ADVOCACY FOR BETTER HEALTH Cooperative Agreement No: AID -617-A-14-00004

AAnnnnuuaall PPrrooggrreessss RReeppoorrtt OOccttoobbeerr 11st,, 22001166 –– SSeepptteemmbbeerr 3300th,, 22001177

Submitted to

Submitted to U.S. Agency for International Development (USAID), Uganda Plot 1577 Ggaba Road, Nsambya. Kampala

Submitted by

Moses Dombo, Chief of Party USAID/PATH Advocacy for Better Health Project Tel: +256 312 393200

OCTOBER 30TH, 2017

The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government

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TABLE OF CONTENTS

TABLE OF CONTENTS ...... 2

LIST OF TABLES AND CHARTS ...... ERROR! BOOKMARK NOT DEFINED.

LIST OF ABBREVIATIONS AND ACRONYMS ...... 3

EXECUTIVE SUMMARY ...... 4

1.0 INTRODUCTION/BACKGROUND ...... 8

2.0 PROJECT IMPLEMENTATION ...... 9

2.1 RESULT 1: CITIZENS DEMAND IMPROVED QUALITY SERVICES ...... 9

2.2 RESULT AREA 2: CSOS EFFECTIVELY ADVOCATE FOR AND REPRESENT COMMUNITIES ON POLICIES/ ISSUES OF CITIZENS CONCERN IN THE HEALTH AND SOCIAL SECTORS...... 14

2.3 RESULT AREA 3: INSTITUTIONAL CAPACITY OF CSOS STRENGTHENED ...... 20

3.0 LESSONS AND IMPLEMENTATION CHALLENGES ...... 29

4.0 PROJECT MANAGEMENT ...... 30

6.0 PLANS FOR YEAR 4…………………………………………………………………………………………………………………………..33

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LIST OF ABBREVIATIONS AND ACRONYMS

AAG Advocacy advisory group ACODEV Action for Community Development AMELP Activity Monitoring, Evaluation and Learning Plan ARUWE Action for Rural Women Empowerment CHC Communication for Healthy Communities CAOs Chief Administrative Officers CDFU Communication for Development Foundation Uganda CIDI Community Integrated Development Initiative COP Chief of Party CSO Civil Society Organization DCOP Deputy Chief of Party DMC District Management Committee DO Development Objective GOU Government of Uganda HUMCs Health Unit Management Committees ICWEA International Community of Women in East Africa I-DO Integrated Development Options IEC Information, Education and Communication IP Implementing partner IR Intermediate Result JIACOFE Jinja Area Communities Federation KACSOA Kapchorwa Civil Society Organizations Alliance KADINGO Kalangala District NGO Forum KRC Kabarole Research Centre LADA Literacy Action and Development Agency M&E Monitoring and Evaluation MEEPP Monitoring and Evaluation of the Emergency Plan Progress MARPs Most-at-risk populations MOH Ministry of Health MOU Memorandum of Understanding MUCOBADI Multi-Community Based Development Initiative NAFOPHANU National Forum for People Living with HIV/AIDS in Uganda NUPAS Non- U.S. Organization Pre-award Survey OACA Organizational and Advocacy Capacity Assessment OD Organizational Development RACOBAO Rural Community Based Organization RMNCAH Reproductive Mother Neonatal Child and Adolescent Health SDS Strengthening Decentralization for Sustainability SHRH Strengthening Human Resources of Health STF Straight Talk Foundation USAID United States Agency for International Development USG United States Government TA Technical Assistance NAFOPHANU National Forum of People Having HIV/ AIDS Networks in Uganda

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Executive Summary

This report gives an account of USAID Advocacy for Better Health (ABH) project accomplishments, lessons drawn/ implementation challenges during year three. It also highlights the major focus for year four.

In year three, innovatively scaled up its activities with all the 479 community groups in its district of focus. This was aimed at empower citizens on their rights and responsibilities related to health and social services. The Patients Charter was maintained as the bedrock for messaging on rights and responsibilities. A specific lens was also given to empowering these groups with knowledge on the 90-90-90 goals for HIV treatment and prevention. The community groups also continued tracking and monitoring the availability of health commodities and human resources in lower level health facilities. Advocacy forums were also organized and leveraged by the groups, to hold their leaders accountable for the quality, availability and accessibility of health services, including demanding for policy based changes from decision-makers.

For efficiency and effectiveness gains, ABH adopted a new paradigm—of having with a thematic focus on priority disease areas: HIV/AIDS; TB; Malaria; Nutrition; Reproductive, Maternal, Newborn, Adolescent and Child Health (RMNCAH). This was done alongside focus on three priority advocacy areas: health commodity security, human resources for health (HRH), and domestic financing. The project also reorganized its self, by assigning project Advocacy Officers thematic areas.

Some of the notable accomplishments during the year include;  Advocating for the development and commencement of work on the Anti HIV Stigma and Discrimination Policy  Advocating for the drafting TB Desk Guide for the prevention and control of TB by health workers  Advocating for the establishment of the Parliamentary TB Caucus, the Parliamentary Forum on Quality Health Service Delivery, the Parliamentary Forum on Nutrition, that will be leveraged to expedite future legislation.  Advocating for the availability of the 13 UN Lifesaving Commodities that yielded the directive from the Permanent Secretary (PS) of the Ministry of Health (MoH) to District Health Officers to ensure appropriate storage and use of oxytocin to control postpartum hemorrhage.  Commencing work on guidelines to operationalize the Immunization Fund  Advocating for the availability of quality malaria Rapid Diagnostic Tests (mRDTs), which yielded a directive from the Director General of the Ministry of Health to the Commissioner General of the Uganda Revenue Authority, banning the importation of poor quality mRDTs)  Holding the first ever National Presidential Dialogue on the Quality of Health Services in Uganda  Holding to major dialogues on the status of Human Resources for Health in the country. The outcome of one of the dialogues was the establishment of a multi-disciplinary Task Force chaired by the Under Secretary of MoH and aimed at the ensuring the absorption of PEPFAR financed staff  Advocating for the retention of the health sector budget for the FY 17/18 at Uganda shillings 1.8 Trillion, averting a proposed cut of 30% from the FY 16/17 budget  Coalescing with other CSOs and Parliament to ensure the obtainment of the Certificate of Financial Implications from Ministry of Finance, Planning and Economic Development, as a big step towards expediting the implementation of the National Health Insurance Scheme.  Conducting the Non-U.S. Organization. Pre-Award Survey and the annual Organizational Advocacy and Capacity Assessments  Commencing the recruitment of interns and fellows aimed at creating a network of professionals with skills to support sub awardees and CBOs  Providing targeted technical assistance to sub awardees

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 Initiating the documentation of a longitudinal case study that will profile six ABH partners and their progress in the three result areas of the project over the life of the project.

Below is a table summarizing ABH’s progress on performance indicators:

INDICATOR TOTAL BY YEAR REPORT FOR YEAR(S) 2017 – 2017--Data as at Oct 25, 2017 IP NAME: ADVOCACY FOR BETTER HEALTH

INDICATOR INDICATOR TITLE FY 17 TARGET FY 17 ACTUAL FY 17 % NUMBER ACHIEVEMENT 1 ABH1.1 % OF HEALTH FACILITIES THAT REPORT 25% 49% 196% IMPROVEMENTS IN SERVICE DELIVERY [25/100] [49/100] 2 ABH1.1.1 % OF CITIZENS WHO REPORT HAVING 45% 23% 50% PARTICIPATED IN AN ACTIVITY TO DEMAND [45/100] [22.5/100] FOR IMPROVED HEALTH AND SOCIAL SERVICES IN THE LAST ONE YEAR 3 ABH1.2.1 % OF SUB GRANTEE CSOS THAT 75% 100% 133% DEMONSTRATE INFLUENCE ON HEALTH AND [75/100] [16/16] SOCIAL SERVICES AGENDA 4 ABH1.2.2 % OF DISTRICTS WITH ANNUAL WORK PLANS 50% 40% 80% THAT INCLUDE CITIZENS’ CONCERNS FOR [50/100] [14/35] IMPROVED HEALTH AND SOCIAL SERVICES 5 ABH1.3.1 % OF CSO WITH IMPROVED 70% 90% 129% ORGANISATIONAL MANAGEMENT CAPACITY [14/20] [18/20] 6 ABH1.3.2 % OF SUB-GRANTEE CSOS THAT 80% 85% 106% DEMONSTRATE IMPROVEMENTS ON THE [16/20] [17/20] ADVOCACY COMPONENTS OF THE OACA 7 ABH1.3.3 NUMBER OF SUB-GRANTEE CSOS THAT 6 16 267% ATTAIN ADEQUATE PERFORMANCE AS DEFINED IN ORGANIZATIONAL AND ADVOCACY CAPACITY ASSESSMENT 8 ABH1.3.4 NUMBER OF TARGETED CSOS WITH 1 2 200% MANAGEMENT SYSTEMS THAT QUALIFY THEM TO RECEIVE DIRECT DONOR FUNDING IN ACCORDANCE WITH USAID’S NUPAS 9 3.1.2 - C - 2.0 PERCENT OF MEN AND WOMEN WHO SAY 62% 37% 60% - CI HEALTH SERVICE DELIVERY IN PUBLIC HEALTH [62.4/100] [37.4/100] FACILITIES HAS IMPROVED IN THE LAST ONE YEAR 10 ABH1.1.1.1 % OF CITIZENS WHO DEMONSTRATE 32% 51% 159% UNDERSTANDING OF RIGHTS AND [32/100] [50.9/100] RESPONSIBILITIES RELATED TO HEALTH AND SOCIAL SERVICES 11 ABH1.1.2.1 % OF COMMUNITY GROUPS WHOSE ACTION 48% 128% 266% PLANS ADVANCE INTO IMPLEMENTATION [48/100] [296/232] PHASE 12 ABH1.1.2.2 NUMBER OF FUNCTIONAL ADVOCACY 418 416 100% FORUMS AT SUB COUNTY LEVEL 13 ABH1.2.1.1 % OF CSO ADVOCACY INITIATIVES WHICH 60% 100% 167% ARE SUPPORTED BY EVIDENCE [60/100] [21/21] 14 ABH1.2.2.1 % OF CSOS ACTIVELY INVOLVED IN PUBLIC 60% 150% 250% SECTOR PLANNING PROCESSES [12/20] [18/12] 15 ABH1.2.3.1 NUMBER OF CSOS THAT ARE INVOLVED IN 16 11 69% JOINT ADVOCACY INITIATIVES

