FPA districts in the next quarter.

FPA also participated in the quarterly supply chain stakeholder meeting where Essential Medicines-SPARS (EM-SPARS) performance of various partners’ districts was presented. Whilst FPA does not directly pay for EM-SPARS visits, it has supported MMSs to plan and prioritize their activities and coordinated with respective IPs to facilitate their activities. The IPs include Rakai Health Sciences Program (RHSP) for the Central Cluster, Baylor Uganda for Rwenzori Cluster, and Mildmay Uganda/Infectious Diseases Institute (IDI) for Albertine Cluster.

Routine SPARS supervision by MoH and IPs delivering HIV, and other programs continued to dwindle with many facilities not being visited on schedule. For example, out of the 213 facilities that were due for supervision, only 59 (28%) facilities were visited in the 11 districts during the reporting period. Additionally,

4/11 districts had no SPARS visit for Figure 1: Trends in EM-SPARS Visits the quarter; these were Kibaale, Kyegegwa, Kyankwanzi, and Ntoroko. SPARS average score in the FPA-supported districts stands at 21.40 compared to the national average of 19.40 and corresponds to an improvement from 21.17 in the previous quarter for facilities visited. Such gaps will be addressed through mentorship, supportive supervision as well as through performance review meetings at district and regional level.

1.2.3 Conduct quarterly action review on FP commodities FPA participated in monthly review of the stock status and supply plans for FP commodities and monitoring the inter-warehouse transfers between NMS and Joint Medical Stores (JMS). Going forward, FPA will further monitor timely execution of the inter-warehouse transfers to minimize delays in picking and distribution of commodities after the decision has been taken by the MoH. FPA will also coordinate with the warehouses, MoH, as well as the SSCS Activity to monitor the order fulfillment for FP commodities and provide it to USG IPs on a case by case basis.

The FPA supply chain officers also supported the MMSs to review the stock position and order Cycle 3 fulfillment and further supported them to develop redistribution plans where needed. The actual 4

redistribution of the commodities, however, was not always executed because of the lack of facilitation. While FPA works out a more sustainable solution, commodity redistribution will be supported by outreach partners as well as those visiting health facilities for various reasons such as supportive supervision, mentorship, etc. FPA also provided technical assistance to USG and Uganda Family Planning Consortium (UFPC) supported IPs for the implementation of the One Facility, One Warehouse guidelines and other aspects of supply chain management.

1.2.4: RH web-based reporting and monitoring in 11 FPA districts In preparation for the national rollout of RH web-based reporting through DHIS2, FPA participated in a training of trainers (ToTs) that were then charged with the responsibility of rolling out the reporting to their districts of operation. FPA has been nominated to the national taskforce to monitor rollout of the system and ensure that the data generated used to improve quantification and ordering for FP commodities at both district and national level. The taskforce will also ensure that each district is appropriately supported continually to provide quality data in the system for decision making.

While the facility level rollout will primarily target HC II and HC III level facilities, midwives, members of the DHTs, as well as district-based partners will also be trained as the system will further catalyze the implementation of the One Facility, One Warehouse guidelines for facilitation and redistribution of FP commodities to address short term stock-outs in the districts. Facilities are expected to begin ordering in the next quarter. FPA is coordinating with the SSCS Activity, MoH, and the consultant to address gaps in the reports in the system and generate important operational reports including that for non-reporting facilities in each order cycle.

1.2.5 One Facility, One Warehouse implementation In this quarter, FPA developed a draft implementation plan for district-level implementation of the One Facility, One Warehouse guidelines. These will be useful for the district, facility, and IP staff in identifying and coordinating operational issues among the various actors. Each of the 11 FPA districts will be engaged to develop district-specific manuals to be completed this Financial Year (FY) and define the appropriate forum that will be used to monitor and report on implementation progress. Once established, FPA plans to use the lessons learned Kibaale District Budget conference: FPA District Activity Officer (DAO) highlights FPA Objectives and best practices to support the USG IPs to roll out a similar intervention in their districts.

Building on the training that was conducted in Y1, the FPA team continued to engage with the DHTs, MMSs, and IPs to ensure adherence to the guidelines. However, it was noted that there are still partners in the FPA districts that are yet to adopt full implementation of the guidelines. In collaboration with MoH, FPA will continue to support such partners.

One of the main challenges for implementation has been FPA’s limited ability to monitor order fulfillment and stock levels of each of the FP methods to appropriately respond to anticipated stock risks. This limitation is related to lack of web-based reporting such that at the national level, commodity status at service delivery points cannot be visualized. This will be addressed when the RH web-based reporting is fully operational. FPA plans to explore use of alternative methods of obtaining such data at least monthly as an interim measure. Additionally, dashboards have been developed to provide insights into the performance of individual facilities.

1.3: Cross-sectoral coordination and institutionalization FPA continued to engage with key government ministries, departments, and agencies whose work affects fertility, population matters, and planning, including NPC, NPA, and MoGLSD. FPA engaged NPA to explore opportunities for collaboration and to align FPA interventions to the new third National Development Plan (NDP). Priority activities were identified as supporting MoH and other key FP stakeholders to participate in the Human Capital Development Programing meetings; and development of district-specific action plans for hot spot districts that have high fertility, teenage pregnancies, and child marriages. These revised activities were approved by USAID for implementation in Y2. FPA will work with NPA in Y2 to support the MoH’s R&IH division and other stakeholders to engage in the human capital development program of NDP III, chaired by the Ministry of Education and Sports and the Community Mobilization and Mind-set Change chaired by MoGLSD, to ensure FP integration.

At district level, FPA participated in district budget conferences in Kibaale, Kyenjojo, Kyegegwa, and Butambala where the districts presented performance of the previous financial year budget and priorities for FY 2020/21 were defined. In Kyenjojo district, FPA collaborated with a local CSO, Western Uganda Faith Based Organization Network (WUFBON), to present a paper to the conference highlighting areas that need more budget allocation. Across several districts, FP featured as a priority area requiring more budget allocation in the health budget and pronouncements were made for the district to start integrating FP into other departmental budgets. FPA learned that FP is mainly budgeted for at the health facility level but not at the different departmental levels. In the next quarter, FPA will work to strengthen the multisectoral collaboration at district level to support the functioning of multisectoral working groups in line with the NDP III that is taking the program-based approach.

1.4: Use of data for program design, management, and decision making FPA has continued to engage in interventions that support data use for design, management, and data- driven decision making. During this reporting period, FPA conducted a Gender, Youth and Social Inclusion (GYSI) Analysis, FP data verification, and internally held a data feedback and performance review meeting to assess Y1 performance. Details of these are presented in the Monitoring, Evaluation, and Learning (MEL) section.

Completeness and timeliness of Health Managing Information System (HMIS) reporting Despite growth in the use of electronic methods to enhance completeness and timely reporting of health data, there still exists much room for improvement. During FY21 Q1, FPA collaborated with DHTs in the 11 supported districts to conduct verification of FP data in 206 health facilities that were identified as having gaps in reporting. In addition, FPA continued to work with the health facility in- chargers, District Biostatisticians, and HMIS focal persons at the Health Sub-District (HSD) to ensure monthly HMIS reports; 105 reports were submitted and entered into DHIS2 in a timely manner.

