Uganda Voucher Plus Activity Quarterly Report Year 4, Quarter 4 July – September 2019

Re-submission date: 4 November 2019 Submission Date: 31 October 2019

Number: AID-617-LA-16-00001 Activity Start Date and End Date: January 29, 2016 to September 30, 2020 Name: Dr. Christine Mugasha

Submitted by: Christine Namayanja, Chief of Party Abt Associates 6130 Executive Boulevard Rockville, MD 20850, USA Tel: +1-301-347-5000 Email: [email protected]

Copied to: [email protected]

This document was produced for review by the United States Agency for International Development USAID|Uganda Voucher Plus Activity Uganda Mission (USAID/Uganda).

Contents

Acronyms and Abbreviations ...... iii

Activity Information ...... iv

1. Activity Introduction ...... 1 1.1 Activity Description ...... 1 1.2 Performance Analysis to Date ...... 2

2. Activity Implementation Progress ...... 6 2.1 Summary of Implementation Status ...... 6 2.2 Progress Narrative ...... 7

3. Guiding Principles ...... 11 3.1 Partnership, Collaboration, and Stakeholder Engagement ...... 11 3.2 Inclusive Development ...... 12 3.3 Learning and Adaptation ...... 12

4. Leadership and Development ...... 12

5. How has Activity Addressed AOR Feedback from Last QR? ...... 12

6. Summary Financial Management Report ...... 13

7. Management and Administrative Issues ...... 13 7.1 Key Management Issues ...... 13 7.2 Resolved Management Issues...... 16

8. Planned Activities for Next Quarter Including upcoming Events ...... 16

9. Annexes ...... 18 9.1 Activity Work Plan ...... 18 9.2 Special Reporting Requirements ...... 25 9.3 Success Stories ...... 32 9.4 Stakeholder Engagement to Foster Collaboration, Coordination, and Adaptive Management ...... 35 9.5 Updated Learning Agenda Schedule ...... 38

USAID|Uganda Voucher Plus Activity i

Table 1. PMP/Project Indicator Progress...... 2 Table 2. Y4Q3 Activity Implementation Status ...... 6 Table 3. Y4Q3 Financial Report ...... 13 Table 4. Summary of recoveries from VSPs during Q4 ...... Error! Bookmark not defined. Table 5. Y5Q1 Planned Activities ...... Error! Bookmark not defined.

Figure 1. Total monthly VSP reimbursements January 1, 2017 to September 30, 2019 ...... 15 Figure 2. Avg monthly claims turn-around time (days) November 2016 to September 2019 ..... 15

USAID|Uganda Voucher Plus Activity

ACRONYMS AND ABBREVIATIONS

ADHO Assistant District Health Officer AMELP Activity Monitoring and Evaluation Plan ANC Antenatal Care ART Antiretroviral Therapy BEmONC Basic Emergency Obstetric and Newborn Care CEMONC Comprehensive Emergency Obstetric and Newborn Care CME Continuing Medical Education DHIS District Health Information System DHO District Health Office DHT District Health Team EDHMT Extended District Health Management Team EMTCT Elimination of Mother-to-Child Transmission EOP End of Project FP Family Planning HC Health Center HIV Human Immunodeficiency Virus HMIS Health Management Information System HPU Health Partners Uganda IP Implementing Partner IR Intermediate Result K&L Knowledge and Learning MCH Maternal and Child Health MNCH Maternal, Newborn, and Child Health MOH Ministry of Health MPDSR Maternal and Perinatal Death Surveillance and Response OBA Output-Based Aid PNC Postnatal Care PPFP Postpartum Family Planning PPPH Public-Private Partnerships for Health QI Quality Improvement RBF Results-based Financing RHITES Regional Health Integration to Enhance Services RMNCH Reproductive, Maternal, Newborn, and Child Health SBCC Social and Behavior Change Communication SBCCO Social and Behavior Change Communications Officer SGBV Sexual and Gender-Based Violence TBA Traditional Birth Attendant UDHS Uganda Demographic and Health Survey UGX Ugandan shilling USAID United States Agency for International Development USD United States Dollar USG United States Government VCBD Voucher Community-Based Distributor VHT Village Health Team VMA Voucher Management Agency VSP Voucher Service Provider VSLA Village Savings and Loan Association

USAID|Uganda Voucher Plus Activity

ACTIVITY INFORMATION

Activity Name: Uganda Voucher Plus Activity Project: The Voucher Plus Activity is a five-year (2016–2021) project of the United States Agency for International Development (USAID) that aims to increase use of health services for pregnant women by promoting safe, facility-based deliveries among poor women to reduce maternal and neonatal morbidity and mortality in Eastern and Northern Uganda. Activity Start Date and End January 29, 2016–September 30, 2020 Date: Name of Prime Abt Associates Implementing Partner: [Contract/Agreement] AID-617-LA-16-00001 Number: $24,499,611 Name of Sub-awardees and Communication for Development Foundation Uganda – UGX Dollar Amounts: 5,913,526,140 (approx. 1,845,670 United States Dollars (USD)) PricewaterhouseCoopers–UGX 10,148,838,667 (approx. USD 2,899,668) Plus provider reimbursement UGX 29,520,000,000 (approx. USD 9,000,000). BDO Uganda–UGX 2,913,532,719 (approx. USD 859,789). Major Counterpart Ministry of Health (MOH), District Health Management Teams (DHMTs), Organizations: World Bank (WB), Marie Stopes Uganda (MSU), Regional Health Integration to Enhance Services (RHITES), implementing partners (IPs), and Communication for Healthy Communities (CHC) Geographic Coverage Agago, Alebtong, Amuria, Amuru, Apac, Budaka, Bulambuli, Bukedea, (districts; also, note any Butebo, Butaleja, Dokolo, Gulu, Kaberamaido, Kapchorwa, Katakwi, changes): Kitgum, Kole, Kumi, Lamwo, Lira, Manafwa, Mbale, Ngora, Nwoya, Omoro, Otuke, Oyam, Pader, Pallisa, Serere, Sironko, Soroti, Namisindwa, Kwania and Kapelebyong. Reporting Period: July 1– September 30, 2019

USAID|Uganda Voucher Plus Activity

1. ACTIVITY INTRODUCTION 1.1 Activity Description

The Uganda Voucher Plus Activity (the Activity), led by Abt Associates, provides quality obstetric, newborn, and postpartum family planning services to very poor Ugandan women in the North and East. Ultimately, the Activity improves health equity by ensuring the poor in 35 districts have access to information and services to support healthy pregnancies and deliveries. To do so, the Activity identifies and accredits private providers to deliver a package of services, for which the providers are reimbursed by the Activity. Simultaneously, the Activity works with community volunteers, including Village Health Teams, who sell vouchers at 4,000 Ugandan shillings (UGX) to women who qualify, while also providing safe motherhood information to target populations. The voucher service package includes four antenatal care (ANC) visits; elimination of mother-to-child transmission of HIV services (EMTCT); delivery with a skilled birth attendant and referral for complications, postnatal care, and postpartum family planning (PPFP). By targeting very poor women to receive the voucher, the Activity seeks to provide financial protection to this vulnerable population to avoid catastrophic out of pocket payments. The Activity strengthens the capacity of participating private providers through clinical and administrative mentoring, supervision, and auditing to improve service quality. The Activity also ensures providers contribute to the district health management information system, and address other facility gaps. The Activity actively engages District Health Offices in building this capacity of private providers, stimulating private-public partnerships for health that ultimately strengthen district health systems. Providers also receive training to participate in the Activity contracting mechanism, allowing them the opportunity to learn necessary skills in managing timely and correct claims submission and reimbursement that will allow for future participation in MoH health financing mechanisms. Finally, the Activity contributes evidence on output-based health financing mechanisms in Uganda to support the MOH to efficiently implement health financing mechanisms. The Activity will achieve its overall goal of increasing access to safe delivery through two Intermediate Results (IRs): • Increased use of high-quality voucher-covered reproductive, maternal, neonatal, and child health (RMNCH) and family planning (FP) services in designated program districts • Increased capacity of public and private sector to develop longer-term health financing options The targets for this Activity are: • Provide 250,000 safe deliveries • Ensure 50 percent of all women with vouchers access four antenatal care (ANC4) visits • Enroll 100 percent of HIV-positive pregnant women in EMTCT services • Increase postnatal care (PNC) services to cover at least 50 percent of women who deliver with a voucher, and their babies • Provide PPFP services for 50 percent of women who deliver with a voucher Voucher Plus activities are implemented in close collaboration with Ministry of Health (MOH) and district health teams. Synergies with stakeholders are optimized, especially with other USAID implementing partners (IPs), the MOH/World Bank Reproductive Health Voucher Project and other health and non-health organizations. Annex 8.1 contains a Gantt chart showing the approved work plan for Year 4.