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The major lessons drawn/challenges faced during the year were:  The provision of uninterrupted technical assistance, is imperative to ensuring the appreciation and ownership of the project’s thematic focus on HIV/AIDS, TB, malaria, nutrition and RMNCAH by sub awardees.  It is important for the project through its sub awardees to keep track of, and participate at almost all stages of the government planning and budgeting cycle, for the effective integration of issues of citizens concern that are affecting the delivery of quality health services.  Working consistently work with the Parliamentary Committee on Health and other Parliamentary forums, is an important way of equipping them with well packaged evidence that informs their legislation.  Partnership with implementing partners and other CSOs not only leverages comparative advantages, but also ensures that the project triangulates and refines its advocacy evidence.  Advocacy forums at Sub-county and District level are critical platforms for duty bearers to hear from the citizens and for them, to provide critical information to the citizens, which greatly enhances social accountability.  It is important to leverage partnerships with key government departments to champion the project’s advocacy agenda. A clear case in point is the current relation the project has with the Office of the Prime Minister, to champion its nutrition advocacy agenda.  The implementation of the Mexico City Policy led to the loss of RHU as a sub awardee, which required the project to implement alternative measures

Year four Plans:

Being the last year of sub granting to sub awardees and the second last year of project implementation, ABH will consolidate the gains of the first three years as well as laying strategies for sustainability of project related outcomes. Attainments in community empowerment, advocacy and capacity building will be reinforced through documentation and dissemination of success and change stories.

ABH will pursue a theme based focus on disease/ thematic areas: HIV/AIDS; TB; Malaria; Nutrition; Reproductive, Maternal, Newborn, Adolescent and Child Health (RMNCAH). Priority advocacy themes will include commodity availability and commodity security, recruitment motivation and retention of human resources for health (HRH), and increasing public domestic financing for health.

The project will intensify its national level advocacy efforts as a way of ensuring that duty bearers address systemic impediments to the quality of health and social services. This approach will not relegate ongoing community empowerment and district-based advocacy initiatives, but rather ensure a strong linkage and synergy between district-based and national level activities for stronger, more sustainable and higher impact advocacy outcomes that impact a range of policies and communities across the country.

Targeted technical assistance and capacity strengthening activities for sub awardees will also be sustained.

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1.0 Introduction/Background

USAID Advocacy for Better Health (ABH) is a five-year, US$19,980,735 that was awarded in 2014. The project is aimed at improving the availability, accessibility and quality of health services in Uganda. Implemented by PATH and Initiative’s Inc., the project aspires to support citizens to demand for their rights and more fully engage communities in the planning and monitoring of health services, while also enhancing the ability of civil society organizations (CSOs) to conduct advocacy to strengthen health-related policies, budgets and programs. The project has three specific result areas:

1. Result Area 1. Citizens demand improved quality of services. 2. Result Area 2. CSOs effectively advocate for issues of citizens’ concern in the health sector. 3. Sub-Result Area 3 Institutional capacity of CSOs strengthened

The project’s theory of change stipulates that IF citizens’ knowledge and awareness of their rights and responsibilities were increased (to stimulate collective consciousness); and IF the capacity of CSOs was built to effectively empower and represent communities, THEN, citizens would believe and have confidence that they can hold their leaders accountable and influence them to change health and social policies in their favor. This empowerment and confidence would motivate citizens to get organized; reach consensus on their priorities and plans of action; and demand for better health and social services from their duty bearers. The persistent collective voice and actions from citizens and CSOs would compel leaders and duty bearers to respond by changing the necessary policies and taking other actions that lead to improvements in the availability, accessibility and quality of health and social services.

For effective advocacy gains in year three, the project shifted its paradigm by adopting a more thematic focus, with a lens on priority disease areas: HIV/AIDS; TB; Malaria; Nutrition; Reproductive, Maternal, Newborn, Adolescent and Child Health (RMNCAH). This was done alongside focus on three priority advocacy areas: health commodity security, human resources for health (HRH), and domestic financing. The project also reorganized its self, by assigning project Advocacy Officers thematic areas. This reorganization also included assigning every sub awardee thematic areas that guided their implementation. Consolidated synergy between district and national level sub awardees was also created, to ensure that systemic impediments to health service delivery are appropriately championed from district to national level.

The sections below highlight the major accomplishments by the project, including lessons/challenges drawn. They also give a snapshot of the major plans for year four.

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2.0 Project Implementation

2.1 Result 1: Citizens demand improved quality services

Overview Under this result area, the USAID Advocacy for Better Health (ABH) project aims at empowering citizens in the 35 districts of operation with knowledge on their rights and responsibilities related to health and social services. Empowerment under this project is measured using different parameters such as the ability of citizens to speak out on issues affecting health care and their ability to engage their leaders and service providers (commonly known as duty bearers) to respond and take action on the same issues affecting health and social service delivery. Coupled with a number of interventions at national and sub-national levels, the project utilized integrated approaches to achieve its community empowerment objectives, riding on the strength of existing community based groups, individual and collective citizen action and responsibility.

Socialization of the 90-90-90 targets, Test and Start policy, Patients’ Charter and the project’s priority advocacy issues through media, IEC tools and face-to-face interventions:

ABH utilized a series of communication platforms including Radio and TV talk shows, Radio and TV spot messages, posters and community groups to socialize the 90-90-90 treatment targets alongside the Test and Start policy based on the 2015 WHO guidelines. The interactive radio talk shows were held on 15 FM stations (national level – 4, district level - 11). Guests hosted on the shows included both technical and political leaders from districts where ABH works. On the same communication platforms, priority advocacy issues related to health commodity security, domestic health financing and human resources for health (HRH) were articulated in line with the Sarah Nanyondo in blue blouse from MAFOC (ABH partner) being thematic focus on MCH HIV/AIDS and TB, hosted in studio at Elgon FM in Mbale Malaria and Nutrition.

All communications on the issues mentioned were premised on the project’s advocacy and communications strategy that emphasized the project’s tagline “Where Everyone is Accountable, Everyone Wins”. See TV spot messages on YouTube on MCH and HIV - MCH: https://www.youtube.com/watch?v=EbaUBgi3PrI HIV/TB: https://www.youtube.com/watch?v=x3hXV6BhLKk. The project also introduced the “SUPER CITIZEN” Big Idea to model empowered and responsible citizens through branded promotional tools such as t-shirts, stickers, umbrellas, backpacks, posters, and rain coats among others and these were mainly targeting community members. The “SUPER CITIZEN” Big Idea is still being nurtured, with support from CDFU, to ensure it effectively communicates and promotes the project brand to the public especially at community level where it has been very difficult for people to remember Advocacy for Better Health with all the interventions that have happened there.

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Identification and orientation of community groups and CSO partners on the 90-90-90, Test and start policy, differentiated service delivery models and health facility assessment tool:

The project scaled up its scope of working with community groups in year three to cover all the 479 sub counties, this is time scaling up working with groups that are composed of people living with HIV. The main objective of working with PLHIV groups was to socialize the 90’90’90 treatment targets, the Test and start policy and the differentiated service delivery models. All the new and old groups, alongside the CSO partners, were oriented on the new approaches and priority areas of focus for year three. They were also oriented on how to effectively carry out health facility assessments using a standard tools developed by the project to track and monitor availability of health workers and drugs for HIV/TB, MCH and Malaria particularly at health center IIIs. These efforts have resulted into a more effective and coordinated process of evidence collection that has been informing advocacy engagements between citizens and duty bearers at community, district and national level. Some of the results from such health facility assessments have been used to write successful abstracts for international conferences, such as the one that was held in Copenhagen, Denmark in June 2017 on Health and Humanitarian Logistics.