During FY21 Q1, 96% of health facilities submitted monthly reports on time compared to 98% recorded in previous quarter (FY20 Q4). Figure 2a) shows a decline in reporting rates. This is partly attributed to low reporting rates observed in Kibaale and Kiryandongo districts (Figure 2b). In Kibaale district, the Biostatistician was engaged in a results-based financing (RBF) assessment and received limited support from the HMIS focal person to have reports entered in DHIS2. While in Kiryandongo district, some private facilities, especially clinics, were less interested in submitting HMIS reports hence the low reporting rates. By the end of FY21 Q2, quarterly reporting rates in 8 out of the 11 supported districts was at 100% except for districts of Kibaale (78%), Kiryandongo (79%), and Kyankwanzi (99%) (Figure 2c).

2a): Monthly Reporting rates (Overall) 2b): Monthly Reporting rates in selected districts

100 98 98 Kibaale Kiryandongo 98 98 98 98 97 95 96 100 96 95 94 94 93 80 94 60 92 40 90 20 88 0

2c): Quarterly Trend in Reporting rate by district 100

0 Kibaale Kiryandongo Kyankwanzi Buliisa Butambala Gomba Rakai Bundibugyo Kyegegwa Kyenjojo Ntoroko

FY20 Q2 FY20 Q3 FY20 Q4 FY21 Q1

Figure 2: Trends in Monthly and Quarterly reporting rates

Completeness was calculated as the proportion of non-blank fields in HMIS section 2.6 – 2.6.4. Section 2.6 captures data on FP methods, contraceptives dispensed are recorded in section 2.6.1, while minor operations and integrated service in FP are captured in section 2.6.2 and 2.6.3 respectively, with PPFP 7

recorded in section 2.6.4. Nearly all data fields in HMIS section 2.6 and 2.6.1 from facility reports were more complete than those in HMIS section 2.6.2 -2.6.4. Figure 3a shows overall improvement in the proportion of health facilities submitting complete reports. The steady increase in the proportion of facilities submitting complete reports was observed in the districts of Rakai, Butambala, and Buliisa (Figure 3b).

3a) Completeness reporting rate (Overall) 3b). Completeness reporting rate (selected Districts)

HF with Non-Complete Reports (%) HF with Complete reports (%) Rakai (%) Butambala (%) Buliisa (%)

100% 50% 30% 90% 45% 25% Start of 80% 40% FPA

70% Mentorships, 35% 20% DQA/data 60% 30% vereification 50% Start of FPA 25% 15% 40% 20%

10% Complete Complete reporting

- 30% 15% Complete Complete Reporting 20% 10% Non 5% 10% 5% 0% 0% 0% Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

FY20 Q1 FY20 Q2 FY20 Q3 FY20 Q4 FY21 Q1 FY19 Q1FY19 Q2FY19 Q3FY19 Q4FY20 Q1FY20 Q2FY20 Q3FY20 Q4FY21 Q1 Figure 3: Trend in proportion of HFs with complete FP reports

Stock out rate of contraceptive commodities at FP service delivery points

FPA continued to monitor stock out rate of contraceptives at the facilities based on depot- medroxyprogesterone acetate (DMPA) which is provided routinely in most of the health units. During this reporting period, about 4.5% of health facilities in the 11 supported districts experienced stock outs. Compared to the previous quarter (FY20 Q4), the overall average stock out rates declined by 4.7 percentage points (Figure 4). This is attributed to improved monitoring of FP commodity stocks and

redistribution activities conducted during this quarter. However, slightly more health facilities reported stock outs of contraceptives in December 2020 (Figure 4).

Stock Out (%) Stock Available (%)

Figure 4 Quarterly and Monthly Trends of DPMA stock Status

Proportional to the number of health facilities in the district, Buliisa district had a high percentage of health facilities that were stocked-out, while districts of Kibaale, Butambala and Ntoroko registered no stockouts. Meanwhile a high proportion of health facilities in Kyenjojo districts were missing FP stock status reports (Figure 5). FPA is following up with the district teams to support the replenishment of stocked out health facilities.

List of HFs stocked-out during FY21 Q1

District Subcounty Health Unit Buliisa Biiso Subcounty Biiso Prison Clinic Buliisa Buliisa Town Council Buliisa HC IV Buliisa Buliisa Town Council Buliisa Prison HC II Buliisa Buliisa Town Council Uganda Martyrs HC II Bundibugyo Bundingoma Subcounty Bundingoma HC II Bundibugyo Kaghema Town Council Kisuba HC III Bundibugyo Kirumya Subcounty Bundimulangya HC II Bundibugyo Ngite Subcounty Kasulenge HC II Bundibugyo Ntandi Town Council Ntandi HC III Bundibugyo Ntotoro Subcounty Mantoroba HC II Bundibugyo Tokwe Subcounty Buhanda (Bundibugyo) HC II Gomba Kifampa Subcounty Kifampa HC III St. Jude Thaddeos Karungu Kiryandongo Kiryandongo Subcounty HC III Kyankwanzi Ntwetwe Town Council St. Thereza Ndibata HC II Byamungu Diagnostic Nursing Kyegegwa Rwentuha Subcounty Home (Rwentuha) HC II Kyenjojo Bufunjo Subcounty St. Klaus HC III Rakai Ddwaniro Subcounty (Rakai District) Buyamba Disp &Mu HC III Rakai Kagamba Subcounty Kayanja Prisons Clinic HC II Rakai Kyalulangira Subcounty Heal The Nation HC II Figure 5: DPMA stock status by District

1.4.1: Support to NMS and MoH on FP procurement planning for public sector facilities In collaboration with the USAID/SSCS Activity, FPA engaged with MoH to establish a taskforce to address gaps in quantification for FP commodities as part of the FY21/22 procurement planning for government- supported facilities. The taskforce developed consensus on the approach and coordinated technical assistance to MoH and NMS to improve FP quantification and kit content for HC II and HC III level facilities. The task force consisted of representation from FPA, the Clinton Health Access Initiative, UNFPA, SSCS, NMS, JMS, and MoH Pharmacy Department and R&IH Division.

NMS initially postponed the exercise till after elections, but later announced that they had deployed teams to the field. The postponement and resumption threw off the planned activities, including stakeholder meetings involving USG-supported IPs. FPA however continued to collect and analyze DHIS2 and IP data to inform the FY21/22 procurement planning. FPA used available data to define minimum quantities for each FP commodity for each district and level of care that NMS teams and MMSs could use to inform the quantification during the planning meetings with NMS. FPA also developed a quantification template, increasing the FP commodity quantities across all the districts, and conducted an orientation for the NMS teams to proactively support district teams to consider the FP procurement planning process.

During the next quarter, FPA will orient USG IPs to support any districts that are yet to complete the procurement planning process.

1.4.2: Support procurement planning in FPA supported districts FPA supply chain officers coordinated with MMSs in each of the 11 districts to support FP procurement planning. MMSs were oriented on the use of the template, ensuring that the FY21/22 procurement planning process resulted in improved FP method mix and quantities of commodities at all levels of care. By December 2020, the FY21/22 procurement planning exercise had been completed in the districts of Rakai, Gomba, Butambala, Kibaale, Kyankwanzi, Kiryandongo, and Bullisa for all levels, with only higher level facilities completed in Bundibugyo, Kyenjojo, and Ntoroko. For Kyegegwa, the activity will be conducted in the next quarter.

1.4.3: Implementation of the FY20/21 procurement plan During this reporting period, FPA continued to monitor implementation of the FY20/21 procurement plan performance in the 11 FPA districts and where some districts are performing better, FPA will use lessons from these districts to improve performance in others.

