PMTCT Interventions

STRENGTHENING UGANDA’S SYSTEMS FOR TREATING AIDS NATIONALLY

FINAL REPORT

JUNE 2010 – SEPTEMBER 2018

Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement number 617-A-10-00007-00. The project team included prime recipient University Research Co., LLC (URC) and sub-recipients; The AIDS Support Organization (TASO), Integrated Community Based Initiatives (ICOBI), Initiatives, Inc., and Health Research, Inc, Uganda Catholic Medical Bureau (UCMB), Child Chance International (CCI), ACLAIM Africa Ltd, Uganda Protestant Medical Bureau (UPMB), Uganda Muslim Medical Bureau (UMMB) and AIDS Information Centre (AIC).

USAID Strengthening Uganda’s Systems for Treating AIDS Nationally

Final Report

June 2010 – September 2018

Submitted to: Hilda T. Asiimwe, USAID Agreement Officer Representative

DISCLAIMER

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

On the cover: An HIV-positive mother shows off her babies born free of HIV virus following PMTCT interventions. Opposite: A patient receives HIV testing at a SUSTAIN supported healthcare facility.

Table of Contents

Acronyms...... iv Executive Summary...... v Introduction...... 1 Project Overview...... 3 What We Did...... 3 Project Objectives...... 3

What We Achieved...... 6 Partnerships and Collaborations...... 7 How We Worked...... 9 Focus Areas...... 10 HIV Testing Services...... 10 Prevention of Mother-to-Child Transmission...... 12 HIV Care and Treatment...... 15 TB/Multidrug-resistant TB...... 20 Community-Facility Linkages...... 25 Voluntary Medical Male Circumcision...... 27 Nutrition...... 30 Supply Chain...... 32 Laboratory Services...... 34 Adolescent-friendly Health Services...... 39 Health Management Information Systems...... 41 Human Resources for Health...... 43 Quality Improvement...... 46

Challenges...... 49 Contextual Opportunities...... 49 Annex 1: Lessons Learned...... A-1 Annex 2: Performance Monitoring Plan...... A-5 Annex 3: Project Publications...... A-17 Annex 4: Stewardship Assessment Checklist...... A-23 Annex 5: Success Stories...... A-24 Annex 6: Awards and Recognitions...... A-34 Annex 7: Financial Summary...... A-35

Opposite: Amony Concy, 22 years, was treated for MDR-TB at SUSTAIN supported Gulu RRH and is now fully recovered.

September 30, 2018 | Final Report iii List of Acronyms

S 5 Sort, Set, Shine, Standardize, TFU L Loss to Follow-up SPARS Supervision, Performance and Sustain MARPI Most at Risk Populations Assessment, and Recognition AFHS Adolescent-Friendly Health Initiative Strategy Services MDR-TB Multidrug-resistant Tuberculosis SPNO Senior Principal Nursing Officer IC A AIDS Information Centre MTC Medicines and Therapeutics STAR Strengthening TB and HIV & C AN Antenatal Care Committees AIDS Responses Project ART Antiretroviral Therapy MoH Ministry of Health URES Securing Uganda’s Right to Essential Medicines ASSIST Applying Science to Strengthen NACS Nutrition Assessment, SUSTAIN Strengthening Uganda’s and Improve Systems Project Counseling, and Support Systems for Treating AIDS CBC Complete Blood Count NMS National Medical Stores Nationally Project CCI Child Chance International TLP N National TB & Leprosy Program TASO The AIDS Support Organization CD4 Cluster of Differentiation 4 OpenMRS Open Medical Records System TB Tuberculosis CPHL Central Public Health PCR Polymerase Chain Reaction THALAS Targeted HIV/AIDS and Laboratories PEPFAR U.S. President’s Emergency Laboratory Services Project QI C Continuous Quality Plan for AIDS Relief TREAT Timetable for Regional Improvement PITC Provider-initiated Testing and Expansion of Antiretroviral DR-TB Drug-resistant Tuberculosis Counseling Therapy Program EID Early Infant Diagnosis PMTCT Prevention of Mother-to-Child UCMB Uganda Catholic Medical MR E Electronic Medical Record Transmission of HIV Bureau eMTCT Elimination of Mother-to-Child PNFP Private Not-for-profit UEC Uganda Episcopal Conference Transmission of HIV PREFA Protecting Families Against UKNEQAS United Kingdom National QA E External Quality Assurance HIV/AIDS External Quality Assessment OU G Government of Uganda I Q Quality Improvement Service UMMB Uganda Muslim Medical Bureau HAART Highly Active Antiretroviral RHITES Regional Health Integration to Therapy Enhance Services Project UNAIDS Joint United Nations Program on HIV/AIDS HIV Human Immunodeficiency Virus RMEMW Regional Medical Equipment UPMB Uganda Protestant Medical MIS H Health Management Information Maintenance Workshop Bureau System RRH Regional Referral Hospital RC U University Research Company, R H Human Resources UTF R Ready-to-use Therapeutic Food LLC RH H Human Resources for Health SANAS South African National SAIDU United States Agency for Accreditation Service HRPI Human Resource Performance International Development Improvement CMSS Supply Chain Management VMMC Voluntary Medical Male HTC HIV Testing and Counseling Systems Circumcision HTS HIV Testing Services SLIPTA Stepwise Laboratory Improvement Process Towards HO W World Health Organization IAC Intensive Adherence Counseling Accreditation WHO/AFRO WHO Africa Regional Office ICOBI Integrated Community Based SLMTA Strengthening Laboratory YCC Young Child Clinic Initiatives Management Towards DI I Infectious Disease Institute Accreditation IEC Information, Education, and MS S Short Message Service Communication