Advocacy action planning by community groups on a monthly basis:

As part of the standard process of conducting effective citizen-led advocacy, the project worked with and supported 479 community groups in the 35 districts to organize and conduct monthly advocacy action planning meetings. The action plans prioritized issues that were identified during routine tracking and monitoring of service delivery such as stock out of essential commodities including drugs for HIV/TB, health worker absenteeism and other challenges facing health facilities that would require the attention of duty A community group member in Bufumbo sub county, asking a question bearers. during a monthly meeting in Mbale

Advocacy forums at sub county and district level conducted:

Advocacy forums continued to be a critical advocacy and accountability platform that citizens utilized to raise to their duty bearers issues that continue to affect the quality, accessibility and availability of health services in their communities. Througout the year, CSO partners together with community groups mobilized citizens and duty bearers to participate in up to 1308 advocacy forums. Some of these happened at district level like in Kisoro, Mpigi and Busia. Some community groups went a notch higer to package evidence collected during routine tracking and monotoring of service delivery into evidence dossiers that they would present to their duty beaers on these forums.

Duty bearers are increasingly appreciating this approach of advocacy forums saying it was helping in reducing animosity between comunities, their leaders and health workers over service delivery gaps and because of not appreciating each one’s roles and responsibilities.

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Dr. Chebet Benjamin (in the picture) is one of the many senior health workers that commend the use of advocacy forums in search for solutions to challenges crippling service delivery. He, one time, attended an advocacy forum at Budadiri HCIV in Sironko district which he heads and this is what he had to say;

“When you were planning the first advocacy forum, all health workers were hesitant to host the citizens within the health facility premises. However, after discussions with the ABH team from MAFOC, we eventually accepted to have the advocacy forum. The advocacy Dr. Chebet Benjamin I/C Budadiri HC IV forums have helped in improving client- provider relationships. Staff and clients are happy with the services offered. We have also improved on health worker’s attendance to duty since all the midwives are accommodated at the facility and all departments have updated duty rosters.”

However, what remained a challenge for partners was how to find a direct linkage to active government- initiated barazas in the districts for leverage. Nevertheless, efforts will still continue in year four to explore how to work with the Office of Prime Minister to ensure any existing baraza platforms are leveraged in the 35 districts where ABH is operating.

Media articles referencing Advocacy for Better Health:

Throughout the year, ABH received a lot of media coverage for its various events happening at national and sub-national levels. CSO partners also directly engaged media to raise the profile of issues within their mandate. For instance, NAFOPHANU engaged the media in tours across districts to document evidence of stock-out of HIV/TB drugs which was used to engage duty bearers at district and national level for solutions. Some ABH events, such as the Presidential Dialogue on Health, also received live media coverage of both NTV and NBS Television. Subsequently, a number of stories and articles were filed featuring ABH staff, partners and beneficiaries at community level. Some of these stories can be accessed online on the links below;

TV talk show on domestic financing for health and HIV in particular: https://www.youtube.com/watch?v=Tx6O7eAzmxI&feature=youtu.be)

Monitor Story on Presidential dialogue at Colline Hotel, Mukono: http://www.monitor.co.ug/News/National/health-services-to-donors--activists-tell-government/688334- 4120472-9jdwap/index.html

Feature story on community empowerment tactics in Kalangala district: http://www.monitor.co.ug/SpecialReports/-drama-fight-HIV-Kalangala/688342-3473924-10jxe5c/index.html

Feature story on stock out of TB drugs: https://www.newvision.co.ug/new_vision/news/1460297/treating- tuberculosis-districts-hit-isoniazid-stockout

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Social media engagement:

The project also bolstered its online presence on social media platforms of Facebook and twitter by dedicating someone to manage the platforms on a daily basis. Most of the engagements on social media have been of a promotional nature and focusing on upcoming major events such as media appearances, broadcasts/telecasts and high profile advocacy events, among others. By the end of the year, Facebook alone had 466 followers, 474 page likes and more than 1000 post reach. Similarly, Twitter account had 170 followers and 728 tweets. These were able to generate 41,897 impressions (reactions and engagements combined) and 604 post visits. This demonstrated that there an increasing need for digital/online communication in the project’s advocacy efforts.

People’s Parliament on NTV to discuss MCH and HIV/AIDS-related issues:

The project also sponsored two sessions of the popular People’s Parliament TV show on NTV with a major focus on MCH and HIV issues. The show on MCH was held in Mityana district that has had episodes of unexplainable maternal deaths in the past. It attracted the participation of districts leaders (District Health Officer, District Chairperson, and Resident District Commissioner) who discussed the critical health sector challenges in the district. These ranged from poor state of maternity wards, to break down of referral system, limited community sensitization on nutrition, lack of ambulance, water shortage in health facilities, stock outs of essential drugs and other lifesaving commodities. Others in attendance were community group Participants at the live session recording of People’s Parliament at members that are affiliated to the project Royal Suites Hotel, Bugolobi, Kampala in June and curious citizens who wanted to discuss issues affecting MCH in their district. The show on HIV was held in Kampala and it attracted top civil society groups involved in HIV/AIDS advocacy including Young Positives, Positive Men’s Union and other HIV constituents. Others in attendance were national level partners and government agency representatives such as the Uganda AIDS Commission. The show discussed extensively HIV financing with advocates calling on government to consider long term sustainable strategies to support its HIV response instead of relying heavily on external funding from development partners. The two sessions were broadcast on two consecutive Saturdays at 8-9pm with repeats on Mondays at 3-4pm.

2.2 Result Area 2: CSOs effectively advocate for and represent communities on policies/ issues of citizens concern in the health and social sectors.

This Result Area aims at enhancing the effectiveness of sub awardees to capture citizens’ concerns related to health and social services, gather evidence around those issues, and engage duty bearers to take action in form of policy change, policy formulation or policy implementation, including budgetary allocation.

This section gives an account of the major accomplishments made against the advocacy ASKs (disaggregated by thematic area) the project targeted to accomplish during year three:

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HIV/AIDS:

Anti HIV Stigma and Discriminatory Policy

In order for the 90-90-90 goals for HIV treatment and prevention to be attained, mitigation of stigma and discrimination is critical. The lack of a standard alone Anti HIV Stigma and Discrimination policy in Uganda could never impact the attainment of these goals. Cognizant of this, the Advocacy for Better Health Project, working through its sub awardee the National Forum for People Living with HIV Networks in Uganda (NAFOPHANU), advocated to the Uganda AIDS Commission (UAC) to develop this policy. UAC through its HIV Prevention Technical Working Group, convened a number of meetings to develop a road map for the writing of this policy. A concept note was developed and shared with stakeholders, and UNAIDS picked interest in this process. Since then UNAIDS has donated resources for a consultant to lead the policy development process. This process is currently ongoing, and we are optimistic that it should finalized in the project’s year 4.

Socializing the Consolidated Guidelines for HIV Prevention and Treatment

With the launch of the Consolidated Guidelines for HIV Prevention and Treatment by the Ministry of Health (MoH) in December 2016, the project continued to work on socialization of the policy, guidelines and the provisions thereof, especially among PLHIV and key populations such as sex workers. Working with the Alliance of Women Advocating for Change (AWAC)—an umbrella organization for female sex workers, to organize a one-day national meeting aimed; “The Effective Moses Dombo addressing female sex workers during involvement of sex workers in the fight against HIV/AIDS the meeting towards achieving 90-90-90 treatment targets by 2020 in Uganda”. This meeting was attended by 114 Participants from 23 Districts (Northern region: Amuru, Lira, Gulu; Eastern region: Tororo, Mbale, Busia, Soroti, Luuka, Iganga; Western region: Mbarara, Kabale, Kabarole, Kasese, Kamwenge, Masindi, Hoima; Central region: Masaka, Nakasongola, Wakiso, Mukono, Kampala, Luwero and Buikwe) across the country. The key outcomes from this meeting included; the need to mobilize peers to seek and access HIV Testing and Treatment services, lobbing and advocating for scale up of optimum friendly HIV Testing and Treatment services so that the underserved sex workers take a stake in the HIV response through the AWAC Umbrella, and advocating for attitude change and promotion of right based approach to quality health care services for key populations. The project will continue working with key populations, as a critical mass to the attainment of the 90-90-90 goals.

Stock status tracking of HIV and TB commodities

Through its sub awardee NAFOPHANU, ABH sustained its regularly tracking, sharing and triangulating of stock status updates on HIV and TB commodities from the districts, with the Ministry of Health. Additionally, and in partnership with the 479 community groups in ABH’s 35 focus districts, the project continued conducting monthly health facility assessments (HFAs) to generate advocacy evidence on health commodity status, especially at health centers II and III. Evidence generated from this stock status tracking, has been used to inform the quarterly meetings that is convened by NAFOPHANU, between CSOs and the National Medical Stores. The purpose of these meetings is mainly to discuss health commodity stock status concerns, and chart feasible ways to ensure increased collaboration and accountability. Overtime and from the overall summary stock status updates from MoH Pharmacy Division, there has been a reduction of the previously rampant stock out of HIV and TB commodities.