1.4.4: Support Health Information, Research and Innovation Technical Working Group FPA has continued to provide technical support to MOH- Division of Health Information (DHI) by participating in the monthly virtual research and innovation TWG meetings. Acting on the request of the TWG, FPA supported the DHMTs and health in-chargers in 11 supported districts to quantified MNCH/FP HMIS tool requirement for FY20/21. Refer to section 4.2.4 under Monitoring, Evaluation, and Learning for more details.

RESULT 2: POSITIVE SOCIAL NORMS AND BEHAVIORS ENHANCED TO IMPROVE HEALTHY TIMING AND SPACING OF PREGNANCIES

2.1: Knowledge and understanding of root causes of social norms and their distribution SBC design workshop In partnership with USAID/SBCA, FPA participated in a SBC design workshop that aimed to review SBCC materials developed by CHC for the purposes of adopting them to support communication activities in FPA-supported districts. Also, barriers to FP uptake, particularly social cultural norms and systemic challenges, were identified and targeted/strategic interventions to address these barriers were highlighted. This includes targeting men as both beneficiaries and influencers of FP, communicating the benefits of FP, tackling norms and attitudes with key community gatekeepers (such as community leaders, cultural and religious leaders) and providing balanced messages on FP methods and side effects. Several materials were adopted and FPA’s SBCC strategy will hinge on Uganda’s National FP SBCC Strategy. Other materials that were adopted include champion materials to support interpersonal communication (IPC) activities for FPA.

2.1.1.1 Engagement of community and national radio stations TV stations, to deliver key information on FP Motivating audiences to discuss topical health issues through Radio. Radio mobilization activities in FY21 Q1 concentrated on radio talk shows aimed to provide a conducive environment for behavioral adoption. Working with the district health teams and community gate keepers, FPA aired 18 radio talk shows on nine radio stations including CBS, Buddu FM, Unique FM, Radio Kiboga, Kiryandongo broadcasting services, Biiso FM, Voice of Tooro, Bundibugyo development Radio, and Karuguza development radio. Key topics discussed included addressing FP myths and misconceptions and raising awareness about gender-based violence (GBV) (including in FP use) throughout the 16 days of activism and World Aids Day. A total of 108 calls were made by listeners; the majority asked about: • Addressing FP side effects • Appropriate age to initiate FP • Gender differences that lead to GBV especially for females • Why HIV is persistent in Uganda regardless of the interventions that government instituted to curb its spread

The callers’ concerns were addressed immediately by the team of experts on the talk show and will be incorporated into all communication activities across different channels in the subsequent quarters. To further enhance knowledge of FP/RH FPA will print and disseminate materials to both health workers and beneficiaries (2.1.1.2)

2.1.1.3: Review and development of resource training packages for resource persons FPA gathered resources from government departments and IPs to strengthen the tools for implementation. These included kingdoms’ action plans on FP and gender, policy statements and pronouncements, National Male Involvement strategy for Prevention of GBV by MoGLSD, and documented best practices like Emanzi and the young emanzi tools. The documents have been reviewed and discussions with key stakeholders such as the MoGLSD focal point and UNFPA representative are 11

under way to harmonize resources for engaging resource persons. For different kingdoms, using their policy statements is one way of reechoing their commitment and garnering their support in their communities. The final training package will be shared in the next quarter once there is final concurrence with key ministry technical teams. Activities under 2.1.2 (Community group engagement and interpersonal communication interventions) will be implemented in Q1, following onboarding of CBOs and obtaining a waiver to facilitate government officials.

2.2: Innovative solutions to address root causes of social norms at the household and community levels developed and scaled: Identification of youth champions at subcounty level

Building on the youth engagement meetings held in Y1, FPA worked closely with DCDOs and POs to verify and identify influential young people willing to become champions for the Activity. The FPA Youth Officers met with the district officials including ADHOs, Chief Administrative Officers (CAOs), DCDOs, Subcounty Development Officers (SCDOs), Pos, and Community Development Officer (CDO) in order to vet previously identified champions, identify additional champions, and Identification of Youth & gender group: FPA Youth discuss key youth related issues at the district Officer in discussion with Gender Officer, Buliisa level. District

The issues that were addressed during the meetings included the role of the champions in building demand for FP at the community level and barriers to FP uptake by young people.

Using a set of criteria developed by FPA and the district officials, a total of 110 champions (53 M, 57 F) were identified across the 11 districts of implementation. The champions are representative of the district/community leadership, cultural, and religious institutions. The age disaggregation of the champions is as follows: zero adolescents 10-14, 7 youth 15-19, 47 youth 20-25, and 56 young people 26 to 30. Criteria for youth champions selection

Development of a youth and gender approach for FPA

The FPA youth and gender technical team developed a youth and gender strategy which details community engagement that ensures youth and gender integration. The strategy is benchmarked upon the social ecological model which focusses on the target beneficiary at the center and how best to reach their varying levels of influence to impact their overall outcomes. It will also be benchmarked upon Roger Hart’s ladder of youth engagement (Figure 6) and Kabeer’s measurement of women empowerment (Figure 7). The strategy, which presents the youth and gender strategy in detail and expounds on the interrelatedness between gender and youth interventions will serve as a guide to all youth and gender interventions.

Figure 7: Hart’s ladder of youth engagement Figure 6: Intersectional approach to gender

Health facilities visits to gauge providers on youth responsive services to clients

Youth officers in the three FPA regions visited health facilities to follow up on accuracy and timeliness of data reporting. The objective of this activity was to identify whether the facilities were reporting accurately on youth specific indicators; identify ways to support them to improve reporting; and to identify opportunities for collaboration of youth champions and health facilities - including referral mechanisms for young people.

Youth Officer engagements also enabled discussions with young/first-time mothers present at the health facility to build demand for post-partum family planning (PPFP) and long- acting reversible contraceptives (LARCs). As a result of the visits, the FPA team agreed on ideal days to meet with key groups (adolescents and youth and first-time/low parity mothers) with health facility teams. In Ntoroko district, for example, due to the overwhelming number of young mothers who visit the Rwebisengo Health Centre IV, the records showed that Tuesday had the highest attendance and this day Youth officer FP/RH information with was selected to meet with the young mothers at the health young mothers at Rwebisengo HC IV, facility to build demand for FP. Ntoroko District Other interventions under 2.2 will be implemented in Q2.

2.3 Mechanisms to optimize multi-sectoral approaches for addressing social norms developed and institutionalized; to be implemented in Q2 now that the waiver is in place to engage government officials.

RESULT 3: ACCESS TO QUALITY, VOLUNTARY FAMILY PLANNING INCREASED Family Planning Uptake Summary

During FY21 Q1, a total of 86,222 FP users were served in the 11 FPA supported districts bringing the cumulative number of FP users served since inception of FPA to 253,577 and representing a 1% increase from baseline. Of the users served in FY21 Q1, 43,765 (51%) were new users and 42,457 (49%) were repeat users. More (52%) adult FP users, ages 25 years and above, continue to access FP services compared to adolescents ages 10-19 years and youth ages 20-24 years who constitute 16.9% and 30.7%, respectively (Figure 8). The upward trend for both new users and revisits was observed in FY21 Q1 compared to FY20 Q4. Both new users and revisits increased by 26% (Figure 9).

Figure 8: FP uptake by Age group Figure 9: Quarter Trends of FP Uptake by user type

Albertine cluster contributed more to the FP users served in FY21 Q1 compared to the Central and Rwenzori Clusters (Figure 10). While in the same period, Kyankwanzi district served the highest number of FP users and least were served in Ntoroko district (Figure11). The high numbers in Kyankwanzi is attributed to condom distribution campaign that targeted to prevent unwanted pregnancies and spread of HIV among HIV discordant couples, sexually active community individuals living within and round bars and lodges. Through this campaign alone a total of 18,706 condom users were recorded at Ntwetwe HC IV during this reporting period.