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1.2 Performance Analysis to Date

Project Indicator Progress—USAID Standard Indicators and Project Custom Indicators Strategic Objective: Provide measurable improvements in safe motherhood services by supporting health financing and innovative service delivery models in the private sector Table 1. PMP/Project Indicator Progress Quarterly Quarterly Quarterly Quarterly Annual Baseline Data Year 4 Status – Status – Status – Status – Performan Year 4 Year 4 Year 4 Year 4 ce Indicator Annual Achieved Comment(s) Annual Cumulativ Q3 Q4 to Date Year Value Cumulativ Q1 Q2 e Planned (%) e Actual Target1 2.1 and 2.2 Number of health facility deliveries 2016 0 64,320 79,984 15,152 27,478 20,208 17,133 124.3% Improvements in clients’ care seeking supported by voucher behaviors as the project matured explain the positive results that represent 106.5% achievement of quarter’s target and cumulatively accounts for 124.3% of the annual target. Cesarean section rates from voucher 2016 0 12% 9.2% 9.5% 9.3% 9.2% 9.1% Overall, caesarean section rates for supported facilities the Activity are within the MOH recommended rates of not higher than 10-15%. Health facility still birth rate from 2016 0 9 10.3% 7.5% 11.0% 10.1% 12.0% Performance is due to improved voucher supported facilities reporting from Voucher Service Providers (VSPs) in the later quarters of the year. Proportion of health facility deliveries at 2016 0 90% 114.3% 94.2% 171.0% 126.0% 106.5% The performance here is due to voucher supported facilities improved client follow ups Percent of mothers initiating 2016 0 90% 85.4% 93.1% 81.0% 83.0% 91.4% The performance is due to improved breastfeeding within 1 hour after birth documentation of services in the at voucher supported facilities claims forms by providers. Number of pregnant women who 2018 0 35,000 42,051 11,800 10,629 10,490 9,132 120.1% The high performance is explained attended antenatal care provided by by more clients buying the voucher in skilled health personnel at least 4 times the 1st trimester, and increased during pregnancy from voucher utilization of the full voucher services supported facilities package. Number of pregnant women who 2018 0 85,000 69,528 21,453 20,270 21,317 6,488 82.0% There were no new clients in Q4 as attended ANC 1 provided by skilled voucher sales stopped in Q3.

1 When applicable USAID|Uganda Voucher Plus Activity 2

Percentage of pregnant women 2018 0 15% 12.0% 17.0% 13.0% 10.4% 11.0% attending 1st ANC visits within the 1st trimester at voucher supported facilities Number of pregnant women attending 2018 0 12,750 9,219 3,655 2,639 2,212 713 72.3% 1st ANC visit within the 1st trimester from voucher supported facilities Percentage of women who attended at 2016 0 50% 60.1% 40.0% 40.0% 81.0% 30.0% The denominator here has always least four antenatal care visits (ANC4) been voucher sales but since voucher during pregnancy sales stopped in Q3, the Activity used “active vouchers in circulation”. This significantly increased the denominator. Percentage of infants born to voucher This performance is under reported supported women living with HIV due to the delayed documentation receiving ARVs as prophylaxis for 0 90% 81.2% 89.5% 77.2% and reporting of ART numbers by elimination of mother-to-child 2016 referral facilities. transmission Percentage of voucher supported 2016 0 100% 75.3% 70.0% 93.5% 76.7% 77.5% This performance is under reported pregnant women living with HIV who due to the delayed documentation received antiretroviral drugs to reduce and reporting of ART numbers by the risk of mother-to-child transmission referral facilities. with HIV Proportion of mothers receiving 2016 0 45% 55.0% 60.0% 50.2% 55.2% 60.0% Enhanced client follow ups combined postnatal care checks within 6 weeks with increased counselling and postpartum from voucher supported health education by VSPs during facilities pregnancy and at delivery explain the Number of mothers receiving PNC 2018 0 32,160 43,607 11,714 10,447 11,163 10,283 136.0% improvements in PNC uptake checks within 6 weeks postpartum from voucher supported facilities Number of newborns not breathing at 2016 0 2,500 2,806 624 912 589 682 112.2% Increased availability of newborn birth who were resuscitated in United resuscitation kits and enhanced States Government (USG)-supported provider competencies at the VSP level facilitated the improvements in programs specific to voucher supported this indicator sites

USAID|Uganda Voucher Plus Activity 3

Number of USG-assisted community 2016 0 650 585 585 515 510 518 80.0% Termination of 13 VSPs in Year 4 health workers (CHWs) providing FP led to a decrease in number of active information, referrals, and/or services Voucher Community-Based during the year Distributors (VCBDs) Number of additional USG-assisted 2016 0 40 37 19 17 1 0 92.5% Because voucher sales stopped in CHWs providing FP information and/or Q3, there was no need to recruit services during the year additional CHWs ANC1 0 95% 99.3% 73.3% 76.4% 164.0% 21.3% Changes in the denominator from Percentage of vouchers voucher sales to vouchers in redeemed ANC2 0 60% 107.0% 71.3% 80.0% 157.0% 43.2% circulation explain the seemingly lower performance. To avoid a nil ANC3 0 60% 96.3% 63.0% 69.0% 133.3% 47.1% denominator, we used “active vouchers in circulation”, in Q4. 2016 ANC4 0 50% 60.1% 40.0% 40.0% 81.0% 30.0%

Delivery 0 70% 114.3% 52.0% 80.0% 155.1% 56.3% Postnatal care 0 50% 55.0% 60.0% 50.2% 55.2% 60.0%

Postpartum FP 0 45% 15.4% 15.5% 12.7% 15.2% 20.2% 2.1.2 and 2.1.4 Percentage of USG-assisted service 2016 0 100% 100% 100% 100% 100% 100% All VSP provide comprehensive FP delivery sites providing FP counseling counselling to voucher clients and/or services Number of USG supported service 2016 0 150 156 155 151 148 146 97.3% Termination of facilities during Year delivery points offering any modern 4 explain the performance.

USAID|Uganda Voucher Plus Activity 4

Quarterly Quarterly Quarterly Quarterly Annual Baseline Data Year 4 Status – Status – Status – Status – Performan Year 4 Year 4 Year 4 Year 4 ce Indicator Annual Achieved Comment(s) Annual Cumulativ Q3 Q4 to Date Year Value Cumulativ Q1 Q2 e Planned (%) e Actual Target1 contraceptive method from voucher supported facilities Percentage of women who received 2016 0 100% 85.0% 91.0% 80.0% 78.0% 95.4% New adaptations to reduce lost postpartum counselling for FP from opportunities, enhanced counselling Voucher supported facilities and health education by VSPs during pregnancy and at delivery, and improved documentation of services in claims forms explain the improvements in PNC uptake Number of clients provided with FP 2016 0 32,160 12,300 2,350 3,502 2983 3,465 38.1% Performance is due to adaptive services at Voucher supported facilities programming by Activity, such as VSPs hosting on-site FP camps as well integration of FP into Young Child Clinics to reduce missed opportunities Percentage of pregnant women who 2016 0 90% 77.0% 128.1% 122.0% 71.4% 108.1% Performance is affected by a slightly received all the three doses of smaller denominator of ANC1 intermittent preventive treatment for attendance as a result of no voucher malaria rom voucher supported facilities sales in the quarter. 3.3 3.3.1 Percentage of voucher supported health 2016 0 95% 97.0% 95.5% 94.2% 92.0% 97.0% Although 100% VSPs were reporting facilities reporting into District Health in Year 4, 97% were reporting Information System 2 (DHIS2) directly into DHIS while 3% were reporting through their districts. 3.3.5 Number of voucher- supported mothers 2018 0 150 194 0 0 0 194 129% 194 voucher mothers were linked linked to existing local village savings and and enrolled into CHIS schemes. loan associations (VSLAs) to encourage This started as two VSP facilities saving for their health (Aero and Alleuyah Maternity Number of Village Savings and Loan 2018 0 30 0 0 0 0 0 0% Centre) during Year 4. This Association Schemes sensitized by information was generated in Voucher Plus to incorporate saving for PY4Q4, hence the lump sum figure health component in their schemes is represented in this period. The high performance is attributed to effective collaboration with Health Partners Uganda through the CONNECT Girls Activity. USAID|Uganda Voucher Plus Activity 5

2. ACTIVITY IMPLEMENTATION PROGRESS 2.1 Summary of Implementation Status

Table 2. Y4Q3 Activity Implementation Status IR Summary of Planned Activities Actual Achieved in Quarter Activities Shifted in Quarter to Next Period IR 1: – Create demand for RMNCH services – The Activity stopped distributing -The DQA will be Increased use of and distribute vouchers vouchers to begin the phase down done in Q1Y5 high-quality – Distribute information, education, and over the final year voucher- communication (IEC) materials to – Tracking service redemption covered VCBDs through the web-based SMS maternal, – Conduct client follow-ups to improve system neonatal and service redemption – Provided 113 on-site mentorship child health – Implement a web-based SMS visits, reaching 217 providers (MNCH) and FP reporting mobile system to fast-track – Continued to support the four health services voucher sales and redemption public sector private wings in designated – Use peer VCBD approach to enhance – Conducted 3 CMEs on SGBV program VCBD supervision districts – Worked with DHOs to improve service linkages at private facilities – Conduct annual facility-community linkage meetings – Worked with the various district – Reward VCBDs with certificates technical focal persons to support VSPs improve lab, eMTCT, – Provide hotline services Immunization, FP and medicines – Provide quality assurance technical stock management practices support to facilities, including the four – Conducted annual clinical audit enrolled private wings of public – Made 63 visits to 35 district health facilities offices to brief district health – Conduct joint facility monitoring visits officers on Activity implementation with district health officers (DHOs) progress – Conduct continuing medical education – Worked with RHITES, DHOs & (CME) on sexual and gender-based other IPs to facilitate service violence (SGBV) and youth-friendly linkages in the districts especially services for EMTCT, FP, immunizations and – Improve service linkages/referrals ambulance services – Strengthen laboratory capacities at facilities – Strengthen medicines stock management at facilities – Facilitate private providers' participation in Extended District Health Management Team (EDHMT) review meetings – Strengthen documentation, storage, and utilization of clients' data – Independent Verification and Evaluation Agency (IVEA) to audit claims, claims processing, health