iv USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Executive Summary

he Strengthening Uganda’s Systems for Treating AIDS n Per the U.S. President’s Emergency Plan for AIDS Relief Nationally (SUSTAIN) project, supported by the United (PEPFAR), strengthen Human Resources secondments for T States Agency for International Development (USAID), public and private health facilities at health units in Uganda. was awarded in June 2010 to support the Ugandan Ministry of The USAID/SUSTAIN project has been a pacesetter for the Health (MoH) to strengthen systems for the delivery of quality last eight years of national programmatic changes to the HIV/ HIV/TB prevention, care, and treatment services at selected TB response. The project efficiently rolled out national policies regional referral and general hospitals. USAID/SUSTAIN wa at regional referral hospitals by supporting implemented by University Research Co., LLC pilot-testing of each change using short- in collaboration with two international partners In the year 2014, the learning-cycle pretests. This work yielded (Health Research, Inc./HealthQual, and Initia- project was recognized several novel innovations, such as the HIV tiExves, Inc.) and eight local partners: The AIDS among the top 10 best screening tool, order checklist, cell phone Support Organization, Integrated Community text-based reminders for reporting, and Based Initiatives, ACLAIM Africa Ltd., Child worldwide HSS projects facility performance reviews, which have Chance International, AIDS information Centre, by USAID Washington been adopted at the national level and scaled Uganda Catholic Medical Bureau Uganda Prot- up by the other implementing partners in the estant Medical Bureau, and Uganda Muslim (award in the annex country. Medical Bureau. section). Using the SUSTAIN health systems The project worked in 326 health facilities, strengthening approach, based on the World including 12 regional referral hospitals (RRHs)of the 14 in Health Organization’s Health Systems Framework, the project Uganda, to achieve all its objectives, which were to: hinged on stakeholder involvement for each building block n Ensure provision of quality and sustainable HIV/AIDS care to ensure sustainability and attainment of results. In the year and treatment, laboratory, prevention of mother-to-child 2014, the project was recognized among the top 10 best transmission of HIV (PMTCT), and TB/HIV services; worldwide HSS projects by USAID Washington (award in the n Enhance the quality of HIV/AIDS care and treatment, annex section). laboratory, PMTCT, and TB/HIV services; and The project together with the MoH developed 165 trainer of n Increase stewardship by the MoH to provide sustainable trainers at the regional referral level and subsequently built and quality HIV/AIDS care and treatment, laboratory, the capacity and skills of more than 1,421 additional health PMTCT, and TB/HIV services within the public health workers in various service areas through didactic and on job system. skills building training sessions. More than 95% of the health workers trained are employed by the Government of Uganda Over the eight years of implementation, the project evolved to (GOU) and are equipped to offer sustainable HIV services adapt to changes in its scope due to emerging needs in the to clients in need. SUSTAIN supported institutionalization of national response to HIV and TB treatment. The scope of the quality improvement approaches at RRHs and supported the project changed four times during the implementation period, establishment of functional regional and health facility quality and additional objectives were added, namely: improvement committees. These committees spearheaded n Support the MoH to scale-up PMTCT and voluntary medical data utilization and focused on process and system male circumcision (VMMC) as HIV biomedical interventions improvements to enable continued improvement in all health for infection prevention. facility units.