Figure 10: FP users by Cluster Figure 11: FP Users by district

The monthly uptake of FP in the 11 FPA-supported districts has continued to increase from the inception of the Activity since March 2020. The continued mentorship of health workers on proper documentation and reporting of FP data and data verification activities conducted during this quarter can be linked to consisted upward trend of both new users and revisits (Figure 12).

Figure 12: Monthly trends of FP users (New and Revisits)

Number of Mothers receiving Post-partum FP services Providing PPFP is essential for ensuring the health and well-being of women and their babies. Women who are 0 to 12 months postpartum would want to avoid pregnancies in the next 24 months, however a majority do use contraception. FPA has worked with the DHTs in the 11 supported districts to encourage quality counselling and provision of PPFP services at health facilities. Further, FPA has continued to mentor health service providers especially midwives who attend to postpartum mothers on proper documentation and reporting of PPFP outcomes.

During this reporting period, a total of 10,348 postpartum mothers received PPFP services within 12 month after giving birth. This increased by 76.6% from 5,861 registered in FY20 Q4. The increase is attributed to improved documentation of PPFP data by health workers mentored by FPA teams at various health facilities during this quarter and in the previous quarters. The observed upward quarterly trend of PPFP uptake is as well reflected in the proportion of post-partum mothers receiving PPFP services (Figure 13). The proportional increase however remains below 50%.

13a): Quarterly trends in PPFP uptake 13b): % trends of mothers receiving PPFP services

Figure 13: Trends in PPFP uptake

Figure 14 shows that a majority, over 90% of PPFP users during this reporting period, received injectables (55.6%) and implants (35.7%), with 93% receiving PPFP services between 6 weeks to 12 months after giving birth.

Figure 14: PPFP uptake by method and time service was received.

Contraceptive Method Mix Figure 15 shows, that similar patterns of contraceptive method mix across quarters seems to have slightly changed in FY21 Q1. In this period, more (46%) FP users accessed condoms followed by injectables (32%) contrary to the trend in the previous quarters where more FP users were accessing injectables. This change in preference is linked to high proportion of FP users ages 15 years and above documented to have received condoms as a preferred method of FP during FY21 Q1 as shown in Figure 16. On the other hand, users of implants declined by 4 percentage points while users of injectables reduced by 9 percentage points compared to the previous quarter (FY20 Q4).

Figure 15: Quarterly trends in Contraceptive mix (Jan-Dec 2020)

Figure 16: Contraceptive method mix by age group (Oct-Dec 2020)

Trends in Long Acting and Reversible Contraceptives (LARCs) Figure 17 shows that there was a slight decline in the number of Implant and intrauterine device (IUD) insertions in FPA supported districts in FY21 Q1 compared to those inserted in FY20 Q4. Implant and IUD insertion reduced by 2% and 5%, respectively. The few number of implant and IUD insertion could be linked to a possible reduction in the demand for FP service in the month of December and low numbers served in October 2020. Further, monthly trend analysis of implants and IUD users shows that Implant insertions among users ages 20 years and older declined in November while those aged below 20 years sharply reduced in December 2020. Meanwhile for IUD users, insertions declined in December 2020 for young adolescents and adults 25 years and older (Figure 18).

Figure 17: Quarterly Trend of Implants and IUDs inserted (Oct’19-Dec’20)

Figure 18: Monthly trend of Implant & IUD by age group (Jan-Dec’20)

3.1: Provider readiness to deliver quality voluntary family planning services 3.1.1 Training of Health Workers and Village Health Teams (VHTs) on FP 3.1.1.1: Support ToTs to conduct integrated mentorships in the 11 districts. USAID approval was required to move forward with the mentorship ToT for government health workers. In anticipation of their approval, the FPA team…In anticipation of their approval, the FPA team made necessary preparations including a presentation of the concept to DHOs and other DHT members for their inputs and the development of mentorship tools and checklists for further review and input by the DHTs.

Following development of action plans by the ToTs trained in Y1, the FPA team followed up on implementation of the action plans with ToTs; offered supportive supervision; shared the training outcomes with facility in-charges where the ToTs are operating; and supported the ToTs to conduct Continuous Medical Education (CME) in their respective facilities during this reporting period. A total of 16 CME sessions were conducted to update other health workers on FP quality service delivery, sharing best practices such as PPFP and client-centered FP services, while also strengthening ToTs facilitation skills in preparation for the mentorship activity with other health facilities. Supportive supervision emphasized IUD and Implant insertions and removals, integrating FP health education into the Young Child Clinic (YCC), documentation of FP (including Fertility Awareness Methods [FAMs]), use of HMIS, and the need to regularly update FP commodity stock cards and verification of stock. Whilst it is still early to relate this support to system changes, there are some facilities that have started showing improvements especially in reporting and these will be continually supported for improved service delivery.

Joint mentorship for HMIS conducted in Y1 also identified areas for emphasis during the planned integrated mentorships. These include assessing, counseling, and documenting PPFP and FAM. With USAID’s formal approval on 28th December 2020, ToTs will be supported to conduct mentorship following the Presidential elections when health workers have returned to their duty stations.

To streamline quality assurance in FP service delivery, FPA supported the establishment of model sites at better performing health facilities supported by some of the trained ToTs. The characteristics of model sites include presence of separate FP room with adequate privacy; FP information, education, and communication (IEC) materials displayed; infection and prevention protocols available and displayed; TIART chat displayed; patients’ rights displayed; waste management protocols available and displayed; sterilization equipment available; standard operating procedures (SOPs) of instrument preparation available; client consent forms; demonstrable team work during FP service provision; presence of qualified staff in service delivery areas; availability of supplies; etc. The objective of establishing model sites was for them to serve as demonstration sites for ideal service provision, quality assurance, and FP clinical compliance. These quality assurance standards are to be cascaded during mentorship of the auxiliary facilities.

3.1.1.3: Training of VHTs in short term FP methods

Training of VHTs will be conducted in next quarter. In preparation for the training, FPA conducted a training assessment in all 11 districts. Working with the district health offices, the team identified VHTs that had been trained in FP, dates when training was conducted, which VHTs were still active, those that had been trained but not active, and reasons for inactivity. This information is the basis for the suitable capacity building for the VHTs identified. It will also be helpful to address gaps identified that lead to VHTs not being active. From this exercise, FPA teams compiled lists of VHTs to be trained, sub-counties where training will be hosted, and agreed on training schedules with theDistrict Health Educators (DHEs)/VHT focal persons. Four VHTs per facility will be trained from 219 health facilities (both public and Private-not- for-Profit [PNFP]) UFPA is supporting, bringing the total of 876 VHTs to be trained.

3.1.2 Support facilities to integrate FP service at different care entry points 3.1.2.1 Printing of FP IEC Materials

To ensure quality screening of clients for contraceptive use, FPA engaged WHO’s Uganda office which provided up to 150 Medical Eligibility Criteria (MEC) wheels out of the 600 copies requested. FPA also contacted Johns Hopkins Center for Communication Programs to request a shipment of 396 copies of Global FP Hands and Tiahrt Counselling Charts which were received. The books and counselling guidelines will be used by health workers and FP service providers to provide accurate information and advise clients on a comprehensive method mix. Other tools that have been printed and distributed include the Pregnancy Checklists, FP Handouts, Tally sheets, and VHT Referral forms. In the next quarter, FPA will continue engaging WHO for additional MEC wheels and explore available opportunities for printing additional tools. Engaging VHTs and satisfied users to promote FP will be prioritized in the next quarter, and so will support to health facilities to conduct integrated outreaches.