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Tuberculosis (TB):

TB desk guide drafting and finalization

The National Tuberculosis and Leprosy Program (NTLP) is mandated to produce and revise TB Desk Guides and dependent on need. The last version was produced in 2010. This guide is an important job aid that guides health workers (especially front liners in busy health facilities) to make right decisions about the management of a TB patient.

Since the last edition was produced, many changes have taken place. These include; the emergence of drug-resistant TB, need Members of Parliament during the TB Forum for improved and or new interventions in TB infection control, orientation meeting held at Grand Imperial, Hotel new developments in diagnostics, policy changes in TB treatment following (including the emergence of new drugs and new treatment regimens), need for skills to communicate to patients and caretakers more effectively, and realization of new TB key affected populations.

The project in partnership with NAFOPHANU and NTLP has collaborated to ensure that a draft TB Desk Guide is developed. This draft is now pending final edits and printing for circulation. The new guide will be very instrumental as a reference tool for health workers, in TB case detection and diagnosis given the rising numbers of TB cases as per the recent TB prevalence survey.

Establishment of the Parliamentary TB Caucus

ABH worked with Champions from Parliament to establish the Parliament TB Caucus. This caucus will be leveraged to steer future legislation on TB issues, and also to create a platform through which the profile of issues affecting TB services can be raised.

A half-day meeting to orient members of this caucus, raise their awareness and highlight the policy gaps that exist in addressing TB was held. The meeting was also aimed at strengthening partnership and collaboration with other TB key players. It was attended by 14 MPs, USAID TRACK TB project, Uganda Cares, Ministry of Health (National TB and Leprosy Program), AIDS Information Centre (AIC), Uganda Stop TB Partnership (USTP), and Welfare Development Network (WEDNET) Africa. The project will continue working with this caucus to discuss and champion policy issues regarding TB.

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RMNCAH

As part of its advocacy for the availability of the 13 UN Life Saving Commodities, ABH presented evidence to the MoH Maternal and Child Health (MCH) cluster working group, on the use and storage of oxytocin, sustained media advocacy (largely through TV and radio), and held multiple face to face meetings with the MoH Permanent Secretary (PS). These activities resulted in a directive by the PS to District Health Officers, to ensure the use and storage of oxytocin in the UNEPI cold chain fridges (see the directive herewith).

Furthermore, project sub awardees i.e Coalition for Health Promotion and Social Development (HEPS) Uganda, and White Ribbon Alliance were nominated to work with Samasha Foundation, to conduct regular and periodic follow ups on the stock status of Life Saving Commodities. With these positive development, ABH will continue working to ensure then availability of oxytocin in remote health facilities. MoH Permanent Secretary’s letter on the storage and use of oxytocin

Establishment of the Immunization Fund

Parliament of Uganda passed the Immunization Act in 2016, and later accented to by the President. The Act aims at;

a) Encouraging / enforcing immunization as a cost-effective and efficacious public health measure against diseases of public health importance and, b) Increasing domestic financing for immunization services through establishment of an immunization fund.

Excerpts of the Gazetted Immunization Act

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As a step towards the establishment of the Immunization Fund and on request by the PS MoH, PATH supported MoH to gazette the Act. PATH-ABH is currently working with MoH and a team of legal experts to develop regulations for the Immunization Fund. In order to fully incorporate key issues in the regulations, PATH worked with Ministry of Justice & Constitutional Affairs (MoJCA) and MoH to conduct focused district consultative meetings in Mbale, Sironko and Budaka. The project will continue with its advocacy, to ensure that this fund is established.

MALARIA

Advocacy for quality Malaria Rapid Diagnostic Tests (MRDTs)

In partnership with MoH and HEPS (a sub awardee), the project focused its efforts on generating evidence to inform advocacy for the implementation of the 2012 WHO malaria Test, Track and Treat policy and the Uganda Malaria Strategic plan 2014-2020.

Through key informant interviews with various stakeholders, the project identified the problem surrounding affordability and quality of malaria Rapid Test Diagnostic (mRDT) kits. It was discovered that mRDTs only attract a tax of 2% if they are cleared as medical supplies-which is supposed to be the standard practice through National Drug Authority (NDA), however importers tend to opt to clear them as ordinary merchandise, attracting a tax of 18%. This not only raises concern on the quality of the mRDTs being imported, but also makes the kits expensive, since an extra cost is passed on to the consumers.

Armed with evidence, ABH in partnership with MoH organized a National Multi-stakeholder dialogue on the malaria response. The dialogue brought together over 100 participants from Ministry of Health, National Drug Authority, Central Public Health Laboratory (CPHL), Members of Parliament, Development partners, CSO’s and Media. From the multi stakeholder dialogue, the meeting agreed to focus the campaign on 4 key issues which have since guided the campaign, the include;

Moses Dombo-ABH Chief of Party giving remarks at the National Multi- Stakeholder Dialogue on Malaria

 Expediting the new NDA law so that it is empowered to regulate all mRDTs on the market;

 NDA increasing its efforts on post-market surveillance;  MPs should ensure that there is more funding for malaria programs;  Subsidizing mRDTs to improve their affordability.

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Directive from the DG MoH

Further fact finding engagements by the project, unveiled that the taxation of mRDTs was being done illegally at custom points. Through these national level engagements, the Director General (DG) MoH wrote to URA banning the importation of unregulated mRDTs. This also influenced the Uganda Revenue Authority’s written communication to all its boarder control offices, instructing them to ensure that no mRDTs should be cleared for import, without express clearance from NDA. The project will continue monitoring compliance with implementing these directives.

NUTRITION

The Uganda National Nutrition Advocacy Platform

In a bid to Harness Partnerships for Strengthened Nutrition Advocacy and Investments, a Uganda National Nutrition Advocacy platform to champion nutrition advocacy comprising of up to 15 organization/implementing partners including; UNICEF, FHI360 (FANTA and CHC projects), AVSI (SCORE project), JSI (SPRING Project) and World Vision was established under the leadership of ABH. As a product from this partnership, a joint Multi-Stakeholder Nutrition Advocacy Action Plan was developed guided by the District leaders displaying their letters of commitment framework provided under the Uganda National Nutrition and Communication Strategy 2015-2019. This platform meets quarterly to review progress on nutrition issues that require advocacy, so as to lay out plausible courses of action.

Through this platform, the project has seen partners support OPM to organize regional advocacy and experience sharing meetings on nutrition, with the aim of prioritizing budgetary allocation for nutrition interventions in the respective districts, including prioritizing the functionality of District Nutrition Coordinating Committees. At these meetings that were attended by nearly 400 participants, district leaders signed letters of commitments. The project will continue pursuing the implementation of these commitments.

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Formation, orientation and launch of the Parliamentary Forum on Nutrition (PFN)

In order to strengthen high level nutrition advocacy and legislation in Uganda, the project was at the forefront of the formation, orientation and the launch of the PFN. The launch that was presided over by The Rt. Hon Speaker of Parliament

The Rt. Hon Speaker of Parliament making her speech

(Rebecca Alitwala Kadaga) and The Rt. Hon Prime Minister (Dr. Ruhakana Rugunda),

The Rt. Hons Speaker of Parliament & Prime Minister officially launching was attended among others, by district PFN leaders; members of parliament; government Ministers; Heads of Ministries, Departments and Agencies; CSO organization; USAID; and implementing partners. Both the Rt. Hon Speaker of Parliament and the Rt. Hon Prime Minister pledged commitment to ensure that nutrition interventions are prioritized.

Given parliaments vital role in the representation of rights holders, decision making, policy guidance, resource appropriation and accountability for development, the project will continue working with the PFN, to champion budget advocacy for nutrition interventions, coupled with the establishment and functionality of District Nutrition Coordination Committees.

Regional Nutrition Advocacy events in Eastern and Central Uganda

As a way of supporting the implementation of the National Nutrition Advocacy and Communication Strategy through advocacy activities at national, regional and district levels in Uganda. PATH/ABH worked closely with the Nutrition Secretariat— OPM, to organize two-day regional meetings on the implementation of District OPM’s Mr. Boaz Musiimenta, addressing participants Nutrition Action Plans (DNAPs) for the 23 districts of Bukwo, Kapchorwa, Sironko, Mbale, Bududa, Kumi, Pallisa, Budaka, Butaleja, Namutumba, Bugiri, Busia, Iganga, Kaliro, Kamuli, Mayuge, Mpigi, Mityana, Sembabule, Kayunga, Luwero, Nakasongola, and Kalangala.

The main objective of these meetings were to enable the Local Government leadership (District Chair Person, Resident District Commissioners, Chief Administrative Officers, District Planners, District Health Officers, District Education Officers, Production Officers, and District Community Development Officers) to single out nutrition sensitive and specific activities, as part of the advocacy agenda. ABH will continue following up progress with the prioritization of these indicators with the respective district leadership.