September 30, 2018 | Final Report v To ensure efficient HIV service delivery, the project patient care and management. The project also supported implemented robust supply chain management systems the renovation of antiretroviral therapy clinic spaces, MDR-TB strengthening activities, leading to over 92% HIV commodity wards, VMMC minor theaters, Regional Medical Equipment availability rates, and kept accurate programmatic data Maintenance Workshops, and laboratory units, which led (with less than 1.3% DQA median deviation) in the health to improved service delivery. Through implementation of management information system to facilitate reporting to both quality improvement projects, the project has been able to the MoH and donors on a quarterly basis. The develop best practices and change package project also encouraged MoH ownership and . . . leaders at all levels booklets that are key resources for all partners stewardship of HIV service delivery by training must help to remove the implementing similar work as they focus on leaders and advocating for the placement of low-cost changes that can be implemented to these in the HIV service delivery units. Currently, great divide between improve process and system gaps. all HIV and TB clinics at previously supported the central and local To sustain the results of the USAID/SUSTAIN sites are led by GOU-employed health workers government structures program, leaders at all levels must help who are adequately trained and skilled. From to remove the great divide between the the client perspective, over 95% of those who that continues to central and local government structures that were interviewed reported satisfaction with limit the influence of continues to limit the influence of the RRHs the services offered at SUSTAIN-supported on lower-level facilities’ service delivery. clinics (September 2017 client satisfaction the RRHs on lower- This gap affects the extent to which the survey results) compared to 41.5% in the 2008 level facilities’ service competencies at the RRH can be cascaded National Service Delivery Survey. delivery. easily in the region to support service delivery RRHs have been transformed into sustainable improvements. In addition, the gap in health regional centers of excellence for the delivery of HIV/ service delivery financing needs to be bridged—specifically, AIDS and TB care and laboratory monitoring. A total of human resources for health financing and diagnostic 256,187clients have received lifesaving antiretroviral treatment, commodities financing. including 30,223 pregnant and lactating mothers resulting The SUSTAIN project experience has demonstrated the in a decrease in vertical transmission of HIV from 8% in importance of strong stakeholder involvement, collaboration, 2011 to 2.5 by March 2018. A total of 13,081 registered and a focus on HSS in improving the quality of services while new and relapsed TB cases were successfully treated. adapting to short learning processes, rapid scale-up, and the Additionally, 259 of the identified cases of multidrug-resistant institutionalization of gains achieved. TB (MDR-TB) were confirmed cured after treatment. A total of 143,072 males were offered VMMC services as HIV prevention. Over 686 PEPFAR-seconded health workers were deployed at health units in over 58 districts to support

vi USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Introduction

niversity Research Co., LLC Figure 1. A map of Uganda summarizing USAID/SUSTAIN major areas of (URC) implemented the technical assistance. UStrengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) project, supported by the Kaabong Hospital United States Agency for International Lamwo Kitgum Development (USAID), from June 2010 Kotido HC IV

to September 2018. Project staff worked Arua RRH Amuru Gulu Pader in close collaboration with the various Gulu RRH Agago Abim Hospital Omoro divisions of the Ugandan Ministry of Moroto RRH Nwoya Otuke Health (MoH) and regional and district Oyam Lira RRH Matany Hospital Kole Alebtong hospitals to implement the program Lira Amudat Hospital Dokolo and improve HIV/AIDS and TB services. Apac Tokora HC IV District local government teams also Soroti RRH Amolatar Amudat became important stakeholders and Hoima RRH counterparts who focused on enhancing Kapchorwa Sironko human resources for health (HRH) Kibuku Mbale RRH productivity. Butaleja

Fort Portal RRH Iganga Mubende RRH Jinja RRH SUSTAIN worked in all five programmatic Kawolo Hospital Bugiri regions of the country. Major areas Kampala of technical assistance included

comprehensive HIV/AIDS services, Kiruhura Rubirizi management of TB/HIV coinfection, Masaka RRH Buhweju Mbarara Supported Facilities by FY 17 improved productivity and general Mitooma Sheema (Comprehensive HIV, TB, and HRH support) support for HRH, laboratory services, Rukungiri Isingiro Comprehensive HIV and TB support Ntungamo and functionalization of Regional Medical HRH support Equipment Maintenance Workshops Kisoro Kabale RRH Comprehensive HIV, TB, and HRH support (RMEMWs). Additionally, the project carried out renovations for 7 HIV clinics, 18 laboratories, 6 multidrug-resistant (MDR-TB) care spaces, 7 RMEMWs, 11 Strong working relationships with a different health care facilities. Through VMMC minor theaters, and one blood broad set of partners served as a the award of sub-grants and provision bank. Over the course of the eight years keystone to the project’s achievements of technical support, USAID/SUSTAIN of implementation, SUSTAIN supported with MoH, international and local built local capacity for improved clinical 12 regional referral hospitals (RRHs), 53 organizations, health unit and district services and strengthened financial and private not-for-profit (PNFP) and general management, health workers, and other administrative management systems to hospitals, and 261 Health Centres II, III, implementing partners who collectively efficiently use donor funds to improve and IV (Figure 1). supported service delivery at the results.