3.2: Innovative approaches to support implementation of targeted interventions Support to CBOs to integrate FP will be prioritized in the next quarter

3.3: Evidence-based practices to reduce financial barriers to voluntary FP adapted and scaled up.

3.3.1: Through the sub granted partner UPMB, FPA will train and Scale up Community Health Insurance (CHI) in PNFPs facilities as an alternative financing mechanism

3.3.2: Mapping of drug shops and private pharmacies Based on guidance from USAID, FPA conducted an assessment of eight drug shops out of the 17 in Kyenjojo District that were previously supported by the USAID Advancing Partners and Communities project and selected six drug shops that will be supported to provide FP services. Having consulted the District Health Department, an assessment was done in two sub-counties of Kanyegaramire and Kyembogo with highest need for FP services. The six drug shops were selected based on their performance on 10 parameters that included infrastructure and premises, drug shop licensing, staff qualifications and competencies, supervision, commodity availability, storage, record keeping and storage, infection, prevention, and control measures and waste management and Coronavirus Disease 2019 (COVID-19) SOPs. The results for the overall performance are shown in Figure 19. Details on each drug shops performance for the 10 parameters can be found in Annex 2 (Table 2-1).

90% 83% 78% 75% 80% 73% 65% 70% 60% 55% 60% 53%

50% 43%

40% Percentage

30%

20%

10%

0% NEW HOPE COMMUNITY T.T ADE'S BETTER CARE BRIGHT NATASHA ALINDA Overall Drug shops

Figure 19: Overall performance of assessed drug shops

Based on the results in Figure 19, the drug shops listed were selected: Subcounty Drug shop name KANYEGARAMIRE 1. New Hope D/S 2. Community D/S 3. Ade’s D/P 4. Better Care D/P KYEMBOGO SC 5. Natasha D/S 6. Alinda D/S

Overall, the performance for all eight drug shops was high as most performed above 50% with an overall percentage of 65%. The poorly scored areas were commodity availability (48%), supervision (50%), and infection, prevention, and waste management (56%) as seen in the table below. On infection prevention, all drug shops had suitable containers for disposing sharps but were not disposing of the non-sharps waste according to the MoH recommended color codes.

It was also observed that drug shops continued to provide FP services including injectables even during the period that they did not have direct support. A total of 431 clients had been served with injectable contraceptives (DMPA IM and SC) within a period of one-year October 2019 to October 2020. However, there were no records for other short-term FP methods such oral pills, condoms, and other short-term methods. The assessment also revealed that five out of the eight drug shops assessed were more than 10kms from the nearest health facility. The assessment showed that drug shops still had a few commodities according to Figure 20 below.

Figure 20: Commodity availability in the assessed drug shops

Overall drug shops had only 48% of the commodities available for FP the least being T.T (14%). Commodities assessed for availability included DMPA-SC (Sayana Press,) DMPA-IM (Depo-Provera), Oral pills, condoms, emergency contraceptives, and cycle beads, of which most of the drug shops had condoms the least being cycle beads and emergency contraceptives as shown in Table 1. Most of the drug shops reported that most commodities were purchased from pharmacies and others were provided by FHI360 through the USAID Advancing Partners and Communities project.

Table 1: FP commodities Available at assessed drug shops

COMMODITIES

New hope New Community T T. Ade's Bettercare Bright Natasha Alinda score Total DMPA -SC (Sayana Press) 0 1 0 1 1 0 1 0 4 DMPA- IM 0 1 0 0 1 0 1 1 4 Oral Pills 1 0 0 0 1 0 0 1 3 Condoms 1 1 1 1 1 1 1 1 8 21

Emergency Contraceptives 0 0 0 0 0 1 0 0 1 Cycle beads 0 0 0 0 0 0 0 0 0 Note: ‘1’-commodity was available at the time of assessment; ‘0’- commodity was not available at the time of assessment.

Regarding record keeping and reporting, on average 63% of the drug shops assessed had the records (registers, reports) and were reporting as shown in the Figure 21. Only one drug shop did not have any records (Alinda) since it had recently transferred to a new location with no records relating to the new location. All of the drug shops in Kanyegaramire sub-county were reporting to Bufunjo HC III as it is the closest facility. Reports were on file for all except T.T and Bright. Alinda drug shop preferred to report to Kyarusozi HC IV while Natasha was reporting to Kigoyera HC III though had stopped in March 2020 since health workers were no longer picking up reports.

100% 100% 100%

75%

63%

50% 50%

25% 0%

N E W H O P E COMMUNITY T.T ADE'S B E T T E R BRIGHT NATASHA ALINDA OVERALL CARE DRUG SHOPS Figure 21:Table showing performance of record keeping and reporting

Below are summary recommendations from the assessment: • FPA should prioritize supporting the drug shops to secure all short-term FP methods to improve the method mix • FPA should partner with the DHT to strengthen supportive supervision of the drug shops by the nearest health facility to improve reporting and quality of care. • Drug shops should be supported to adopt the MoH HMIS data collection tools for comprehensive reporting and stock management.

Next quarter FPA will focus on supporting the selected drug shops to improve the identified weak areas. The Activity will also be introduced in the two districts of Buliisa and Butambala where six more drug shops in each respective district will be identified and their operators trained on FP.

4. MONITORING, EVALUATION AND LEARNING

4.1 Implementation and Dissemination of Evaluative Survey Findings In December 2020, FPA through virtual means disseminated the FPA baseline (BL)survey (finding to the USAID Family health team. The dissemination of the BL including the GYSI analysis findings at district and regional level will be integrated with the data feedback and performance reviews meetings scheduled to take place in FY21 Q2.

4.2 Improving Data Quality and Use

4.2.1 FP Data Verification and Cleaning During FY21 Q1, FPA MEL and technical staff in close collaboration with district technical teams (Biostatistician, HMIS Focal Person, and FP Focal Person) conducted on-site data verification and cleaning of FP data in 206 health facilities across the 11 FPA-supported districts. The data verification teams checked the FP data reported against primary data sources (FP and related registers) to find out if the data reported was accurate. Inaccurate numbers were corrected both in the facility reports and in the DHIS2 system. This process later aided accurate and timely compilation of monthly and quarterly HMIS reports. FPA will in the subsequent quarters continue to support monthly and quarterly HMIS data verification and cleaning exercises at facility level including in selected drug shops and pharmacies.

FP data Verification at Iwamagwa HC III, Rakai District HMIS Report Validation at Busesa Medical HC III in Kibaale District

4.2.4 HMIS Tool Replenishment and Quantification As a follow-on activity to the distribution of assorted HMIS tools that was delivered to the 11 districts in the previous quarter (July-September 2020). FPA further supported districts with in-kind transport for last mile distribution, replenishing all health facilities lacking critical HMIS tools for documenting and reporting FP data. In addition, FPA worked with the district Biostatisticians, Health unit in- chargers, and Health Information Assistants (HIAs) to forecast the HMIS tool needs for FY20/2021 in 278 health facilities across FPA-supported districts. A total of 196,395 assorted HMIS tools were quantified and a request for printing was submitted to MoH through the USAID/SITES Activity. HMIS Tools Delivered to Kyegegwa HC Figure 22 shows a summary distribution of quantified HMIS IV, Kyegegwa District tools by category and district. In the next quarter (FY21 Q2), FPA will follow-up with USAID/SITES to establish when the next batch of printed tools will be available for pick-up and distribution to districts.