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Cross Cutting Accomplishments:

Partnership with Uganda Parliamentary Forum on Quality Health Services Delivery

In a bid to generate national concern and conversation on the quality of health services in the Uganda and also in anticipation of any legislations aimed at improving health service delivery, ABH worked with Members of Parliament led by Hon. Herbert Kinobere and Hon. Rosette Mutambi, to establish the Uganda Parliamentary Forum on Quality Health Services Delivery. This forum, which was launched by the Rt. Hon Speaker of Parliament, (also its patron), boasts a total of 215 members. The project will continue engaging with this forum and others established in parliament, to ensure legislative movement on priority advocacy Hon Dr. Michael Bukenya- Chair Parliamentary issues related to health. Health Committee representing the Rt. Hon Speaker at the launch. Flanked on his right is the PS MoH Dr. Dian Atwine & Hon Kinobere- Forum Chair

First National Presidential Dialogue on the Quality of Health Services

ABH together with the Parliamentary Forum on Quality Health Services organized the 1st National Presidential Dialogue on Quality of Health Services in the country at Colline Hotel, Mukono. The dialogue was attended by a number close to 400 participants, from civil society organizations, Government, Ministries, Members of Parliament, Donor agencies, USAID and implementing partners. The Deputy US Ambassador to Uganda Ms. Colette Marceline, three Ministers of State i.e. Hon. Moriku Joyce Kaducu (State for Primary Health Care), Hon. David Karubanga (State for Public Service) and Hon. Jenipher Namuyangu (State for Local Government) were also in attendance.

Ms. Colette Marceline Charge de affaires/Deputy US Ambassador to Uganda in her remarks, said that, “Health is the greatest area of partnership between the US government and the Government of Uganda. We are proud of the work that has been ongoing to improve the health of people in Uganda”.

H.E the President of Uganda who was expected to be the Chief Guest, was represented by The Rt. Hon. 1st Deputy Ms. Colette Marcelin-Deputy US Ambassador to Uganda, making her remarks Prime Minister Gen. Moses Ali. In his speech read by The Rt.

Hon. 1st Deputy Prime Minister Gen. Moses Ali, H.E the President welcomed the effort of having the dialogue that was creating a platform to be able to discuss the challenges in the health sector.

ABH and partners put forth the following issues to the government: non-compliance of health sector Ministries Departments Agencies (MDAs) to the National Development Gen Moses Ali, Rt. Hon 1st Deputy Premier- Plan II; limited financing for the health sector including: human reading H.E the President’s speech resources for health, Primary Health Care (PHC); and delayed enactment of critical laws and policies including: The National Health Insurance Bill 2014.

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Recommendations were made to increase financial allocation to HRH including wage and other resources to ensure timely and regular recruitment, training and supervision of health workers. In his speech, His Excellency reiterated government’s commitment to addressing the health concerns in the country but urged the citizens to exercise and eat well to prevent non-communicable diseases such as cancer and diabetes.

ABH will continue pursuing the issues discussed with the st highest leadership in the country. The official launch of the forum by the 1 Deputy Premier

Gen. Moses Ali also officially launched the dialogue that will be an annual event, to take stock of what is happening in the health sector and what needs to be improved upon.

National Dialogues on Human Resources for Health

During the course of the year, ABH organized two major national level dialogues to discuss the challenges with human resources for health (HRH).

National HRH campaign:

Mr. Moses Dombo- ABH Chief of Party presenting Dr. Diana Atwine-(Then) Director Health Monitoring Unit and currently PS Health, makes her submission

The first dialogue was a climax to ABH’s nation-wide campaign that included consultative meetings with stakeholders and a media tour to profile the status of HRH and how it is impacting the delivery of health services. This dialogue purposed to share concerns on HRH and to agree on a common agenda for advocacy. This meeting attracted, representatives from MoH, Parliament, USAID, CDC, WHO, implementing partners such as: USAID Strengthening Human Resources for Health, Marie Stopes, and USAID Strengthening Decentralization for Sustainability, CSOs and the Media. The Chief Guest-Prof Mbonye making his remarks Notable was also Dr. Diana Atwine— the then Director of the Health Monitoring Unit in the President’s Office. The Chiefs of Party of IntraHealth and ABH set the platform for dialogue, by presenting evidence on the current staffing levels, and key advocacy issues (including low staffing, poor remuneration, absenteeism and inadequate housing/accommodation) that require fixing respectively. In his response, the Chief Guest (Prof. Anthony Mbonye—who was representing the Hon Minister of Health), pointed out that H.E the President is

19 prioritizing improving health services, driven by the public outcry for the need for improved health services, which was profiled by ABH and other Stakeholders during the recently concluded elections. This would be attained by implementing the 23 guidelines that he issued under his slogan dubbed, “Kisanja Hakuna Mchezo”. The key areas of focus for health under these guidelines are: - improving infrastructure, addressing drug shortages, tackling absenteeism of health workers (especially due to dual employment), addressing lack of accommodation/houses for health workers, improving supervision especially within the Ministry of Local Government, and laying emphasis on disease prevention (given that 70% of diseases are preventable). Prof. Mbonye also informed the participants that MoH had designed a strategy for implementing these issues, on which they had consensus with the president.

A number of major recommendations made during the dialogue. These included: the need for a wider forum that brings together the Ministry of Public Service, Ministry of Local Government, Ministry of Finance, Planning and Economic Development, District Service Commissions to deliberate on the state of human resources for health and priority areas for improvement; MoH should focus on implementing the six key issues from H.E the President’s guidelines; MoH and MoLG should implement performance based rewards, as a way of ensuring improved performance of health workers and the need to keep the pressure on through advocacy.

National dialogue on PEPFAR contracted staff:

The second national level dialogue was aimed at discussing the need for Government of Uganda to absorb PEPFAR funded staff into the health system. During the dialogue, it was unanimously agreed that Government of Uganda should explore possible ways of absorbing these staff with a unique skillset into the health system. A multi-sectoral Task Force (comprised of the MoH, Ministry of Finance Planning and Economic Development- MoFPED, Ministry of Public Service, Ministry of Gender, Labor and Social Development, Health Service Commission, Public Service Commission, PEPFAR and USAID representatives, as well as representatives from the Private Not for Profit Medical Bureaus) was established. The Under Secretary of MoH chairs this task force, while PATH-ABH and IntraHealth- Strengthening Human Resources for Health were nominated to coordinate Secretariat responsibilities of this Task Force. The task force has held a couple of meetings, to chart a feasible roadmap for the absorption of these staff, mindful of the government planning and budgeting cycle. ABH will continue participating on this task force, and advocating for the absorption of these staff.

Domestic Financing

Expediting the enactment of the National Health Insurance Scheme (NHIS):

In preparation for, and anticipation of the NHIS, the project supported members of the Parliamentary Committee on Health to undertake a benchmarking trip to Rwanda. Upon their return, the committee members worked with the project and other CSOs to secure the long awaited Certificate of Financial Implication from MoFPED, which adds to the momentum towards establishment of the NHIS.

Budget Advocacy for the FY 17/18:

From its evidence generation and interactions with the MoH Budget Technical Working Group, ABH identified a big issue of the proposed budgetary cut of the health sector budget for FY 17/18 by 30%. Through intensified media engagement and advocacy efforts—including meetings with; the Parliamentary HIV/AIDS Committee, the Health Committee, the Rt. Hon. Speaker of Parliament, and CSO coalitions, ABH was able advocate for the retention of the health sector budget for the FY 17/18 at Uganda shillings 1.8 Trillion. Partners during the budget advocacy press conference 20

2.3 Result Area 3: Institutional capacity of CSOs strengthened This result area focuses on strengthening institutional capacity of sub awardees with a focus on their management systems and advocacy capacity.

Conducting the year three Organizational and Advocacy Capacity Assessments (OACA)

The project conducted the annual organizational and advocacy capacity assessments to measure progress of CSOs on their capacity development plans. is year, the project conducted assessments for 18 CSOs given that two (Kabarole Research Centre-KRC and Reproductive Health Uganda-RHU) that opted out of the project. The assessments were conducted using the OACA tool that covers the seven sections on Governance, Administration, Human Resources Management, Financial Management, Organizational Management, Advocacy and Performance Management. The results of the assesment indicate that 17/18 demonstrated improvements in their overall scores while one maintained the same score as year two. A number of CSOs saw a reduction in their sub section scores attributed to staff turnover and new staff in the organizations, new processes that were not complete or not approved. The cumulative progress for each CSO (over the three years of implementation) is illustrated in the graph below;

The year three assessment results indicate that all CSOs made an improvement in their scores except Kalangala District NGO Forum (KADINGO), which is attributed to staff turnover and some of their documents being incomplete. Jinja Area Communities Federation (JIACOFE) made the greatest improvement of 1.0 from a score of 2.8/4.0 to 3.8/4.0, and IDO followed with 0.9 increment in score. Just like in the first and second OACA, governance remains the strongest section (3.6/4.0) followed by Human Resources management (3.3/4.0) Organizational management (3.3/4.0) and Advocacy (3.3/4.0). Financial management, Performance management (3.1/4.0) and administration slowest with 3.0.

The graph below illustrates overall average score for the CSOs in each of the sections.

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Each of the CSOs developed an OACA action plan highlighting the issues, action to be taken, responsible CSO officers and timelines. The actions were prioritized based on the impact of those gaps on organizational operations and USG compliance requirements. The action plans will be the basis for technical assistance provided by the project in year four. The CSOs will review these action plans quarterly to assess and report on progress. In Year four, OACA will be conducted for only 11 CSOs and the rest will be encouraged to do a self-assessment.