USAID|Uganda Voucher Plus Activity 6

IR Summary of Planned Activities Actual Achieved in Quarter Activities Shifted in Quarter to Next Period service verification and partner activity verification and incident reporting

IR 2: – Support and graduate VSPs into – Engaged MOH-RBF team to train -Completion of 2 Increased national results-based financing (RBF) 13 VSPs that had been pre- Knowledge and capacity of scheme qualified in phase one Learning (K&L) Uganda’s public – Facilitate districts to conduct Health – Actively engaged EDHMTs in studies and private Management Information Supervision voucher activities to strengthen sectors to (HMIS) supervision and data quality their understanding of RBF develop longer- assessments at private facilities – Participated in and presented at term health – Facilitate the public-private District Performance Review financing partnerships for health in the districts Meetings options – Strengthen district health – Participated in EDHT meetings management teams’ (DHMTs) – Shared Q3 reports with DHOs understanding of RBF mechanisms – Worked with Save for Health and through active engagement in voucher Health Partners Uganda to support activities VSPS to learn more about CBHI – Together with RHITES and DHOs, – Worked with Health Partners strengthen maternal and perinatal Uganda on reaching VSLAs around death surveillance and response selected voucher facilities to poll (MPDSR) among VSPs savings for health through CBHIs – Share quarterly performance reports – Disseminated learnings on client with districts perception of quality services and – Increase access to village savings and effectiveness of targeting the poor loans associations (VSLAs) for poor with the use of poverty grading tool women to save for health (PGT) with external stakeholders – Implement the learning agenda (see – Worked with Districts and IR 2.2 in this report for more Resource Centres to include 8 VSPs information) and disseminate learnings in DHIS2 – Facilitate VSPs to report into DHIS2 – Build capacity of providers to implement community-based health insurance (CBHI) schemes

2.2 Progress Narrative

This quarter marked the end of the 4th year of the Voucher Activity. Below is the quarterly progress update by intermediate result (IR). See more information in Annex 8.2.

IR 1: Increased Use of High-Quality Voucher-Covered MNCH and FP Services in Designated Program Districts Sub-IR 1.1: Demand for MNCH and FP Services in the Private Sector by the Poor Created in Designated Program Districts During the reporting period, the Activity focused on increasing redemption of vouchers in circulation. Cumulative voucher sales from Activity inception stand at 303,017 (84.2 percent of the end-of-project target of 360,000). There were no community mobilization events during Q4. All effort centered on working with both Peer VCBDs and VSPs to encourage mothers to redeem their vouchers. Sub-IR 1.2: Access to Comprehensive MNCH and FP Services in the Private Sector Improved

USAID Uganda Voucher Plus Activity 7

The Activity continued to work collaboratively with District Health Teams (DHTs), facility managers, RHITES implementing partners (IPs), and other district-based IPs to monitor and further strengthen service linkages for clients from the private sector facilities. Key services targeted for referrals included elimination of mother-to-child transmission of HIV (eMTCT), immunization, family planning (FP), and ambulance transport. A total of 146 VSP facilities received technical and financial support (reimbursements) to offer services to the eligible voucher clients. During the reporting period, three VSPs dropped out of the Activity due to the reduction in demand for services as a result of stopping voucher sales. During the reporting period, 17,133 clients (106.5 percent of the quarterly target and 124.4 percent of the annual target) delivered at VSP facilities using

Newly bought ambulance at Cross Emergency HC a voucher. This brings the cumulative number of deliveries since project inception to 176,744 (70.8 percent of the contractual end-of-project target). The Activity’s contribution to district facility-based deliveries reported into DHIS2 in PY4Q4 across the 35 supported districts was 26 percent. The Activity continued to support private wings of four public facilities to improve access to comprehensive emergency obstetric and newborn care (CEMONC) services for voucher clients and to build the capacity of public sector providers for effective participation in the MoH RBF project.

Sub-IR 1.3: Quality of MNCH and FP Services at Participating Private Sector Facilities Improved The Activity continued to provide on-site technical mentorships, support supervision and quality of care monitoring of supported providers to improve and/or maintain their technical competencies in RMNCH. On their part, the VSPs have continued to plough back their reimbursements to improve their maternal and child health (MCH) infrastructure.

Newly constructed maternity ward at Bukedea Mission Health Center (HC III)

USAID Uganda Voucher Plus Activity 8

A total of 217 health workers were supported through 113 mentorship visits. Additionally, 46 supportive supervision visits were made to VSPs. During the visits, four quality improvement (QI) projects were initiated while 35 previously started QI projects were reviewed with 28 showing good improvement. The Activity team also conducted joint mentorship with RHITES-E for the four VSPs in Kumi district. The joint mentorships focused on On-site mentorship on neonatal resuscitation ANC, PNC, EPI and deliveries, malaria and MPDSR. The Activity also developed standard IEC materials on management of major obstetric complications that the field mentors use to help providers improve their knowledge and practices in early diagnoses and referrals. As part of the Activity’s efforts to improve quality of care and the capacity of supported private facilities, the Activity received a donation of assorted medical equipment and supplies from Project C.U.R.E that was distributed to 44 VSPs. The equipment included delivery beds, examination beds, fridges, Intensive Care Unit beds, wheelchairs, glucometers, sterilizers, blood warmers, chemistry analyzers, waste bins, pulse-oximeters, BP machines, Oxygen concentrators, nebulizers, stethoscopes, clinical gowns and linen, among others. The equipment was handed over to VSPs at two regional functions graced by District officials and officiated by Dr. Martin Ssendyona, the Principal Medical Officer, Department of Standards, Accreditation and Patient protection at Ministry of Health on behalf of the Commissioner. Dr. Ssendyona handing over Equipment to VSPs in Mbale To measure facilities’ adherence to national quality of care standards, the Activity conducted the annual clinical audits at all 143 active VSPs. For the second year in a row, there was marked improvement in facility scores across the regions. Seventy percent of VSPs scored >70% compared to only 54% in 2018, while 25% scored 50–69% compared to 41% in 2018. The proportion of VSPs scoring below 50 percent remained at 5% for 2019. There was significant improvement in adherence to infection control practices, provider competencies, use of HMIS registers and general documentation of clients’ clinical notes. We will customize technical support based on each facility’s needs as per the clinical audit findings. IR 2: Increased Capacity of Uganda’s Public and Private Sectors to Develop Longer-Term Health Financing Options Sub-IR 2.1: Local organizations with the capacity to implement output-based financing activities strengthened The Activity continued to build local capacity under the following four key objectives: 1) strengthening VSP claims management capacity 2) strengthening public-private partnerships 3) strengthening districts’ understanding of performance-based financing mechanisms, and 4) building capacity of private providers to implement RBF and other output-based financing mechanisms. During this period, we implemented the following activities in pursuit of these objectives. Strengthening public-private partnerships for health

USAID Uganda Voucher Plus Activity 9

The Activity sustained its proactive engagements with the MOH, Enabel2 and the districts to ensure they involve the private sector in efforts to improve access to RMNCH services. Our involvement in the national RBF implementers working group and engagement with MOH-RBF team succeeded in fully enrolling 27 voucher-supported PNFP facilities in the URMNCHIP-RBF project. The MOH conducted a week long RBF orientation training for 13 of these VSPs that had missed the training earlier. The training was conducted on July 15-19, 2019 to prepare the VSPs to begin implementing RBF activities. The other VSPs were integrated in the district-based RBF trainings. The Activity also participated in the district inception meetings for the Enabel RBF project in Acholi sub region and advocated for inclusion of qualifying PNFP VSPs. We are continuing to engage the MOH, Enabel, and the faith-based medical bureaus to fast-track the recognition of upgraded health centers II to III to support them to be assessed for inclusion in the URMNCHIP-RBF project. Strengthening districts’ understanding of performance-based financing mechanisms Since inception, the Activity has implemented a broad and inclusive stakeholder engagement strategy (Country Development Cooperation Strategy 2.0 guiding principle 2). Through active engagement with local governments, the Activity has established strong working relationships with a wide range of district and sub-county leaders who actively support both service delivery and community engagement activities. The Activity has continued to engage district leaders in routine activities to improve their understanding of RBF mechanisms. Building capacity of private providers in RBF and other output-based financing mechanisms Joint VSP mentorship with Assistant The Activity is also promoting community-based Dictrict Health Officer (ADHO) Mbale health insurance (CBHI) as a sustainable transition strategy for private health facilities when the USAID/Uganda Voucher Plus Activity ends. We collaborated with Save for Health and Health Partners Uganda (HPU) to support the 52 voucher-supported facilities that were trained on CBHI in Q2. HPU is offering technical assistance to trained providers to develop their concepts and engage necessary stakeholders to launch a successful CBHIS. Five VSPs have engaged their communities and stakeholders and are already showing promising results.

Fred Makaire, the Executive Director, Save for Health, orienting VSPs on how to implement a health Insurance scheme

2 Enabel is a Belgian Development Agency. USAID-Uganda expressed an interest in strengthening its Health System Strengthening (HSS) portfolio by adding a Result Based Financing component complementing other HSS projects in the Acholi Sub-Region. The Ministry of Health has approved Enabel to implement a 4 years RBF project using the National RBF model in 4 districts of the Acholi Sub-region, with USAID the key funding source.