53,506 MCH Tools =191,861 Community Tools = 1,400 Report Forms = 3,134 39,015

37,294 HMIS Tools HMIS Total copies = 196,395

17,115 17,660 11,441 12,793 6,216

Copies assorted of Copies 19 526 810

Number of HFs 11 28 51 10 18 25 22 43 19 30 21

Figure 22: Distribution of assorted HMIS tools quantified by tool category and district

HMIS Mentorships In FY21 Q1, the HMIS mentorship was integrated within the Data verification, cleaning, and HMIS tool distribution activities. This mentorship focused on proper documentation of FP data and it was targeted to address unique gaps identified for each HF visited. Overall, 391 health workers in 203 health facilities were mentored. This includes midwives, facility FP focal persons, stores assistants, and HIAs. In the subsequent quarters, FPA will continue to conduct several sessions of mentoring and coaching to HMIS mentorship at Kimuli HC III Rakai District improve mentee’s essential knowledge and skills in FP metrics recording and reporting, encourage data- driven decision making by mentees, and improve quality of FP service delivery at health facilities.

iHRIS Training Data Entry During this reporting period, FPA in collaboration with the UHSS Activity and MoH obtained access rights to the International human resources information system (iHRIS) system. With these access rights, FPA was able to input into the iHRIS system data for medicines and logistics management trainings and LARC ToTs conducted in the previous quarter. Training data for the for community and cultural youth champions currently been entered will be completed in January 2021.

4.3 Partnership, Collaboration and Stakeholder Engagement In this reporting period, FPA focused on nurturing ongoing partnerships while also expanding to reach new partners to drive its agenda. In November 2020, FPA held a virtual introductory meeting with NPA with the objective to: (i) introduce FPA to NPA, (ii) learn about NPA’s mandate, and (iii) identify and agree areas/opportunities for collaboration. As a result of this and follow-up meetings, the opportunities for collaboration were identified as supporting districts to develop specific actions plans for hot spot districts that have high fertility, teenage pregnancies, and child marriages and supporting MoH and other key FP stakeholders to participate in the human capital development programing under NDP III.

FPA also held a virtual introductory meeting with the CSSA, one of USAID’s recently awarded above-site mechanisms. The discussions focused on sharing the different projects’ mandates and identification of areas of collaboration between the two Activites. Through CSSA, FPA will ensure training of subgrantee CSOs aims to improve their capacity and efficiency in service delivery. Potential areas were identified during the meeting as those that would require support once the CSOs are on board include capacity building in advocacy, accountability and transparency, systems and controls (financial management), leadership and governance (organizational capacity), and scale up of evidence-based interventions and adoption of standard tools in programming and implementation. 25

FPA also participated in the Family Health – Orphans and Vulnerable Children (OVC), IP virtual meeting that was organized by USAID and hosted by FPA in December 2020. The objective of the meeting was to create opportunities to strengthen synergies during implementation, as well as leverage USAID’s broader development portfolio to improve service delivery for OVC households and family health outcomes. The desired outcomes for this collaboration include: increasing uptake of Family Health (FH) services (FP, Maternal Neonatal Child Health (MNCH), Nutrition, WASH, and Malaria) among OVC beneficiaries at facility, community, and household levels; and increase identification of potential OVCs from FH service delivery points for referral and enrollment. The participants that were present for the meeting included USAID (FHT and OVC departments), I Care Activity, TPO Uganda, Integrated Child and Youth Development (ICYD), USAID/RHITES Implementing Partners, TASO Transition and FPA. From the presentation, six districts were selected for the initial pilot, namely Omoro (RHITES – Acholi), Lira (RHITES – Lango), Iganga (RHITES – EC), Mbale (RHITES E), Mbarara (LSDA/ Ankole), and Rakai (FPA).

In November 2020, FPA conducted a pre-award assessment exercise of the CSOs/CBOs that had submitted an Expression of Interest and Concept Note and went through the Grant Evaluation and Selection Committee review. The following methodology was used: • Site visit to the applicants’ offices • Desk Review of the policy documents and other documents submitted by the applicants, and • Interviews to clarify issues and to obtain response to questions raised during the desk review.

The assessment focused on evaluating the organizational, technical capacity, and fiduciary risks of the CSOs/CBOS as well as the existing financial systems and controls used in managing resources. For those applicants who scored highly during the assessment an invitation was extended to their representatives for a 1–day co-creation workshop to provide guidance on developing a full proposal. Pathfinder conducted a comprehensive selection process. Fifty-six organizations submitted Concept Notes in response to a public advertisement. Of those, 18 were invited to submit full applications. An Evaluation Committee was set up and members trained in Pathfinder’s Code of Conduct requirements and signed certifications to comply with the standards of conduct. All proposed grantees went through a comprehensive pre-award assessment and have been screened against the relevant watchlists. The selected organizations are listed in Table 2:

Table 2: List of Grantee by District and Subaward Amount District Grantee Total Budget Total Budget (Uganda Shillings) (USD) Above Site Faith for Family Health Initiative (3FHI) 427,298,326 117,068 Buliisa Lake Albert Children Women Advocacy and Development 261,297,600 71,588 Organization (LACWADO) Bundibubyo & Action for Community Development (ACODEV) 658,978,300 180,542 Ntoroko Butambala & Gomba Family Strength for A Better Child (FASBEC) 377,676,747 103,473 Kiryandongo Integrated Community Based Initiatives (ICOBI) 341,362,003 93,524 Kyankwanzi & Kibale Innovation Program for Community Transformation 629,334,741 172,420 (InPACT) Kyegegwa Hope After Rape (HAR) 304,262,178 83,360 Kyenjojo / Kyegegwa KIND Initiative for Development-Uganda (KIND UG) 391,041,200 107,135 Rakai Brick by Brick Uganda (BBBU) 330,190,059 90,463 TOTAL 3,721,441,154 1,019,573 26

Organizations that were approved by USAID will receive a Fixed Amount Award for eight months effective February 2020 to September 2023 with subsequent extension for Y3 and Y4 following USAID’s approval. FAAs emphasize performance and achievement of results. Payment will be tied to the achievement of well-defined milestones, as evidenced by deliverables, which are quantifiable and closely monitored.

The focus for the CBOs/CSOs is to strengthen leadership and commitment of cultural and religious institutions; support their collaboration with Government to increase the adoption of healthy reproductive behaviors and practices at national level while at district level; increase access to FP information and services at the community level through community level demand creation interventions and community-based FP service delivery; and establish and functionalize community-health facility linkages.

4.4 Collaboration, Learning and Adaption

FPA internal FP Dashboard In order to facilitate a systematic learning process by drawing evidence from a variety of sources to inform the implementation of FPA activities and enhance district and facility performance on FP, FPA has developed an interactive excel based FP dashboard that allows for quick navigation and access to dynamic analytics. The dashboard will provide timely and efficient access to FP core indicators, provide new opportunities for data quality improvement, and offer more robust data analysis and visualization that will facilitate data-driven decision making by management and program teams. This dashboard will also provide a platform for accountability and data use for management at national, regional, district, and facility levels. Figure 23 is a screen shot of the developed dashboard.