Strengthening capacity to develop and implement strategic and operational plans

The project supported three organizations; Literacy Action for Development Agency (LADA), Family Life Education Program (FLEP) and KADINGO to develop strategic plans and one an operational plan.

The process was highly participatory and interactive based on appreciative inquiry model. The strategic planning process built capacity of the staff of the three organizations through identified core teams supported to develop and write their own plans. The process reviewed the history, the vision and mission, core competencies and comparative advantage and the external and internal environment. Key strategic pillars for the strategic plans were agreed and based on the experience with the ABH project, each of the organizations identified advocacy as one of the strategic pillars for the next five years. The process for each organization had both staff and board members attend which was an opportunity to further strengthen the relationship between the two structures. KADINGO Staff & Board review strategic directions

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As part of refining their strategies, each of the CSOs developed a staffing plan, strategic implementation plan, monitoring and evaluation framework and also costed the strategic plan.

The strategic plans define the roadmap for the organizations for the next five years and will inform their resource mobilization efforts. LADA and FLEP have now finalized their plans and their respective Boards have approved while KADINGO is in final stages of completion.

In addition to developing new plans, the team continued to support CSOs who developed their strategic plans in year two to implement their plans. The CSOs- Community Integrated Development Initiative (CIDI), JIACOFE, Action for Rural Women Empowerment (ARUWE), Kapchorwa Civil Society Organizations Alliance (KACSOA), IDO have continued to refer to their plans for implementation but also for resource mobilization. The team also supported Multi-Community Based Development Initiative (MUCOBADI) to review and refine their new strategic plan. In year four, support will be provided to Straight Talk Foundation (STF) and NAFOPHANU to develop their strategic plans while supporting other CSOs to implement their plans.

Supporting ARUWE develop an annual operational plan

In Year two, the project supported ARUWE to develop a strategic plan and annual operational plan for 2016. This year, ARUWE requested for support to develop a detailed annual operational plan for FY 2017/2018. In year 3 ARUWE received approval for 12 proposals submitted to different donors, so the support was meant to integrate all their project activities into one operational plan.

Strengthening CSO capacity for resource mobilization

Resource mobilization has been prioritized by most CSOs in the OACA action plans and the project has identified it as one of the indicators of sustainability. ABH continued to provide technical support through training, review of resource mobilization strategies and guidance and review of draft proposals and concept notes.

During the course of the year, JIACOFE staff and board members were trained given a hands-on training in resource mobilization. Other CSOs like ARUWE, MUCOBADI, KADINGO, FLEP received support to review their concept notes and proposals.

The team also supported organizations like STF, JIACOFE, KADINGO to refine their Resource mobilization strategies. This specific support on resource mobilization and the general support to strengthen systems have put CSOs in a better position to compete for resources from other partners. Some CSO partners have received additional funding from partners that they can directly attribute to the support from the ABH project as follows;

 MUCOBADI: Since they started working with ABH, they have received funding up to the tune of US$1,900.000. This has been from Goal Uganda, the Bantwana project which is now expanding coverage from two to four districts based on capacity and approved proposal to RHITES EC. This MUCOBADI confirms is as a result of the capacity building by the project.  JIACOFE received an award from the RHITES EC and a merited proposal response form the PEPFAR community HIV/AIDS grant. JIACOFE has also submitted a fundable proposal to the Bantwana project and are awaiting feedback. From the assessments by some of these partners, JIACOFE systems were found to be solid and this contributed to the approval of the grant.  ARUWE has in this year received new grants most of the new and existing donors confirmed its due to the systems in place and their capacity in advocacy. One of the grants is to further their advocacy work in some of the districts. They have received new grants of up to US$1,000,000 and are

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awaiting a big grant from the Canadian government (gone through some key steps and approval will be in December 2017) of USD$2,500,000 through a consortium.  FLEP has received approval for a grant from RHITES EC, and funding from Open Society Initiatives in East Africa for one year and are currently negotiating an extension, and the renewal of funding from GUSO. FLEP attributes this to the capacity building support received from the project and the new donors have confirmed it. Support for resource mobilization capacity will continue in Year four.

Strengthening supervision systems and promote quality programs

Seven organizations were trained in supportive supervision and quality improvement. These included JIACOFE, HEPS, MUCOBADI, STF, NAFOPHANU, IDO which were full trainings and one-day orientation for CEHURD. The trainings introduced participants to supportive supervision approach and process and supported the development of supervision checklists and review of their performance management tools and process.

At the end of the training, the participants were able to develop supervision checklists and plans. The organizations were also guided to identify problems in their program implementation, develop solutions using the Plan, Do, Study and Act (PDSA) approach.

The participants appreciated the training as one of the MUCOBADI participants was quoted saying;

“I cannot leave this training without saying something. I have benefited a lot. Although I am a supervisor, I had never received a training in supportive supervision. This session has been beneficial and I now know my role and I’m in a better position to support my supervisees. I was able to develop standards for my program and supervision checklists which will help me in my work. I will always give this as a testimony.”

By the time of the Year three OACAs, most of the CSOs had completed their tools and were implementing their quality improvement plans and this contributed to improved scores in the performance management area. In year four, the project will continue to support other CSOs to implement their PDSAs and to finalize the tools.

Grants management collaborative (GMC) and Supporting CSOs implement their change strategies (PDSAs)

A Grants Management Collaborative (GMC) is a quality improvement approach that brings CSOs together to share achievements and problems, learn from each other’s experiences. It provides an opportunity for organizations to reflect on their programs, identify problems and analyze their root causes and develop solutions to address the problems. The approach uses the PDSA approach to develop change strategies to address problems. This year, the project conducted two national and one quarterly GMCs. The national GMC bring all the CSOs on the project together while the quarterly are held at regional level for the CSOs in that region.

At the national GMC in December 2016, 17 CSOs shared their experience on the implementation of their programs but also on the change strategies developed in March 2016. Although most of the CSOs had not made progress some CSOs had demonstrable results e.g. NAFOPHANU which through the use of linkage facilitators had improved evidence packaging on drug stock outs that was very useful in a successful national drug stock out campaign. The CSOs identified problems and developed change strategies around five themes; community initiatives, use of evidence in advocacy, documentation of best practices, engagement of duty bearers and strengthening coalitions. The CSOs in each of these groups utilized WhatsApp to discuss progress on their strategies and support each other. CSOs received ongoing support to review their change strategies and implementation.

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At the quarterly GMC in March 2017, the CSOs shared progress on the change strategies and success stories from the implementation. The quarterly GMC provided an opportunity for CSOs from one region to learn from each other and to discuss other regional specific challenges. This also provided an opportunity for ABH to review and guide the CSOs to improve on the strategies by identifying clear steps. Each of the CSOs has been supported to track progress on their change strategy, and were able to develop run charts that demonstrate improvements by identifying clear steps for addressing improvements.

In September 2017, the project conducted another national GMC for partners to share their experiences and results from implementing their change strategies CSOs have made tremendous progress on their results one and two as a result of implementing their strategies. E.g. MUCOBADI has seen increased actions from duty bearers due to evidence being provided by the community groups, IDO and Uganda Red Cross Society (URCS) have realized improved community capacity to carry out their advocacy initiatives without support and or presence of the CSO team which is a sign of sustainability of some efforts. The graph below highlights the improvements in the CSOs.

Through improved quality of reports from Advocacy Champions, JIACOFE was able to clearly track action plans that had been implemented by the community groups. In addition to the program results, the use of the PDSA and change strategy has been adopted by some of the organization for other programs and projects and it’s now an organizational practice. Some sub awardees have set up quality improvement committees to oversee and meet regularly to discuss progress on the implementation of the change strategy. At the meeting in September 2017, each of the CSOs was supported to develop a new change strategy given that majority had completed the first cycle. The new cycle focused on two project indicators that have not been achieved on community action plans advancing to implementation stage and functional community forums. The CSOs will be supported in Year four to implement their strategies and track and report on progress and achievements.

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Strengthening NAFOPHANU district chapter to support achievement of the 90-90-90 for PLHIV

In the year two OACA, NAFOPHANU identified the need to strengthen their coordination role for the district chapters, build their capacity to mobilize PLHIV and advocate for their rights with an aim to contribute to the 90-90-90 targets. In Year three, NAFOPHANU was supported to develop a management handbook and performance standards that outline expectations for the District chapters. The handbook outlines seven core sections, including; Governance, Financial management, Cross cutting issues that include; gender and Meeting at NAFOPHANU to review handbook Advocacy, monitoring and supervision and reporting.

NAFOPHANU currently has over 106 district chapters under its mandate. A better coordinated HIV fraternity will promote improved mobilization of PLHIV, evidence collection on issues that affect PLHIV, promote collective voices for advocacy through joint advocacy that will result in duty bearers addressing key issues that affect PLHIV. This will also support the popularization of the 90-90-90 goals, a priority area for ABH advocacy led by NAFOPHANU.