USAID Uganda Voucher Plus Activity 10

Sub-IR 2.2: Evidence, data, and assistance to develop sustainable financing schemes for MNCH and FP provided The Activity continued to implement a robust learning agenda to contribute evidence to local and global learning on sustainable financing schemes for MNCH and FP. In Q4, the Activity finalized two K&L briefs: “Generating Demand for Reproductive, Maternal, and Child Health Services in Rural Uganda” and “Vouchers Improve Equity in Access to Quality Maternal and Newborn Health Services.” In addition to the evidence generated from answering the learning agenda questions, the Activity also generated, documented and adapted programmatic learnings outside of routine programmatic M&E data including client follow up. The Activity will continue to focus on disseminating and using the findings from all K&L studies plus M&E programmatic data in the subsequent quarters to further strengthen the global evidence base. These findings will also be used to share knowledge with the MOH and other partners implementing RBF and other health financing mechanisms.

3. GUIDING PRINCIPLES

3.1 Partnership, Collaboration, and Stakeholder Engagement

The USAID/Uganda Country Development Cooperation Strategy (CDS) 2016-2021 remains significant to the Activity with strong emphasis on collaboration with different partners to forge stronger bonds as we enable districts and VSPS to embrace self-reliance as the core of sustained impact. Engaging the RBF implementing group MOH is a key player in the Activity’s quest to build resilient and more self-reliant partners. The Activity continues to engage the MOH to ensure that qualifying PNFPs eventually transition to the national RBF scheme. This quarter, 13 VSPs assessed in the first phase of RBF in 2018 were trained by the MOH-RBF team. The remaining 14 VSPs were trained along with public sector providers by the District RBF teams. We are also engaging Enabel in the Acholi sub region to incorporate voucher-supported PNFPs into their RBF mechanism that is rolling out early next year. Fostering resilient PPPs to encourage private providers to participate in district health systems District involvement in the Activity is widespread with many leaders harnessing the power of the private sector to deliver services effectively and enable the poor to continue accessing quality, affordable, reliable, and equitable life-saving health services after the Activity close-out. The enhanced synergy between the district and private providers makes a significant contribution to improving how private facilities deliver services. The Activity continues to communicate with DHOs and envisages better synergy between the DHOs and private providers that will ensure Voucher facilities continue to report to district health information systems and receive supervision from districts beyond the project life. Sustained partnership with RHITES IPs The most important outcome of the sustained collaboration with IPs like RHITES Acholi, Lango, and East is the reduction in fragmentation which has helped leverage financial resources (minimizing inefficiencies), influence stakeholders (garnering local support and encouraging behavior change), pooling capabilities (specifically, technical support and complementary skills), and enabled access to information and knowledge, thus amplifying our impact. These gains have been achieved through joint planning and implementation of mentorships and supportive supervision, focusing on MCH technical support, strengthening eMTCT services and MPDSR functionality.

USAID Uganda Voucher Plus Activity 11

3.2 Inclusive Development

This section is not applicable this quarter because the Activity held no community events. 3.3 Learning and Adaptation

Inspiring VSPs to integrate FP into Young Child Clinics to improve FP uptake Over the last couple of quarters, the Activity team learnt that one of the challenges affecting FP uptake is poor integration of FP services into Young Child Clinics (YCC). This quarter, the Activity embarked on supporting VSPs to integrate their FP services into their Young Child clinics to target mothers bringing children for immunization. The Activity worked closely with local FP implementing partners like RHU and PACE to have strategic FP camps at selected VSPs with heavy immunization days. Communities around were also mobilized to come for services. We worked with the local IP staff to offer technical support to the facility providers to provide information and services to the clients who desired in addition to immunization. This effort has seen some improvement in FP uptake this quarter from 15.2 percent in Q3 to now 20.2 percent. We hope to scale up this intervention to other VSPs over the coming year.

4. LEADERSHIP AND DEVELOPMENT

This section is not applicable this quarter.

5. HOW HAS ACTIVITY ADDRESSED AOR FEEDBACK FROM LAST QR?

This section is not applicable this quarter.

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6. SUMMARY FINANCIAL MANAGEMENT REPORT

Table 3. Y4Q4 Financial Report

Activity Financial Analysis a. Total estimated cost (life of activity) $24,499,610 b. Start/end date Start: Jan 29, 2016 End: Sept 30, 2020 c. Total obligated amount (to date) d. Total estimated cost share expected over the life of the activity (if applicable) $1,549,140 e. Total actual cost share to date (if applicable) $2,082,816 f. Total estimated leverage expected over the life of the activity (if applicable)3 g. Total actual leverage to date (if applicable) h. Total expenditure invoiced to USAID/Uganda to date $19,317,342 i. Expenditure incurred but not yet invoiced $65,694 j. Total accrued expenditure (both invoiced and not invoiced); sum of lines h and i $19,383,036 Actual This Projections for the Next Three Quarters of Quarter Q4 Q1 Q2 Q3

Average quarterly expenditure rate by funding source $1,908,613 $2,027,081 $1,198,352 $791,436

7. MANAGEMENT AND ADMINISTRATIVE ISSUES 7.1 Key Management Issues

Funds shortage and Budget considerations for PY5 Abt made several programmatic adjustments to adapt our program to lessons learned as we implemented the Activity. All of these were necessary to meet the needs of our beneficiaries. They included: increasing the reimbursement rates to providers to match a similar program from the MOH; increasing the number of providers in order to reach remote areas; adding neonatal services; expanding technical staff; opening field offices to be more efficient and to guard against fraud better; and expanding the capacity of the voucher management agency (VMA).

3 Cost share (also known as “match”) refers to that portion of an activity cost not borne by the Federal Government and is normally associated with contributions from the prime and sub-recipient sources that receive USAID funds. Leverage also refers to that portion of activity costs not borne by the Federal Government, but it is normally associated with the new, non-public resources – whether money, technologies, or expertise – brought by the private sector and other non- traditional USAID resource partners that are not receiving USAID funds. This is typically done through partnerships with the private sector. Cost share, which must be verifiable from the recipient's records, is subject to the requirements of 22 CFR 226.23 and is subject to audit. Leverage is not subject to these requirements and is not subject to audit, although it must be verifiable. ADS 303.3.10 provides additional information about cost share and leverage under assistance instruments.

USAID|Uganda Voucher Plus Activity 13

All of these adjustments increased expenses for the Activity, and Abt took immediate measures to reduce costs wherever possible. Following the rigorous review of project expenditures and burn-rate in PY4, Abt realized that the Activity would not have sufficient funds in the Agreement ceiling to complete the work scope envisioned in the Agreement. Meetings were held with the Agreement’s officer and justification was provided to obligate $1,033,000 above the current agreement ceiling amount, which would allow Abt to honor all the vouchers in circulation. As Abt awaits USAID final decision on this request, the following steps were taken to avert potential financial liabilities to both USAID and Abt Associates: • Voucher sales to new clients were stopped in April 2019, resulting in a cumulative total of 303, 018 vouchers sold (84.2% of the planned target). • The community engagement sub-award to CDFU was terminated on August 31, 2019. Community engagement activities will be undertaken by peer VCBDs with direct supervision from Abt Associates. • USAID agreed to close the project on September 30, 2020 instead of January 26, 2021. Strategic communications The Activity engaged in different communication activities to reach its target audiences. Through these avenues, more and more people are informed about the USAID Uganda Voucher Plus Activity. This will contribute to advocacy efforts addressing the significance of vouchers in maternal and child health. • Improving the Activity’s visibility: This quarter, the Activity was featured in USAID’s report to the Ugandan people, an annual USAID Uganda publication that highlights some of USAID’s achievements throughout the year (https://ug.usembassy.gov/our- relationship/report-to-the-ugandan-people/). The impact of Voucher Plus has also been shared by USAID Medium Blog, one of USAID’s platforms for sharing its work from around the world (Power of the Maternal Health Voucher on Medium). The Activity also had its stories of change shared in Abt’s global newsletter (https://www.abtassociates.com/who- we-are/news/feature-stories/traditional-birth-attendants-advocate-for-facility-based- deliveries) and was featured in a story aired by a local station, Radio One FM, which highlighted the importance of quality of care in RMNCH..\..\Technical. Docs\Communications docs\Success stories\USAID Voucher 1.mp3. Two stories were published by the New Vision newspaper following the medical equipment handover to VSPs (https://www.newvision.co.ug/new_vision/news/1507774/health-facilities-receive-equipment.

• USAID Communication Partner Meetings: During the quarter, the Activity participated in one communication partner meeting. The Development Communication and Outreach team (DOC) took the partners through the basics of good photography and emphasized the need for impactful pictures in telling the USAID story.

• E-News letters: Using mailchimp (an e-marketing tool), the Activity shared a USAID- approved quarterly E-newsletter with 894 stakeholders. This newsletter highlighted beneficiary stories, VSP and district leadership voices and garnered feedback from some of its stakeholders who underscored the great outcomes of the Activity Provider reimbursements This quarter, the Activity was able to process 90,050 claims. A total of UGX 2,161,501,636 (USD 583,243.8)4 was paid to VSPs. This is a 47.3% decrease against last quarter’s UGX 4,100,684,905 (USD 1,106,498.9). This decrease is attributed to the stoppage of voucher sales to clients.

4 Used exchange rate of 1 USD for UGX 3706 as of October 23,, 2019.

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Figure 1. Total monthly VSP reimbursements January 1, 2017 to September 30, 2019 Re-imbursement trends Jan 17 to September 19 3,500,000,000.00

3,000,000,000.00

2,500,000,000.00

2,000,000,000.00

1,500,000,000.00

1,000,000,000.00

500,000,000.00

Amount expected Amount paid Quarantined amount Rejected amount

The blue line represents the amount invoiced compared to the amounts paid, quarantined, and rejected.