Figure 23: Sample screen shot of the FP Dashboard

After Action Review (AARs) FPA has fostered learning to ensure ideas and information are generated, captured, shared, and applied to improve performance. In FY21 Q1, FPA held one internal AAR meeting to assess Y1 performance reflecting on what worked and what did not work. Following this review, HMIS timely and complete reporting was identified as a gap that was affecting performance across the districts. The immediate action taken was to generate a list of all facilities that had not reported. These health facilities were followed-up and reasons for non-reporting established. On the other hand, strategies to improve timely and complete reporting were brought forward, they include; orienting HF staff on FP and FP documentation through mentorship, replenishing stocked out FP commodities and tools, and sending report reminder SMS messages to health facility in-chargers and HIAs a week prior to reporting date. FPA will in the next quarter conduct district-based data feedback and performance review meetings.

Additionally, FPA technical teams conducted weekly pause and reflect meetings to reflect on different activities executed in the previous week and plan for the following week. FPA also continues to provide technical assistance to MoH in a collaborative manner and through participating in the different TWGs such as MCH, HIS, Supply Chain, and RH TWGs.

Establishment of FP District CQI Teams/ Committees in the 11 FPA districts During FY21 Q1, FPA established Continuous Quality Improvement (CQI) teams that will focus on implementing FP CQI approaches within the 11 supported districts. The approaches will focus on quality of health services that are evidence- based, effective, efficient, accessible, acceptable, equitable, and safe. To guarantee quality health services for clients, FPA together with the district and health facility team will continue to focus on three CQI perspectives of clients, providers, and management. Through interaction and discussions with district teams, the FPA team has learned that quality assurance is an intentional, rigorous, and Establishing CQI Teams: FPA MEL Advisor briefing continuous process that must be integrated into Facility staff about CQI at Karugutu HC IV, Ntoroko FPA’s management cycle focusing on improving District client experience both during and after accessing health services.

In FY21 Q2, FPA will disseminate CQI standards, curricula, guidelines, and protocols; mentor health workers; conduct facilitative supervision visits to monitor the CQI projects implemented by health providers; analyze FP data for decision-making; identify and implement activities to overcome FP provider bias and negative attitudes; and implement accountability mechanisms that allow clients and communities to share feedback on their experience with providers. This will be focused on emphasizing changes in service delivery processes and systems in ways that will enable health facility teams to implement high- impact, evidence-based interventions to achieve better results. The hope is that through this approach, 28

FPA will empower health workers to focus on processes that lead to high yield through integrating FP clinics with other service delivery points, advancing SBCC for demand creation, and overcoming provider bias for effective and efficient delivery of FP services.

Gender Youth and Social Inclusion (GYSI) During this reporting period, FPA conducted a GYSI Analysis which was initiated in Y1. The analysis was conducted in all 11 FPA-supported districts. The main objective was to identify gender norms, power relations, and social and cultural norms, practices, and beliefs in the FPA locations, and understand how they hinder women, men, youth, young parents, and other key populations from accessing and utilizing FP/RH services. The detailed findings can be found in separate report and can be obtained at FPA’s main and regional cluster offices. The following is summary, highlighting findings from the GYSI analysis:

• While gender and disability mainstreaming are mentioned in almost all health sector policies and guidelines – indicating some degree of gender and disability responsiveness – the policies often fall short of the gender and equity-transformative ideal. For example, policy documents recognize gender inequality in decision-making and access to resources as barriers to women's access to reproductive health services. However, national programs have made limited attempts to transform harmful gender norms that drive women’s lack of agency on their reproductive health. Other challenges, such as limited funding, staffing, and supplies, also undermine the full realization of the policies' aspirations. • The prevalence of child marriage ranges from 18-20 percent in the focus/Activity districts. The adolescent birthrate is at 11.5-25.5 percent. These practices contribute to the high Total Fertility Rates (TFR) in the districts – which are between 6-7.4 children per woman (UBOS, 2019b) – compared with an equally high national average of 5.4 children per woman (UBOS, 2019). • Women in the FPA focus districts complained of the numerous side effects of family planning methods that increase their sick days and limit their ability to work. Most rural work is labor- intensive, so the risk of being ill (e.g., having headaches, excessive bleeding, dizziness, and backaches) from the side effects of contraceptives directly affects women’s ability to do domestic and economic work. This deters some from using contraceptives. • The study also found that access to land resources is mostly through patriarchal marriage ties for the average rural woman. Women must produce many children to secure their position in their marital homes, and improve their access to land, contributing to high fertility rates. Women also have limited control over finances. Although services at public health facilities are free of charge, associated costs (e.g., transport to the facilities) are challenging for some women. The cost of managing the side effects of contraceptives is also prohibitive to many. • In the FPA focus districts, 7 percent of women said that their partners make decisions regarding whether to use contraceptives. • There is limited cultural space to discuss sex and sexuality between parents/guardians and children. This situation means that young people are often left to seek information on sexual matters on their own or experiment with sex, hence engaging in risky sexual behavior with an increased probability of teenage pregnancy, early marriage, and early childbearing. Male youth particularly lack positive role models and mentorship to shape their reproductive health choices.

Other aspects that should constitute an enabling environment for youth include positive norms and expectations and an enabling policy and legal environment. Regarding the latter, there is a relatively high prevalence of norms that encourage high fertility rates. As previously indicated, early marriage is widely accepted. • Youth when supported with positive information and skills, youth have participated as peer educators to strengthen sexual and reproductive health. This approach has mainly been used for HIV prevention, treatment, and care programs. Young people have also contributed to promoting their reproductive health by acting on the positive information they receive through behavior change interventions and campaigns. Their actions include staying in school, abstaining from sex, contraceptive use, and preventing HIV, among others.

Key Study recommendations

1. FPA should ensure that interventions for reaching adolescents, youth, women with disabilities, women, and men are mainstreamed in its technical guidance to policymakers at national and local levels, e.g., in costed family planning implementation plans. Interventions should address the underlying norms that drive fertility choices and reproductive health outcomes. This should include evidence-based behavioral change interventions. 2. Ensure that FPA-supported health facilities have adequate staffing of health workers with the right mix of skills. 3. FPA should put in place and support the implementation of protocols to manage the side effects of contraceptives effectively. FPA should also track the number of women and youth followed up and effectively supported to manage the side effects. 4. Promote behavior change approaches that tackle underlying norms through models that engage in multi- generational community dialogues. 5. Address underlying gender norms that limit women’s agency through couples’ interventions. 6. Support life-skills training for girls and people with disabilities to improve their agency to negotiate safer reproductive health choices.

PROGRAM MANAGEMENT Staff Recruitment In this reporting period, Pathfinder filled 10 positions which include 1 Office Assistant, 1 Human Resources Assistant, 3 Finance and Administration Officers, 1 Procurement Specialist, 1 Health Informatics/Data Base Officer, and 3 District Activity Officers. This recruitment brought the total number of Pathfinder recruited staff to 52 and a total of 64 UFPA staff inclusive of partners.

Stakeholder Engagement FPA in this reporting period continued introductory meetings with stakeholders and with Government Ministries and agencies to align activities to the Y2 workplan and prioritize interventions. Meetings with NPA, for example, led to alignment of activities to the recently launched third National Development Plan (NDP III) and its program based planning and budgeting, while engagement of the newly awarded USAID/Civil Society Strengthening Activity (CSSA) identified opportunities for training FPA’s CSO partners to improve their efficiency.

Mobilization for implementation also included identification of CBOs/CSOs to support the implementation of FPA interventions under IR2.