Development of performance standards and pilot testing in 7 districts

Following the finalization of the management handbook, NAFOPHANU was further supported to develop performance standards that will be used to measure performance and compliance by the districts networks on the systems and structures defined in the handbook. The performance standards have a defined standard in each of the core sections of the handbook, performance expectations and guidance on scoring. Below is an example of a standard in advocacy:

Standards Pilot Testing in Kamuli District

CCI.3 Standard: The District Coordinators and District Forum staff are implementing the With the support of a NAFOPHANU advocacy mandate by acting to address issues identified as affecting consultant, the PLHIV at the district sub-county levels. NAFOPHANU team was oriented on the standards Performance Expectations: Score each as M (met), PM (partially met) or NM (not met). before the pilot testing. The standards were piloted 1. _____ The District Coordinator, Program or Advocacy Officer identifies the district governing official, “the duty bearer”, responsible for a specific identified issue. in seven districts of Mityana, Kamuli, Mayuge, 2. _____ When interviewed, there is evidence the District Coordinator, Program or Luwero, Mpigi, Kalangala Advocacy Officer have engaged other district partners, as appropriate, to also advocate and Bugiri. The results of with them on the specific issue. the pilot indicate that districts have started 3. _____ When interviewed, there is evidence the District Coordinator, Program or implementing the Advocacy Officer has engaged the responsible district official to address the specific issue management handbook and that agreement to address the issue has been reached. albeit with challenges of 4. ____ There is documented evidence that the responsible district official is actively inadequate resources, addressing the issue with the intent of issue resolution. equipment like computers and printers which affected 5. ____ The District Forum Coordinator, at least quarterly, reports progress made on advocacy issues resolution to the District Forum governing body. 26 documentation of reports. The challenges have affected the ability of district chapters to document and advocate for issues of PLHIV. The results of the pilot are in the table below.

NAFOPHANU District Forum Standards Pilot Testing

Assessment Findings

D i s t r i c t M e t P a r t i a l l y N o t M e t T o t a l

M e t

M i t y a n a 9 7 10 26

M p i g i 8 8 10 26

K a l a n g a l a 10 11 5 26

L u w e r o 2 3 21 26

M a y u g e 5 9 13 26

B u g i r i 8 13 5 26

K a m u l i 4 3 19 26

From the results of the assessment, there is need for NAFOPHANU to provide support to the district chapters to improve performance as none of the districts achieved 50% of the Scores in the fully met category. Based on the lessons from the pilot testing, the standards have been improved and are now ready for rollout to all NAFOPHANU districts. In year four, NAFOPHANU will roll out the standards to another six districts to cover PEPFAR scale up districts. It is anticipated that these standards will ease coordination of NAFOPHANU member networks and provide the support they need to achieve the 90-90-90. With support from ABH, NAFOPHANU will build capacity in advocacy and resource mobilization to ensure district chapters have the ability to mobilize their sub country chapters on issues of HIV and 90-90-90- targets and to engage with district leaders on key issues of concern.

Training sub grantees in Financial management, USG compliance and Non-U.S. Organization. Pre-Award Survey (NUPAS)

The project conducted two, four-day training sessions in the Eastern and Western regions in financial management, compliance with US Government (USG) rules and regulations, and NUPAS requirements. The purpose of the training was to equip participants with the necessary guidance on the relevant USAID rules and regulations, particularly the new 2CRF200, ADS 303 guidelines and fixed amount awards (FAA) regulations. The training also shared best practices in the areas of Organizational set up/ legal structure, financial Participants pose for a photo moment, soon after the management and internal control, procurement systems, training human resource systems, project performance management, organizational sustainability and provide orientation on the NUPAS process and tools. The

27 training was facilitated by a consultant supported by the finance and OD team. The training was attended by all the 23 sub grantees spread in two regional workshops. The participants appreciated the training for addressing specific concerns related to USG compliance and creating clarity on the agreement provisions. The OD team provided the tools and materials on the NUPAS and augmented the consultants during the sessions. Follow-up has been done through visits and online support, by sharing tools and reviewing draft policy documents. From the year three OACAs, the CSOs demonstrated a better understanding of USG compliance requirements, with improvements in the scores on compliance with USG requirements.

Supporting CSOs to achieve NUPAS capacity

For year 3 ABH had a target of one sub awardee with strong systems and capacity to directly manage USG funds and large advocacy projects. To achieve this target, four sub awardees were shortlisted for NUPAS. A consultant hired by the project assessed their readiness for NUPAS. The four sub awardees included NAFOPHANU, HEPS, STF and JIACOFE. NUPAS focuses on six core areas including; Legal Structure, Financial Management, Human Resources Management, Procurement, Project Performance Management and Organizational Sustainability. The assessment identified good practices but focused more on the gaps in the sub awardee systems, knowledge of the systems and practice. The process included a review of relevant documents, and discussions with key staff in each of the NUPAS sections. The assessment revealed that the sub awardees still required support to address some of the identified gaps. JIACOFE and STF were selected to receive additional technical support to get them ready for the NUPAS. The two sub awardees participated in a one-day training on shared cost allocation, labor time distribution and preparing cash flow statements and follow-on technical assistance to address identified gaps. These two sub awardees were also supported to develop project management manuals that guide initiation, planning, implementation, monitoring and closeout of projects. JIACOFE received support to strengthen its governance structure by developing clear board terms of reference, conflict of interest policy that is now being implemented and procurement committee terms of reference. A final NUPAS was conducted in September 2017, and below are the results which qualify the two sub awardees:

NUPAS results for STF and JIACOFE

STF JIACOFE

Legal structure 3.8 3.5

Financial management and internal control systems 3.8 3.8

Procurement systems 3.7 3.2

Human Resources systems 3.6 4.0

Project performance management 3.5 4.0

Organizational sustainability 3.1 3.5

Average Score for NUPAS 3.6 3.7

The two sub awardees (STF and JIACOFE) will be presented as organizations ready for direct funding from USAID. ABH plans to work with an additional six organizations in Year four (including NAFOPHANU and HEPS), towards achieving the final project target of four sub awardees.

Strengthening governance systems

Although Governance still presents as the strongest OACA section, some sub awardees still have actions to address to ensure functional governance structures. This year, support was provided to RACOBAO, LADA,

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JIACOFE, HEPS and KACSOA to refine their board terms of reference, and review their structures. As part of NUPAS support, JIACOFE developed comprehensive board terms of reference, which were signed off by the Board and Mother donor. LADA started implementing the board terms of reference. The team also conducted a training for CIDI board members on their roles and responsibilities.

The CIDI training targeted the four new members and two senior management staff. The training focused on good governance, roles and responsibilities of the board emphasizing performance management for the board. The participants were taken through the role of management in governance, reviewed the organizational structure and, leadership succession and continuity. The participants were guided on how to develop a comprehensive board ABH team members providing support to CIDI on Governance orientation manual that would include, board roles, organizational policies, code of conduct, whistle blowing, conflict of interest declaration forms, accountability forms where required. Although CIDI has structures in place for leadership succession, they had not documented a succession plan and were guided on how to develop one. CIDI training evaluation results indicated that the Board and management appreciated the training especially clarifying the roles and responsibilities of board members, separation of the board and management responsibilities, succession planning as a critical factor in the sustainability of the organization, the participatory nature of the training, its packaging, content and good facilitation. The team will continue to support CIDI to address the gaps identified in the training but will also work with JIACOFE, Mbale Area Federation of Communities (MAFOC), KACSOA and STF to orient their board members on their role and how to manage conflict of interest.

Orienting CSO on Change management and succession planning

Change management is part of the OACA tool and one of the sub sections that sub awardees found difficult to understand and apply in their work and some sub awardees requested for support. The OD team facilitated change management and succession planning orientation for MUCOBADI, JIACOFE and MAFOC. The session was attended by both staff and board members and all the Sub awardees were receiving this orientation for the first time. On change management, the participants clearly understood the concept and reflected in their environment and identified changes in the internal and external environment. These included new projects, closing projects, change of governing boards, review and change of constitutions and board structures for MAFOC and JIACOFE. Each of the sub awardees developed a change management plan that is currently being implemented. On leadership succession, the participants appreciated the new understanding as they though succession planning is about getting rid of current leaders. The different types of absence were discussed and a draft plan was developed for both MAFOC and MUCOBADI.

Training sub awardees in the use of Quick Books accounting package

The second OACA identified the lack of functional accounting packages in a number of organizations, mainly caused by inadequate skills to fully utilize the QuickBooks accounting package. The finance team facilitated orientation sessions for LADA, KACSOA and MUCOBADI on essential QuickBooks functions for recording financial transactions and preparing reports. Basic forms and policies on travel, workshop & meetings, vehicle management, treasury and procurements were discussed plus actual operationalization of basic internal controls and best practices for office financial operations. The training exposed teams to hands-on skills in the use of Quick Books by working in their system. They were able to demonstrate how entry of line items, project codes, expense/payment approval requirements are performed and how reports and

29 reconciliations are done among other uses. The training team made reference to finance and operations manuals to ensure that the system is properly used for documenting policy. An action plan with recommendations was generated that included expansion of package user rights beyond one user and addressing issues related to upgrading the package. Ongoing support will continue to ensure that QuickBooks is operationalized to improve financial management and reporting. In Year four, a group training will be conducted for six organizations who have skills gaps in this area to ensure a functional Quick books system.