An analysis of the turnaround time based on average number of days from date of claims submission to date of payment received revealed an average of 20.5, 46.7 and 47.2 days for the months of July, August and September respectively. Considering that our contractual requirement is 30 days or less, the average turn-around times of the last two months of the quarter increased to nearly 60 days because most VMA staff were conducting field based reconciliations and verification of VSP services.

Figure 2. Average monthly claims turn-around time (days) November 2016 to September 30, 2019

Contractual 30 day provider reimbursement time

USAID Uganda Voucher Plus Activity 15

7.2 Resolved Management Issues

At end of the PY4Q3, the Activity determined that Ugx 93,177.083 ($25,185) was to be recovered from 8 VSPs who had incidents as reported in the previous two quarters. A total of 90,202,871 (USD 24,379) was refunded back to the Activity through deductions from these provider reimbursements. The balance of Ugx 2,974,212 ($803.84) will be recovered in the nest quarter. Table 4 provides an update on the recoveries made from affected providers, mainly arising from poor record management. Table 4: Summary of recoveries from VSPs during Q4

Facility Amount Recovered Lake Kyoga Flaer Nursing Home 1,263,211 Abedober Health Centre III 8,279,676 Bata Medical Centre 1,420,060 Aero Medical Centre 8,927,482 Bethesda Hospital Soroti 5,106,105 St. Thereza Nyondo 20,829,751 Attira medical Centre 15,571,383 Pearl Medical Centre 28,805,203 TOTAL 90,202,871

8. PLANNED ACTIVITIES FOR NEXT QUARTER INCLUDING UPCOMING EVENTS

Table 5: Y5Q1 Planned Activities Planned # Events/Activities in Next Quarter Media/USG Involvement 1 Hold sub regional district stakeholder meetings on transition of voucher Yes work. 2 Implement the Activity Monitoring, Evaluation, and Learning Plan. No 3 Participate in monthly national RBF, MCH and Public-Private Partnerships No for Health (PPPH) technical working group meetings to share shared learnings. 4 Provide ongoing technical support to strengthen quality of care at No selected private facilities (on-site mentorships, supervision, and monitoring). 5 Engage District health teams to include the private sector in their routine No monitoring and supervision activities. 6 Implement SMS web-based system to monitor redemption. No 7 Receive, process, and reimburse providers’ fees for services offered. No

USAID Uganda Voucher Plus Activity 16

8 Facilitate learning and adaption on CBHI for VSPs. Yes 9 Participate in national dialogues and symposiums relating to RMNCH, No public-private sector approaches, and health financing. 10 Participate in district meetings and dialogues on MNCH and other related No technical areas.

USAID Uganda Voucher Plus Activity 17

9. ANNEXES 9.1 Activity Work Plan

Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Activity Implementation and Quality Oversight Finance, administration, and logistics Deliver fraud prevention, detection refresher training for partners, including IVEA x-cut Conduct staff performance reviews Conduct monthly Voucher Plus Activity partner coordination meetings Voucher Plus Cooperative Agreement compliance Provide continuous collection and reporting on cost share Submit Quarterly Activity and Financial Reports to AOR Submit Annual Activity and Financial reports for Year 3 Implement EMMP and cascade to VSPs through mentorship and support supervision x-cut Train new staff on human trafficking, FP, and other compliance Conduct quarterly contract review—HQ and Uganda Voucher Activity Team Hold monthly AOR meetings to review Activity progress and address challenges affecting implementation Participate in USAID's monthly COP meetings Activity monitoring, evaluation, and learning Produce and disseminate timely routine and periodic progress reports based on Activity Monitoring and Evaluation Plan (AMELP) indicators and donor reporting requirements to guide decision making and Activity implementation Strengthen the Activity’s demand for and utilization of data to guide and improve programming, planning and decision making processes Support districts to conduct HMIS supervisions x-cut and Data Quality Assessments to improve data quality and strengthen use of MoH HMIS tools to collect and report facility data, including DHIS2 system within voucher supported facilities Conduct Quarterly Performance Review Meeting Implement an SMS-based reporting mobile system to fast track voucher sales, distribution, and

redemption and provide real-time data on these processes

USAID|Uganda Voucher Plus Activity 18

Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Conduct targeted Data Quality Assessments to Partners and VSPs to follow up implementation of

actions and recommendations from Year 3 Data Quality Assessment activities Conduct client tracing and follow-up visits to ensure full voucher utilization and measure client satisfaction with voucher covered services Print and distribute HMIS Tools to VSPs Support implementation of the Peer VCBD approach to enhance VCBD monitoring, performance management, voucher sales, distribution, and redemption Independent Verification and Evaluation Agency Management/Communication Activities: Bi-weekly meetings with COP or Designee; Monthly Voucher x-cut Plus Activity Partner Meetings; Separate Learning Meetings between PwC & BDO Reports Monthly written project updates: Reports on any identified incidents; Technical and financial reports x-cut submitted with findings shared at Uganda Voucher Plus Activity meeting Verification tools Revise all existing Verification Tools; develop and use tools to examine quarantined claims for intensified incidence detection in first 10 facilities; x-cut revise tools for assessing quarantined claims at facility level on basis of findings; prepare report on intensified incidence detection in 10 private facilities Auditing of Claims and Claims Processes Audit claims and claims processes for period of October 2018-September 2019; audit report reviewing the findings of the claims processing system; contact 2% of beneficiaries of services from October 2018-September 2019; develop and test verification tools for assessment of scope and processes of ANC linked to financials; develop and x-cut test verification tools for the assessment of scope and processes of PNC; audit claims processing in 40 facilities; develop and test verification tools for the assessment of scope of FP; separate examination of incidents provided by partner; review quarterly trend analysis of project performance indicators Health Services Inspection and Verification Conduct provider service verification in 40 x-cut facilities; conduct desk-based review of training workshops and partner reports

USAID Uganda Voucher Plus Activity 19

Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Voucher Management Agency Claims management software development & set-up x-cut Maintain and update VMIS at VMA office Voucher production Print vouchers and claims processing stationery x-cut Conduct Voucher verification Distribute vouchers to CDFU Voucher Service Providers Draft VSP contracts x-cut Sign contracts Management of providers claims and payments (reimbursements) Process claims Managing reimbursement of providers, handle x-cut rejected claims, and manage provider accounts reconciliations Data management and reporting Track voucher distribution and sales trends Track voucher redemption trends Monitor reimbursement trends ( e.g. % age of quarantines , rejects) x-cut Submit monthly reports to Abt Scan claims Archive files in the storage area Set up electronic filing system IR1: Increased Utilization of High-quality Voucher-covered MNCH and FP Health Services in Designated Program Districts SIR 1.1: Demand for MNCH and FP services in the private sector by the poor created: Promote the voucher scheme to increase demand for services Voucher distribution Design (adopt) and produce, print and distribute Voucher materials for VCBDs and private providers IR1 (DNIs and poverty grading tools) Equip contracted VCBDs with IEC materials and distribution tools Community mobilization and sensitization to increase demand for vouchers and promote utilization of voucher MNCH services Conduct community education sessions in collaboration with other partners Identify, select, and recruit additional VCBDs Renew contracts with trained VCBDs Conduct door-to-door mobilization and distribute vouchers to eligible clients in the community IR1 Conduct client follow-ups to ensure utilization of voucher supported services Track and monitor voucher distribution activities Hold sub-regional FP orientation meetings with VCBDs Carry out annual facility-community linkage meetings

USAID Uganda Voucher Plus Activity 20

Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Facilitate Social and Behavior Change Communication (SBCC) officers to conduct monthly activities Conduct quarterly SBCC meetings in Kampala to review performance Reward VCBDs with certificates Share monthly client feedback reports Increasing awareness and knowledge for Voucher Plus Conduct mass media awareness and demand IR1 creation activities Provide on-going Hotline services SIR 1.2: Access to comprehensive MNCH and FP services in the private sector improved Provide and document on-site technical support to the four enrolled private wings of public facilities to improve CEMONC referral pathways for voucher clients Implement and strengthen the district-based ambulance referral network; work closely with the DHOs' offices to monitor the implementation of the ambulance referral system by VSPs to improve the referral mechanism for clients Increase access to eMTCT services by accrediting more private facilities as ART centers; work with IR1 DHOs and MoH AIDS Control Program team to re-assess and accredit private facilities that either missed the previous assessment or failed the assessments done in 2016 for ART accreditation to improve access to eMTCT for HIV positive clients Improve service linkages between private facilities and public sector for services not offered in the private sector; work with DHOs, public facility in- charges, and other partners like RHITES and VSPs to improve linkages between contracted facilities and public sector sites for ART, HIV tests, and vaccines for immunization SIR 1.3: Quality of MNCH and FP services at participating private sector facilities Improve VSPs' service delivery capacity Strengthen providers' technical competencies through on-site mentorships; conduct on-site mentorship/coaching to improve providers' competencies to offer quality EmONC and FP services Build capacity of providers to offer youth friendly IR1 services and address SGBV issues through on-site CMEs; conduct facility on-site CMEs on youth- friendly services and handling of SGBV issues Work with RHITES and DHOs' offices (through the District Laboratory Focal Persons) to strengthen the quality of providers' laboratory diagnostic services