Office Support-IT During this reporting period, the IT department installed and issued new laptops to all FPA staff. The laptops are enrolled with Microsoft Endpoint manager. In addition, HP M776 multifunction printers and a dedicated 5mbps internet was setup and installed in all FPA regional cluster offices.

Compliance Activities Compliance review and expenditure verification. During this reporting period, the compliance department conducted a compliance review and expenditure verification/review for all FPA partners for the period March 1, 2020 to September 30, 2020. This aimed at examining all costs/expenses in alignment with their supporting documents and determining whether the expenses incurred are allowable, allocable, and reasonable as indicated in the award. The exercise was also focused on determining the effectiveness and strengthening of internal control systems of the FPA partners and where there are weaknesses, advise management on how to mitigate the issues. FPA also emphasized partner compliance with agency and donor regulations and organizational policies and procedures together with the local laws and regulation as per the statutory requirement.

Compliance to US Abortion and FP Requirements & PLHGA refresher training. During the reporting period, all Pathfinder and partner staff completed and shared their certificates for the two mandatory courses (i.e., Protecting Life in Global Health Assistance and Statutory Abortion (PLGHA) Restrictions – 2020 and US Abortion and Family Planning Requirements – 2020). In order to remind staff of the importance of these regulations, a refresher training on PLGHA was conducted on November 10, 2020. The training emphasized the non-use of USG funds to promote abortion as a method of FP and that the policy prohibits distribution of USG funds to foreign non-governmental organizations “that perform or actively promote abortion as a method of family planning in other nations”.

CHALLENGES AND RECOMMENDATION FPA implementation in FY21 Q1 presented similar challenges faced in Y1. Below is a summary of some of the challenges encountered, mitigation measures, and recommendations. ● One of the main challenges for implementation has been FPA’s limited ability to monitor order fulfillment and stock levels of each of the FP methods to appropriately respond to anticipated stock risks. This limitation is related to lack of web-based reporting such that at the national level, commodity status at service delivery points cannot be visualized. This will be addressed when the RH web-based reporting is fully operational. FPA plans to explore use of alternative methods of obtaining such data at least monthly as an interim measure. Additionally, dashboards have been developed to provide insights into the performance of individual facilities.

● Implementation of activities requiring the participation and facilitation of government staff could not be implemented without activity waiver approval by USAID. The delayed approval led to most activities to be rescheduled for implemented in FY21 Q2, while other were cancelled.

● The COVID-19 related restrictions continued to delay implementation especially in engaging with communities. The USAID/Uganda FPA team followed MoH guidelines and prevention measures to ensure protection of health workers, beneficiaries, and FPA staff. Despite this, implementation was slowed down, often reaching less than the intended beneficiaries in order to achieve the recommended social distancing.

● Barriers to FP uptake prevail, some of which include the fear of side effects, partner opposition to use of contraception, and strong cultural and religious beliefs that are against FP especially for young people. FPA is addressing such barriers through multiple interventions with several target groups such as cultural, religious institutions, multiple sectors of government, young people, etc.

● There are misconceptions and fears that contraception and FP/RH programming that focuses on “children” will lead them to moral decay hindering their moral growth and development, as well as abuse of children’s rights as they are exposed to contraception early. These fears come from people who are expected to support USAID/Uganda FPA to address the challenges. However, the team is working within the MoH and Ministry of Education guidelines to reach different groups with appropriate messages, information, and services via government structures.

PLANNED ACTIVITIES FOR NEXT QUARTER (FY21 Q2) Follow-on activities from Y2 Q1 ● Support partners to identify and document lessons learned and success stories ● Dissemination of the Gender, Youth and Social Inclusion Analysis ● Continue supporting the FP-CIP II development process ● Implement reforms in supply chain management such as RH-SPARS; One Facility, One Warehouse; and web-based reporting of RH commodities ● Support district FP procurement planning

Summary of FY21 Q2 priority activities ● Conduct district-based monthly and quarterly HMIS data cleaning exercises and provide technical support to health units to compile monthly and quarterly reports using revised HMIS tools ● Strategic guidance to monthly FP/RHCS TWG meetings ● Engage existing multi-sectoral structures to integrate FP ● Review and adapt resource training packages for resource persons, e.g. cultural, religious, community, and youth leaders ● Orient community gatekeepers (cultural, community, and religious leaders) to implement actions to address sociocultural norms ● Support ToTs to conduct integrated mentorship for health workers in the 11 districts. ● Support health workers in drug shops and private pharmacies in provision of FP services with a focus on injectables in three districts ● Support interventions for monthly data capture, HMIS reporting supportive supervision, and performance review to enhance quality ● Develop FPA strategies on partnerships, advocacy, SBCC, and capacity building ● Support MoH and other key FP stakeholders to participate in the Human Capital Development Program ● Support the development of district specific action plans for hot spot districts that have high fertility, teenage pregnancies, and child marriages ● Roll out community level and above-site implementation by sub-grantees

ANNEX 1: SUCCESS STORY SUCCESS STORY Addressing Stockouts for Improved Family Planning Services Rwebisengo Health Center on the Right Pathway to Increasing access and supply of contraceptives plays an important role Better Family Planning Service Delivery in reducing the unmet need for voluntary family planning. A well- organized supply chain stretches from the suppliers of commodities to the consumer, ensuring a method mix that provides health facilities with adequate supplies to meet users’ needs. In Uganda, many health facilities face problems with stockouts of contraceptives. This interrupts access and uptake of family planning and reproductive health services leading to unwanted pregnancies.

Rwebisengo health center IV serves over 11,000 people living in Ntoroko District in Western Uganda, including refugees from the Democratic Republic of Congo. The facility faced challenges in storing and managing contraceptive commodities, leading to reoccurring stock outs of family planning methods including condoms, injectables, implants, and pills. Consequently, the facility was unable to offer a wide range of methods to meet its clients’ needs. Often, as a result, clients would leave after failing to access their desired method.

Photo Credit: FPA “Our health center would always run short of the short-term methods such “We have not run out of any stock because as condoms. Our clients would get disappointed when they don’t find the we always order for enough…We now have services,” said Moses Rusoke, Health sub District Medicines Management many clients coming in because they are Supervisor. sure of finding all Family Planning Methods,” Moses adds. Recognizing this need not only in Rwebisengo health center IV, but across the supported health facilities, the USAID/Uganda Family Caption: A health worker in Ntoroko district Planning Activity (FPA) identified select district and health facility staff crosschecking expiry dates of family planning to participate in a training of trainers (ToT) on supply chain commodities to ensure their safety and procedures for essential medicines. They were then able to cascade effectiveness the training with the goal of strengthening capacity of all health facility staff to improve contraceptive commodity security.

Through this training, Rwebisengo health center IV’s midwife and storekeeper learned of the importance of forecasting, procuring, and managing commodities for the provision of quality family planning services. This included ensuring they understood how to use stock cards for tracking and monitoring commodity availability. The health facility now has the capacity to better manage their stock and effectively monitor expiry dates. The facility also reported increased reliability of contraceptive supplies due to timely ordering, therefore their clients now have a variety of methods to choose from.

“We can now manage our stock. Our Clients are not being sent away because of stock outs… We now see more clients coming in each week,” said Moses.

Rwebisengo health center IV is making great strides in reducing challenges that arise due to stock outs as well as addressing the unmet need for voluntary family planning in Ntoroko District.

ANNEX 2: OVERALL ASSESSMENT RESULTS FOR DRUG SHOPS

Table 2- 1: Overall assessment results for eight private drug shops per category assessed