September 30, 2018 | Final Report 1 Christine is HIV positive; despite her status, she has delivered three negative babies. The community which had at one time labelled her a walking coffin, has now recognized her as one of their own upon realizing that 2 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally the battle against HIV&AIDS can be won. Project Overview

What we did Project Objectives

SAID/SUSTAIN, in collaboration with the MoH, utilized Ensure provision of quality and sustainable HIV/ an integrated health system strengthening approach AIDS care and treatment, laboratory, PMTCT, and Uto achieve results (Figure 2). The approach focused TB/HIV services within select public and private on strengthening health information systems, supporting health facilities a skilled and expanded health workforce, improving the The project started with 34 hospitals which were transitioned commodity/supply chain management system, improving in from the Timetable for Regional Expansion of Antiretroviral infrastructure, supporting hospitals with both human Therapy (TREAT) program to continue USAID support. By the resources (HR) and operational grants, and improving the end of the second year, more than 50% of these health units quality of laboratory services within the public health care were transitioned out to other implementing partners, leaving system for both general and HIV-related health care service the project to concentrate support mainly at regional referral delivery. The project implemented these many interventions hospitals (RRHs) and the Karamoja Region (which did not have by using a structured quality improvement (QI) and mentoring any implementing mechanism). The RRHs were equipped and approach. supported to deliver high-quality HIV services.

Figure 2. USAID/SUSTAIN approach to health systems strengthening

SUSTAIN Health Systems Strengthening Approach

S y nt (inclu oc Results m nme ding i o er M e n ov OH ty o G ) c E Laborato ry e c Improved n H a R access in F High Quality, to and Better Strengthened hospital Improved HIV/TB service Patient-Centered utilization Health leadership/management HIV/TB delivery performance H s of quality Outcomes M e C Services n l S i i c s HIV/TB e i r n d t I e e C s nf M id t services , ra v u F st re o n l a ructu r e tu m P r ily re m e , C Ca n om lth ro munity Hea vi En

September 30, 2018 | Final Report 3 Enhance quality of HIV/AIDS care and treatment, Support the Ugandan Ministry of Health (MOH) laboratory, PMTCT, and TB/HIV services to scale-up prevention of mother-to-child transmission of HIV and voluntary medical male To ensure the continuum of response, the project leveraged circumcision as HIV biomedical interventions for community structures to refer people for HIV testing and infection prevention antenatal care (ANC) services, distribute antiretroviral medication, conduct TB contact tracing, create demand for A comprehensive package of VMMC services—which included voluntary male medical circumcision (VMMC), track clients renovation of minor theaters, procurement and distribution in HIV care who are lost to follow-up and retain clients in HIV of VMMC supplies and equipment, training of VMMC teams, care, among other activities. quality assessments, and supportive supervision—were provided to USAID/SUSTAIN-supported facilities implementing QI was one of the major cornerstones of USAID/SUSTAIN’s the prevention program. To create demand for VMMC, the work. In line with the MoH QI framework, Hospital QI project ventured into the community to educate men on the Committees were created in all supported hospitals to build benefits of VMMC, visiting various venues and using various a management structure in support of QI initiatives taking mechanisms, such as a film van. The project also supported place throughout the hospitals’ various departments. The VMMC camps, before which mass vaccination campaigns for committees were tasked with the identification of priority tetanus were held. improvement objectives for each hospital unit, which they monitored throughout implementation. During the sixth year of SUSTAIN, regional QI committees were formed to support Strengthening PEPFAR Human Resources improved service delivery in the districts, also supported by Secondments for public and private health the RRHs. facilities at select hospitals

The project helped to enhance the quality of HIV/AIDS care SUSTAIN supported the MoH in scaling up comprehensive and treatment—as well as services regarding the prevention elimination of mother-to-child transmission (eMTCT) services of mother-to-child transmission (PMTCT), laboratories, and by increasing both the identification of new HIV-positive TB/HIV—through both didactic trainings and mentorships pregnant women and their initiation onto antiretroviral therapy based on MoH curricula, national scale-up plans, guidelines, (ART). The project helped to establish mother–baby pair care and policies. SUSTAIN used national trainers seconded by points to increase the retention of mother and baby in HIV care the MoH to train regional trainers. These regional trainers then and helped to improve the clinical outcome of the mothers cascaded skills development to the RRH staff and lower-level by intensifying clinical and laboratory monitoring. Scale-up health facilities. A critical component of all clinical trainings included enhanced support and tracking of mothers to reduce was the integration of mentoring and coaching in the weeks the loss to follow-up (LTFU) rates of the identified HIV-infected and months following training to help health workers apply mothers. their new skills. The project worked closely with the MoH, with hospitals, and later with the district service commissions to ensure absorption Increase stewardship by the MoH to provide of the seconded staff into the government payroll system. sustainable and quality HIV/AIDS care and treatment, laboratory, PMTCT, and TB/HIV services within the public health system