USAID Uganda Voucher Plus Activity 21

Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Strengthen providers involvement and interest in quality of care improvements through rolling out and monitoring the implementation of the MOH's SQIS assessments by all VSPs Conduct annual clinical audits to check level of VSPs' adherence to MOH quality of care standards of care; collaborate with DHTs to conduct annual clinical audits to measure level of adherence to MH standards of care and generate information for graduating private facilities into MoH GFF/RBF project Conduct Quarterly Technical support Visits to VSPs by DCOP and Quality Assurance Advisor to routinely monitor quality of care at facilities Conduct routine joint technical support supervision to VSPs together with DHOs' office and RHITES teams; work with DHTs and RHITES to develop joint annual supervision plan, conduct joint support supervision to all participating facilities on routine basis, and hold performance review meetings Facilitate VSP peer learning among low-performing and high-performing facilities; work with DHTs and RHITES implementing partners (IPs) to support cross-site learning visits for quality improvements between low-performing and high-performing sites Strengthen medicines stock management at VSPs; work with RHITES and District Medicines Management Supervisors to improve medicines stock management at VSPs Foster private providers' participation in the quarterly district performance review meetings and/or region-based quality improvement meetings by the DHT and RHITES partners to bolster a CQI culture in VSPs Support facilities to adhere to the Environmental Management and Mitigation Plan(EMMP) best management practices Strengthen documentation, storage, and utilization of clients' data by all supported private providers IR2: Increased capacity of Uganda’s public and private sectors to develop longer-term health financing options SIR 2.1: Local organization/entities with the capacity to implement output-based health financing program strengthened Management of providers claims and payments/reimbursements, strengthening VSP abilities to manage claims Produce and distribute claims processing stationery to providers, and support in appropriate use Reimburse providers and handle quarantined IR2 claims and accounts reconciliations Conduct quarterly field reconciliation visits to resolve unpaid quarantined VSP claims, provide on-

USAID Uganda Voucher Plus Activity 22

Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S site capacity building on record keeping and accurate claim generation practices

Issue letters of continuity to VSPs to continue providing services under the current contractual terms Data management and reporting to improve VSP capacity, capacity of Village Health Teams (VHTs) to target the right voucher beneficiaries, and the capacity of DHT's analysis of private sector areas for improvement Track voucher distribution and sales trends IR2 Track voucher service redemption trends Monitor reimbursement units and trends Improved capacity of private providers to participate in output-based payment mechanisms Renew provider contracts for Year 4; note contracts contain more detailed recommendations for investing profits, adhering to quality and health system improvements, fraud prevention and control Perform contracts management roles with VSPs; include handling provider reimbursements for service offered , handling rejected claims and accounts reconciliations Monitor improvements in providers' adherence to output-based financing contracts through reduction in rejected and quarantined claims on provider reimbursements. Encourage, monitor, and document providers' reinvestments of reimbursement profits into improving systems and quality of care at their facilities Facilitate supported private providers to report into DHIS2; work with District Biostatisticians and IR2 MoH resource center to include new VSPs into DHIS2, facilitate linkage between biostatisticians and VSPs for routine technical support to ensure timely, complete and accurate HMIS reporting and monitor providers' reporting practices into DHIS2 Work with District Biostatisticians and or HMIS Focal persons to conduct joint data quality assessment audits at VSPs to strengthen data capture, reporting and utilization by providers Work with URMCHIP to identify suitable VSPs for RBF training during regional RBF roll-out Facilitate private sector participation in district and national dialogues on service delivery and HSS Build capacity of providers to implement Community Based Health Insurance Scheme (CBHIS) as a financing sustainability plan; identify and work with a suitable partner with strong expertise in building private providers' capacity in CBHIS in Uganda to train and mentor at least 50 VSPs on CBHIS Build DHTs knowledge and capacity in output based aid mechanisms

USAID Uganda Voucher Plus Activity 23

Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Strengthen DHMTs' understanding of RBF mechanisms through active participation in facility assessments, accreditation, monitoring of quality, reviewing provider claims during the claims reconciliation processes, and clinical audits for private facilities within their districts

Work with RHITES IPs in Eastern and northern regions to strengthen the capacities of districts IR2 and contracted providers to conduct MPDSR Share Activity performance progress reports with Districts to update them but also show the Activity's contribution towards the district's general health metrics Conduct annual Activity performance review meetings for district stakeholders to share progress, learnings, emerging issues and identify areas of synergy Promote and leverage community-based solutions to stimulate saving for health to improve response to RMNCH Collaborate with CDOs, Local governments and other IPs like Bantwana World Education, map and identify village loan and savings schemes in the Eastern and Northern regions to link voucher clients to. Conduct community dialogues on health issues in IR2 all identified and functional VSLAs Sensitize and work with VSLAs and/or other savings groups to adopt a health savings component Work with VCBDs to link voucher mothers/families to VSLA and other community- based organizations to promote saving for health SIR 2.2: Evidence, data, and assistance to help develop sustainable financing schemes of MNCH and FP provided Implement Learning Agenda and disseminate findings Disseminate successes, innovations, learnings, and challenges through various channels including the IR2 Budget Sector technical working group, RBF Implementing Team, district stakeholder meetings, annual activity review meeting, annual assembly of RMNCH partners, and MCH technical working group, and periodic stakeholder newsletters

USAID Uganda Voucher Plus Activity 24

9.2 Special Reporting Requirements

This annex presents programmatic indicators on maternal and child health, as well as FP and reproductive health. Please note that we use the submission date of the voucher claim rather than the treatment date.

Table A- 1. Voucher Sales Against Targets ...... Error! Bookmark not defined. Table A- 2. Voucher Redemption by Type of Service ...... Error! Bookmark not defined. Table A- 3. Safe Deliveries by Type ...... Error! Bookmark not defined. Table A- 4. Delivery Outcomes for Y4 ...... Error! Bookmark not defined. Table A- 5. Contribution of Voucher Plus Deliveries to District Statistics for Y4 Error! Bookmark not defined. Table A- 6. Y4Q3 PPFP Attendance and Deliveries ...... Error! Bookmark not defined. Table A- 7. Y4Q3 PPFP Uptake by Method ...... Error! Bookmark not defined. Table A- 8. Central Level Stakeholder Engagement ...... 35 Table A- 9. District Level Stakeholder Engagement ...... 35 Table A- 10. Learning Agenda ...... 38

Figure A- 1. ANC Services by Visit Type ...... Error! Bookmark not defined. Figure A- 2. Quarter ANC Attendance, Disaggregated by Age ...... Error! Bookmark not defined. Figure A- 3. Cumulative Facility Deliveries Against End of Project (EOP) Targets Error! Bookmark not defined.

Health

A. MATERNAL AND CHILD HEALTH (MCH) The Activity works to improve accessibility and quality of basic interventions that can and have saved millions of lives, focusing on five key areas.

Voucher sales and redemption As shown in Table 1, the Activity did not distribute vouchers during the reporting period. Instead of selling new vouchers, the Activity prioritized quality services and reimbursement to VSP for the vouchers already in circulation.

The cumulative annual voucher sales stand at 69,986 representing 56.9 percent of the annual target while the inception to-date sales are 303,017 representing 84.2 percent of the end-of-project target of 360,000 vouchers.

Table A- 1. Voucher Sales against Targets Y4 Q1 Y4 Q2 Y4 Q3 Y4 Q4 Cumulative Quarterly voucher sales 29,583 30,902 9,501 0 303,017 Quarterly sales target 30,766 30,766 30,766 30,766 360,000 Percent 95.0% 112.2% 42.3% 0% 84.2%

NB: Quarterly Voucher sales numbers were adjusted for the 8,060 vouchers that were recalled from the VCBDs in Q4 before being sold to clients.

USAID|Uganda Voucher Plus Activity 25

Table A- 2. Voucher Redemption by Type of Service Servic Y4 Q1 Y4 Q2 Y4 Q3 Y4 Q4 Cumulati Y4 Y4 Q4 e Type Client Client Client Client ve Client Redemption Achieved Visits Visits Visits Visits Visits Target Redemption

ANC1 15,327 26,381 21,317 6,488 206,986 95% 21.3% ANC2 27,583 20,443 13,153 60% 43.2% 13,452 181,166 ANC3 11,969 23,701 17,361 14,351 146,855 60% 47.1% ANC4 13,819 10,490 91,32 50% 30.0% 8,612 88,255 Delivery 15,152 27,478 20,208 17,133 176,744 70% 56.3% PNC 8,670 13,791 11,163 10,283 89,742 50% 60.0% PPFP 2,350 3,502 2,983 3,465 26,641 45% 20.2%

Service Redemption As reflected in Table 2 above, this quarter’s redemption rates were affected by the denominator used, “active vouchers in circulation as a proxy for voucher sales.” Active vouchers in circulation is defined as all vouchers sold to VCBDs one year ago (from November 1, 2018 to October 10, 2019) that have not been redeemed for a delivery, PNC or FP. The decision to use active vouchers in circulation was reached after consulting with the AOR. Previously, the denominator used had been quarterly voucher sales, but this would not work for future quarters given that voucher sales have ended. This change resulted in a significantly larger denominator for ANCs and delivery, which depended on Voucher sales for specific periods. However PNC and FP are not affected because their denominator is the number of actual deliveries attained during Q4, which is not affected by the stoppage of voucher sales. The performance in Q4 is unlike that of Q3 where service redemption rates were way above the set targets for the reporting period due to the low denominator value (i.e., voucher sales achieved in Q3 before stoppage of sales). Given that there have been no new clients since July 2019, it is expected that ANC visits will continue to decline as existing clients move through the ANC cascade to delivery.