Documenting the case study

Initiatives is leading the documentation of a longitudinal case study that will profile six ABH partners and their progress in the three result areas of the project over the life of the project. The partners include HEPS, JIACOFE, MAFOC, KACSOA, ABH staff interviews ARUWE Board member and an Advocacy Champion ARUWE and NAFOPHANU.

To support this documentation, a data base has been developed to track data on the OACAs from year one to year four, document progress on the change strategies, identify data on performance on result one and two, based on the quarterly data validation exercises conducted by the M&E team and quarterly and annual project reports. Data will also be collected through interviews with CSO teams, as well as district and community stakeholders that are familiar with the project and the CSO work. The data base is progressively being populated with available data as the teams plan to collect additional information through OACAs and progress reports. The OD team has also developed tools for interviews with key stakeholders including CSO staff, board members, District leaders, advocacy champions and community members. The tools were pre- tested with MAFOC, ARUWE, JIACOFE and NAFOPHANU stakeholders, and actual data collection will start in year four.

Recruitment of Fellows and Interns

During the quarter, ABH launched an Internship and Fellowship Program aimed at creating a network of professionals with skills to support sub awardees and CBOs in building management and advocacy capacity.

The recruitment process identified interns and fellows interested in learning and gaining experience in advocacy while participating in capacity building for sub awardees and CBOs; and in furthering their knowledge and skills in community mobilization and empowerment approaches, evidence based policy advocacy and organizational development. Four hundred seventy (470) applicants responded to the call for the internship program, with 34 (20 females; 14 males) successfully completed the interviews. Twenty-eight (28) applicants responded to the fellowship advert and 16 applicants (7 females; 9 male) successfully completed the interviews. The recruitment will be finalized in the first quarter of year four. The project has developed modules and associated materials and curriculum to guide their learning. An orientation for both interns and fellows is also planned for the first quarter of year 4.

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2.4 Project Management

Opting out of sub awardees:

During the course of the year, two sub awardees namely Kabarole Research Centre (KRC) and Reproductive Health Uganda (RHU) voluntarily opted out of the relationship with ABH. The former opted out due to other competing priorities, while the latter because of their values, didn’t not sign the certificate of compliance with the Mexico City Policy. ABH filled in these gaps by increasing the scope of existing sub awardees such as; Action for Community Development (ACODEV) to take on an additional district of Kyenjojo, and HEPS to take an additional district of Kamwenge. Two District Advocacy Officer were also recruited to by ABH, to sustain district and community empowerment activities in the Kabale and Kisoro districts. A potential sub awardee (Katuna MARPS) also underwent a risk assessment, and submissions made to the Agreement Officer in USAID. It is our hope that this potential sub awardee is ratified, to sustain the work with key populations in Kabale and Kisoro.

Ratification of new sub awardees: The project received concurrence from USAID’s Agreement Officer and the AOR, to work with three new sub awardees, as per the summary below:

# Sub Grantee DUNS Number Total Estimated Amount in USD

1 International Community of Women 850554815 $70,047 Living with HIV East Africa (ICWEA)

2 White Ribbon Alliance –Uganda 561221077 $50,039 (WRA-U)

3 Uganda Network of AIDS services 366489060 $99,442 Organization (UNASO)

The new partners are catalyzing and galvanizing the project’s national level advocacy efforts towards; the attainment of the 90-90-90 goals, the implementation of the differentiated services delivery model and the Consolidated Guidelines for HIV Prevention and Treatment, as well as ensuring the building of effective inroads by networks for advocacy on systemic impediments to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH).

Collaboration, Learning and Adapting (CLA):

As part of its CLA agenda, ABH project team members participated in a number of international learning invites and conferences.

Production of a bi-monthly “Advocacy Alerts!” newsletter: During the year, the project produced and disseminated two editions of the Advocacy Alerts! Newsletter. The purpose of the newsletter is to document and share with staff, partners and donors, simplified information about major events, meetings and other advocacy milestones that the project has been able to accomplish, without waiting for periodic reports which usually carry a lot of detail. The previous editions can be accessed online.

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The American Evaluation Association Conference (AEA), 2016 in Atlanta GA, USA: The Advocacy for Better Health M&E Specialist attended and presented at the conference. He shared on the Designing indicators for policy advocacy in a developing world: Experiences from Uganda. The AEA Conference brings together evaluators, evaluation scholars, and evaluation users from across sectors to share and learn from the successes (and failures!) of the international discipline and practice of evaluation. The conference offers a forum for the professional exchange of knowledge and skills related to evaluation. The M & E Specialist had the opportunity to share with and learn from 20 speakers of the over 1000 speakers, majorly through presentations; including participation in workshops, panels, and oral/paper sessions.

The Pan African Social Accountability Learning Lab: The Deputy Chief of Party (DCoP) participated as a panelist at the Pan African Social Accountability (PASA) held in Manzini Swaziland from October 16-21, 2016 themed, “Unlocking Africa’s Potential for Participatory Governance”. The purpose of the event was to interrogate methodologies on how contextual factors foster and or inhibit social accountability programming and the impact thereof. The DCoP was part of a panel where he shared lessons from ABH was entitled, “The East African context and social accountability: experiences, what is and isn’t doable and opportunities for innovation in Uganda, Tanzania & Kenya”.

The Health Systems Research conference in Vancouver: In November 2016, two Initiatives staff participated in the Health Systems Research conference in Vancouver. The conference provided an opportunity for the project to learn from different experiences in other countries on key issues related to the project. Key to this was community engagement approaches tried in other countries related to developing and reviewing action plans and human resources for health. Experiences were also shared on country ownership of donor funded programs but also on the work of community health workers that can be tapped into to improve performance of the ABH project.

9th Annual Health and Humanitarian Logistics (HHL) Conference: In June 2016, the project M&E Specialist, and Community Empowerment Officer, attended the 9th annual Health & Humanitarian Logistics (HHL) Conference in Copenhagen, Denmark. The two presented posters on “Improving Health Community Security through Citizen-led Advocacy: A case of Regular Assessments in Uganda's Health Facilities” and “Leveraging Citizen Empowerment in Advocating Health Commodity Security: The Advocacy for Better Health Story in Uganda”.

3.0 Lessons and implementation challenges

Below are the major lessons drawn/challenges faced by ABH during year 4:  The provision of uninterrupted technical assistance, is imperative to ensuring the appreciation and ownership of the project’s thematic focus on HIV/AIDS, TB, malaria, nutrition and RMNCAH by sub awardees.  It is important for the project through its sub awardees to keep track of, and participate at almost all stages of the government planning and budgeting cycle, for the effective integration of issues of citizens concern that are affecting the delivery of quality health services.  Working consistently work with the Parliamentary Committee on Health and other Parliamentary forums, is an important way of equipping them with well packaged evidence that informs their legislation.  Partnership with implementing partners and other CSOs not only leverages comparative advantages, but also ensures that the project triangulates and refines its advocacy evidence.  Advocacy forums at Sub-county and District level are critical platforms for duty bearers to hear from the citizens and for them, to provide critical information to the citizens, which greatly enhances social accountability.

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 It is important to leverage partnerships with key government departments to champion the project’s advocacy agenda. A clear case in point is the current relation the project has with the Office of the Prime Minister, to champion its nutrition advocacy agenda.  The implementation of the Mexico City Policy led to the loss of RHU as a sub awardee, which required the project to implement alternative measures

4.0 Plans for Year Four

Being its final second last year of implementation, and last year of sub granting to sub awardees, the project will pursue measures that enhance consolidation of the gains of the first three years as well as laying strategies for sustainability of project related outcomes. Attainments in community empowerment, advocacy and capacity building will be reinforced through documentation and dissemination of success and change stories. ABH will pursue a theme based focus on disease/ thematic areas: HIV/AIDS; TB; Malaria; Nutrition; Reproductive, Maternal, Newborn, Adolescent and Child Health (RMNCAH). Priority advocacy themes will include commodity availability and commodity security, recruitment motivation and retention of human resources for health (HRH), and increasing public domestic financing for health.

The project will intensify its national level advocacy efforts as a way of ensuring that duty bearers address systemic impediments to the quality of health and social services. This approach will not relegate ongoing community empowerment and district-based advocacy initiatives, but rather ensure a strong linkage and synergy between district-based and national level activities for stronger, more sustainable and higher impact advocacy outcomes that impact a range of policies and communities across the country.

Informed by USAID Uganda’s Country Development Cooperation Strategy—CDCS (2016-2021), ABH will pay special attention to the most vulnerable demographic group, young persons aged between 12 to 18 years, who make up nearly 60% of the population. This demographic group, typified by the 14 to16 year old girl, is the locus for advocacy programming and implementation. Key advocacy priorities affecting this group are:

 Campaigns to end teenage pregnancy and child marriages; including OVC retention in school.  Ensuring that priority is given by duty bearers to nutrition, both in school and out of school.  Advocating for the equitable access to HIV prevention services, especially aimed at attainment of the 90-90-90 targets.  Broadening access to Family Planning services, including age appropriate reproductive health education. Targeted technical assistance and capacity strengthening activities for sub awardees will also be sustained.

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