In consultation with the AOR, the Activity has determined to use active vouchers in circulation to calculate the redemption rates during the next reporting periods. Figure 1 below shows that ANC attendance proportionately increased during the quarter over all the four ANC visits. The majority of clients completed at least three ANC visits. As in past periods, ANC4 attendance remained relatively low compared to other visits mainly because most clients purchased vouchers after the first trimester, making it difficult for them to attend ANC four times before delivery time.

USAID Uganda Voucher Plus Activity 26

Figure A- 1. ANC Services by Visit Type

Figure 2 below shows that mothers aged 25 years and above used ANC services more than those under 25. The age group of 10-19 years represents the smallest number, which is consistent with national data. Although Uganda has a high teenage pregnancy rate, the percentage of pregnancies below 25 are lower than those above 25 years. The figure also indicates a marked reduction in ANC1 attendance across the age groups unlike in the previous reporting periods. It is also important to note that pregnant women can buy a voucher at any gestation of the pregnancy, and not necessarily in the first trimester. Only 20% of voucher clients historically bought vouchers in their first trimester.

USAID Uganda Voucher Plus Activity 27

Figure A- 2. Quarter ANC Attendance, Disaggregated by Age

Deliveries Figure 3 presents the Activity’s performance in terms of deliveries vis-a-vis the quarterly targets. Although the actual number of deliveries has slightly reduced compared to Q3, the figure indicates that the Activity still surpassed its Q4 delivery target (of 16,080 voucher deliveries) by 7 percent. This performance represents 124.4 percent of the cumulative Y4 annual target and 70.7 percent of the end- of-project target of 250,000 births.

USAID Uganda Voucher Plus Activity 28

Figure A- 3. Cumulative Facility Deliveries against EOP Targets

Table A- 3. Safe Deliveries by Type Y4 Q1 Y4 Q2 Y4 Q3 Y4 Q4 Cumulative to Delivery Type Date C-section 1,426 2,567 1,851 1,553 14,797 Assisted 1,523 2,402 1,680 1,295 21,087 Normal 12,203 22,509 16,677 14,285 140,860 Total 15,152 27,478 20,208 17,133 176,744

Similar to previous quarters, Table 3 shows that most clients delivered normally as desired (accounting for over 80 percent of deliveries), while cesarean sections remained steady at nine percent, which is within the MOH and WHO acceptable range of no more than 10–15 percent of all deliveries.

Table A- 4. Delivery Outcomes for Y4 Period Y4 Q1 Y4 Q2 Y4 Q3 Y4 Q4 Cumulative to Outcome Date Measures Deliveries 15,152 27,478 20,208 17,133 176,744 Live births 15,040 27,186 20,006 16,929 175,361 Still births 112 307 202 204 1,383 FSBR = 8.0 Maternal deaths 6 10 7 4 101 MMR = 58.0

USAID Uganda Voucher Plus Activity 29

The Activity recorded 4 maternal deaths this quarter compared to 7 deaths in Q3. As in past quarters, the main cause of the maternal deaths has remained postpartum bleeding. All of these deaths were reviewed by VSPs, and reported to DHOs through the HMIS. Cumulatively, the Activity has recorded 101 maternal deaths since inception. Although the current Activity MMR of 58 is much better than the national average of 336/100,000 (Uganda Demographic and Health Survey [UDHS], 2016), the Activity continues to support the districts, RHITES partners, and other implementing partners in areas of operation to avert all deaths.

Table A- 5. Contribution of Voucher Plus Deliveries to District Statistics for Y4 Period Total District* Deliveries Paid for Percentage Contribution Deliveries by Voucher Plus of Voucher Deliveries to District Totals Oct–Dec 2018 45,090 15,152 34.0% Jan-Mar 2019 67,946 27,478 40.4% Apr-Jun 2019 67,556 20,208 29.9% Jul-Sep 2019 65,892 17,133 26.0% *Total district deliveries = Total deliveries registered across the 35 districts implementing this Activity. Source DHIS2 as of Oct 21st, 2019.

This quarter, the Activity contributed to 26 percent of all district deliveries reported into DHIS2 in the 35 supported districts. The Activity used collated and aggregated data on deliveries from the DHIS2 for all of the 35 supported districts combined in order to better understand its contribution. As noted, our contribution to district deliveries has declined and is expected to decline even further over the coming quarters as the number of vouchers in circulation decline.

B. FAMILY PLANNING AND REPRODUCTIVE HEALTH

Increasing uptake of postpartum family planning services This quarter, the Activity registered a five percent increase in the proportion of women utilizing postpartum FP services from 15.2 percent in Q3 to 20.2 percent in Q4. The FP target has remained ambitious given the deep-rooted, socio-cultural and religious beliefs surrounding FP services in the two regions of operation and the fact that over a third of our facilities are Catholic.

Table A- 6. Y4Q4 PPFP Attendance and Deliveries Y4 Q3 Q1 Q2 Q3 Q4 Cumulative Deliveries 15,152 27,478 20,208 17,133 176,744 PPFP 2,350 3,502 2,983 3,465 26,641 Percent 15.5% 12.7% 15.0% 20.2% 15.1%

The Q4 improvement in PPFP attendance is due to the extra efforts and new strategies the Activity employed over this period. These strategies included working collaboratively with other local district FP partners to organize FP camps at VSPs with young child clinics (YCC) and supporting/mentoring VSP providers to strengthen the integration of FP into YCC to improve the targeting of mothers when they have brought children for immunization. This was done at few selected non-catholic high volume VSPs. The providers were also mentored on FP provision during these events. The Activity piggybacked on the existing local IPs like PACE and RHU to secure FP products and mobilize communities for the FP camps. During the reporting period, the Activity also engaged MOH and obtained a formal letter authorizing Joint Medical Stores (JMS) to start supplying 49 VSPs with free FP commodities from the Reproductive Health Commodities Alternative Distribution system (ADS). This will improve VSPs’ access to FP

USAID Uganda Voucher Plus Activity 30

products from JMS. Thirty-five VSPs applications were not approved due to their limited capacity to handle FP products as a result of having lost their trained staff over time. The Activity will continue working with all the key stakeholders to address the social and health system determinants limiting FP use. Table 7 presents results on PPFP updates by method and quarter.

Table A- 7. Y4Q4 PPFP Uptake by Method No. of No. of No. of Y4 Q4 Cumulativ No. of Cumulativ Users – Users Users % e % FP Method Users – e No. of Y4 Q2 – Y4 – Y4 Y4 Q1 Users Q3 Q4 Female condoms 8 8 7 10 0.3% 147 0.6% Contraceptive 6 9 11 0.3% 0.6% 8 150 pills Male condoms 50 60 59 23 0.7% 736 2.8% Tubal Ligation 55 108 123 97 2.8% 858 3.2% IUCD 105 179 171 417 12.0% 1,418 5.3% Moon beads 214 297 110 130 3.8% 1,560 5.9% Injectable 444 677 476 542 15.6% 5,209 19.6% Implants 810 1,271 903 1,146 33.1% 7,191 27.0% LAM 656 896 1125 1,089 31.4% 9,372 35.2% Total 2,350 3,502 2,983 3,465 100.0% 26,641 100.0%

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9.3 Success Stories

Program Element: Health Key Issues: Ending Preventable Maternal and Child Death Operating Unit: USAID/Uganda

“I delivered at the health center for the first time”

Akullu mother of 4 children at Alanyi HC III soon after delivering at a Health Facility for the first time

Body Copy: 23 year old Akullu Agnes from Omer Village, Ailoro Parish, Amugu sub-county in Alebtong District is married to Ocen Geofrey. The couple has four children. Three of the four were delivered at a Traditional Birth Attendant’s (TBA’s) home. It’s the fourth child that was born at Alanyi HC III with the help of a voucher. Agnes got the voucher from Evelyn Awidi, a Voucher Community Based Distributor (VCBD), who sensitized her about the benefits of delivering at a health facility and advised her to buy the voucher.

Talking to Agnes about her decision to get the voucher, she noted: “all the three times I gave birth at the TBA’s home, I would struggle to pay the TBA for her service as she would demand for either money or a goat, which my husband could not afford. Although my mother in-law would negotiate for these costs, it all remained expensive. I also feared going to deliver at the facility because I could not afford the ‘mama kit’ which is required before health workers help you deliver.”

Quote: “The health worker diagnosed me with malaria, which was treated at no extra cost. During my subsequent visits, I was provided treatment without any additional costs. I safely delivered at the facility with good care from the midwives. I intend to use family planning method since I have the opportunity with the voucher. Delivering from the health facility was safer for me and the baby compared to the TBA’s place.”

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Background Information: This story is about a mother of four delivering for the first time at a health facility as a result of the USAID Uganda Voucher Plus Activity. It occurred in Alebtong district Uganda. The story occurred under the Health Category. Contact Information: Christine Namayanja, Chief of Party, ([email protected]; +256 312506900 “Our Health facility has greatly improved; thanks to Voucher” Body copy: In 2010, Alleluyah Joint Maternity clinic started in a small rented house with only five rooms. Supported by Marie Stopes, the clinic offered maternal health services, cancer screening and treating manageable illnesses that could arise during pregnancies, like malaria and urinary tract infections. The clinic also had an outpatient department (OPD) with 50 mothers of which 30 were accessing FP services monthly. In case of emergencies, mothers were referred to other health facilities. The clinic before partnering with voucher Also, the clinic did not have equipment like microscopes, ultra sound machines and modern beds. In terms of management, the clinic had only 2 midwives and 1 clinical officer.

In spite of the challenges, a number of clients seeking medical services especially women kept increasing; and this raised a question, “what was the plan?’ The coming of the USAID Uganda Voucher Plus gave the clinic a head start to that question. ANC service intake increased from 200 mothers to more than 500 monthly. A count of 60 to 80 mothers attained FP services while IPD & OPD registered 300 mothers monthly. The human resource was beefed up with 2 extra Clinical officers, 2 lab technicians, 1 records officer and an The current clinic following the surge in the number of clients administration support staff. since partnership with the Voucher Plus Activity

Quote “We constructed new structures like a theatre to carry out operations, procured clinical equipment and associated medicine, and pay staff adequately to enhance performance at the clinic.” The clinic purchased a vehicle to transport pregnant mothers in need of emergency referral. The clinic ensures data is reported and

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utilized at national and local levels. The DHOs and MOH have recognized the clinic because the Voucher Plus Activity has enabled us to rise to a standard worth recognizing.” Quote: “The USAID Uganda Voucher Plus has given us visibility and enabled us to improve the quality of services we deliver. We are among the best facilities offering quality maternal child health services.”

Background Information: This story is about a health care provider improving his health system to enable access to safe deliveries for poor pregnant women as a result of the USAID Uganda Voucher Plus Activity. It occurred in Alebtong district Uganda. The story occurred under the Health Category. Contact Information: Christine Namayanja, Chief of Party, ([email protected]; +256 312506900) Private providers have improved health indicators in the district Body Copy: Human resource management was one of the major challenges faced in our health facilities in Apac district. With few support staff, most of the facilities did not have experienced doctors, midwives and nurses to ensure that services were provided effectively. The USAID Uganda Voucher Plus “Dr. Emer Mathew - DHO, Apac district Activity has enabled significant improvements in the private sector and helped to increase choice Dr. Matthew Emer, DHO Apac District and access to quality maternal health services. The facilities are hiring qualified staff, equipping their facilities with essential drugs, and making visible infrastructural developments.

Quote: “The impact of this Activity has been felt by the district, health facilities involved and the community. As a district, there has been an improvement in health indicators. At the community level, many mothers are able to access services they would have otherwise not been able to and the facilities have gained a lot that will remain in the facilities to enable continuity.”

Background Information: These stories provide local stakeholder perspectives on the Uganda Voucher Plus Activity in Apac district. This story occurred under the Health Category.

Contact Information: Christine Namayanja, Chief of Party, ([email protected]; +256 312506900)

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9.4 Stakeholder Engagement to Foster Collaboration, Coordination, and Adaptive Management

Table A- 8. Central Level Stakeholder Engagement

Stakeholder Main contacts Objectives

Dr. Makanga Livingstone • Activity participated in 1 MOH MCH Cluster/Technical Assist Commissioner Working Group meeting in September 2019 to ensure Reproductive Health the contribution of private sector is visible and learnings shared • Participated in 3rd National FP Conference in September • Attended the 2019 National RMNCAH pre-Symposium, Symposium and Assembly Conferences

• Worked with MOH-RBF team to orient 13 VSPs pre-

Ministry of qualified by RBF in 2018 before roll out Dr. Sarah Byakika Health • Continued discussions with MOH RBF team on Commissioner Planning, inclusion of 27 pre-qualified voucher supported facilities Financing and Policy onto RBF

• Officiated at the Activity’s hand over of donated medical Dr. Martin Ssendyona equipment to VSPs in Gulu and Mbale to improve quality of care for MCH services. Principal Medical Officer Quality Assurance & Improvement Department Save for Health Makaire Fred, Executive • Support VSPs to gain deeper understanding of CBHIS Director Enabel Paolo Reggio d’ Aci Participated in the ENABEL RBF project District inception Health Financing Expert meetings in Acholi sub region. Health Partners Sarah Murungi Support VSPs to start up CBHI Schemes and support Uganda COP VSLAs to encourage saving for health.

Table A- 9. District Level Stakeholder Engagement Stakeholder Objective Comments

RHITES-East • Promoting synergy in areas of • Participated in RHITES funded District common interest Performance review and Partner RHITES-N Lango • Fostering effective eMTCT EPI coordination meetings in 7 districts of RHITES-N Acholi and FP linkages Lamwo, Sironko, Kapchorwa, Pallisa, • Participation in stakeholder Bukedea, Mbale & Serere meetings • RHITES N-Lango supported Aloi mission • Capacity strengthening for with 1 Adult weighing scale and 1 BP machine VSP staff and Alenga with 1 delivery set, 3 digital thermometers and MUAC tapes • 4 staff from RHITES N Lango and RHITES N Acholi attended the medical equipment handover function organised by Voucher Plus

USAID Uganda Voucher Plus Activity

Stakeholder Objective Comments

• Attended a Teso regional QI Meeting jointly with RHITES-E at Kumi Hotel, Kumi district and also attended a meeting converged by Iteso Cultural union prime minister which was facilitated by RHITES-E to discuss and jointly address SGBV issues in the region. • Worked with RHITES E and staff from Soroti Regional Referral Hospital to support MPDSR reviews at St. Clare orungo H/C III and Abarilela H/C III (public facility) in Amuria District. • Conducted joint mentorship on MNCH services with RHITES-E in all the four facilities in Kumi district (Olimai community, Mukongoro community, Michoes medical centre and Midas touch medical centre). The mentorship focused on ANC, PNC, EPI and Deliveries, Malaria and MPDSR • RHITES N-Lango supported data management and cleaning for Amuca SDA, Boroboro HC III, Heaven of Peace HC, Aromo maternity Home, Gift life care clinic, Akia HCII and Charis Medical Centre plus voucher facilities in Kwania district ie Abedober HCIII, Aduku Mission HCII, Iwal maternity home. PSI Improving FP service delivery Collaborated with Population services international Uganda and they; • Trained 5 staff on use of misoprostol to prevent bleeding and MVA use in Post arbortal care (2 from Kolonyi hospital, 2 from Bushkor and 1 from Prof Wamukota). • supported Jafo medical centre and Pader maternity home with FP commodities Marie stopes Lira Improving FP service delivery Supported Bata medical Centre and Blessed medical Centre with FP products to strengthen family planning service delivery District local gov’ts and Foster inclusive stakeholder • Strengthened referral and service linkages for health leadership engagement and local-led solutions ART, FP commodities and immunization. to HSS challenges to achieve • Activity team participated in 3 EDHT sustained collaboration and impact meetings held in districts of Mbale and Otuke beyond Voucher Plus Activity during the quarter implementation period • Siloam Nursing home has been supported by Soroti DHO’s Office to start EPI services • Mentorship training organized by Apac district on immunization was attended by 3 VSPs ie Apac medical center, Nightingale hospital and Alenga HCIII • Worked with DLFP Manafwa to assess lab functionality for Kimtab in preparation for accreditation to offer HTS/EMTCT services

USAID Uganda Voucher Plus Activity

Stakeholder Objective Comments

• District Leadership (including Chairmen LCV, CAOs and DHOs) in Gulu and Mbale districts participated in the Medical Equipment handover functions held in the 2 districts • 44 VSPs attended district meetings during the quarter • A total of 63 visits to 35 District Health Offices were conducted to brief the DHOs on progress with the Activity’s implementation • Shared project performance reports for the previous quarter with all 35 DHOs

USAID Uganda Voucher Plus Activity

9.5 Updated Learning Agenda Schedule

Table A- 10. Learning Agenda Project Data Collection Learning Topic Research Question(s) Source Approach Status Year (how, by who) 3 Private Provider Mapping 1. What are the lessons learned in AMELP Learning Qual. KIIs, project staff Completed and Accreditation After- using mapping and accrediting Agenda Question & Action-Review; Long for selective contracting of IR2 SOW Report VSPs?

3 Private Provider Mapping 1. What are the lessons learned in AMELP Learning Qual. KIIs, project staff Completed and Accreditation After- using mapping and accrediting Agenda Question & Action-Review; K&L brief for selective contracting of IR2 SOW VSPs?

3 Voucher Non-redemption 1. What are the reasons behind Operations research Qual. KIIs, consultant Completed Study voucher holders not redeeming requested by AOR and for any services? IR 2 SOW

3-4 Clients’ Perception of 1. What do demographic and AMELP Learning Quant. Client survey, Completed Quality Services, Financial other client characteristics tell Agenda Question and consultant Protection, and Access to us about whether the Activity is IR 2 SOW Services achieving its goal to improve access by the poor to safe motherhood services? 2. What does client feedback tell us about their perception of the quality of redeemed services? 3. Does the Voucher Activity offer some measure of financial protection to clients?

3-4 Effectiveness of the Poverty 1. Was the Poverty Grading Tool AMELP Learning Qual. & KIIs with VCBDs, Completed Grading Tool (PGT) in effective in targeting Agenda Question and Quant. FGD with SBCC Reaching Beneficiaries beneficiaries of the safe IR 2 SOW officers and motherhood voucher? managers, and quant. data from

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Project Data Collection Learning Topic Research Question(s) Source Approach Status Year (how, by who) 2. What are the lessons learned client perception from using the Poverty Grading survey Tool?

3-4 Effectiveness of Demand- 1. What are the lessons learned in AMELP Learning Qual. & KIIs with VCBDs, Finalized; awaiting generation Activities in increasing beneficiary demand Agenda Question and Quant. FGD with SBCC distribution Increasing Voucher for the service package? IR 2 SOW officers and SBCC Redemption managers, client data from addendum to client follow-up tool 4 Vouchers Improve 1. What are the lessons learned in IR 2 SOW Quant. Client survey Finalized; awaiting Equity in Access to improving equity in access to distribution Quality Maternal and quality health services? Newborn Health Services

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