Joint sustainability planning sessions were conducted Opposite page top: SUSTAIN conducted a five-day training between the project staff and hospital teams, including the for 313 healthcare workers from six regional referral leadership. The project and its stakeholders developed a hospitals in Uganda on provision of adolescent health sustainability plan and continued to track attainment of the friendly services. Participants at Mbale Regional Referral milestones in the same manner through the life of the project. Hospital engage in an exercise during a training break. Photo: URC 2016 USAID/SUSTAIN Bernadeta M. Nagita

4 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Figure 3. USAID/SUSTAIN Project Scope

Phase 1 Phase 3 Phase 4 June 2010–June 2015 Dec. 2016–Dec. 2017 Dec. 2017–Sept. 2018 Supported delivery of A second extension was granted to USAID/SUSTAIN USAID/SUSTAIN received a third comprehensive HIV prevention, from December 2016-December 2017 to sustain extension in which the project served care, treatment and laboratory delivery of high quality HIV/AIDS prevention, as a bridge mechanism. During this services at over 34 health care and treatment as well as TB/HIV and DR-TB time, the project scope expanded facilities including 12 Regional diagnosis, treatment, and management services, to include management of HRH and Referral Hospitals through continued prioritization of the following key provision of VMMC, which were implementation strategies previously supported by the USAID- funded Strengthening Decentralization Sustainability (SDS) Program.

June 2010 June 2015 2016 2017 2018

Project Start Up Phase 2 Transition Northern Uganda Support June 2010 June 2015–Dec. 2016 September 2017 Oct. 2017–Mar. 2018 USAID/SUSTAIN transitioned An extension was granted to USAID/SUSTAIN transitioned SUSTAIN continued to support in 32 healthcare facilities from USAID/SUSTAIN from June out support of HIV/AIDS Gulu and Lira Regional Referral TREAT to SUSTAIN 2015–December 2016 to prevention, care and Hospitals and the project’s scope ensure uninterrupted HIV/AIDS treatment and laboratory was expanded to include delivery of prevention, care and treatment services in fifteen supported high quality HIV/AIDS prevention, as well as TB/HIV and DR-TB facilities, following the new care, treatment, as well as TB and diagnosis, treatment, and geographical rationalization laboratory services to an additional management services. direction by USAID/Uganda. 144 health facilities in Northern Uganda. The facilities were previously supported by the USAID Applying Science to Strengthen and Improve Systems (ASSIST) project.

September 30, 2018 | Final Report 5 What We Achieved

Figure 4. A summary of USAID/SUSTAIN results

MEDICAL SERVICE INFORMATION HEALTH HEALTH CARE PRODUCTS, LEADERSHIP & DELIVERY & RESEARCH WORKFORCE FINANCING TECHNOLOGIES GOVERNANCE

148,442 Males 2 Client satisfaction 685 PEPFAR health $23.6M+ 22 Health facilities 19 Hospital leadership circumcised though surveys conducted workers seconded to Disbursed through equipped with state- teams trained in Safe Male Circumcision local governments’ service delivery and of-the-art laboratory management 5 Operational research health units and HR cost-reimbursable equipment, chemistry 2,381,059 Clients studies conducted, and Active participation in RRHs of these 131 grants to health units machines, and counseled and tested findings shared with 15 TWGs at the absorbed into the to support and build GeneXpert machines for HIV MoH to inform policy MoH government payroll the capacity for donor changes; Set up electronic 59,230 Adults and system funds management medicines children started on ART Uganda EMR system and resource Additional 302 Staff management systems fully installed and used mobilization at the 351,744 Pregnant positions maintained at the 12 RRHs at 57 heavy-volume unit level women with known HIV at project-supported health facilities status health units and Data quality for HMIS deployed to HIV service 9,855 HIV-positive indicators improved areas to bridge the new and relapsed through data quality critical HR gaps registered TB cases assessment exercises on ART during TB from 9% to 1.3% treatment

Vertical transition of HIV reduced to less than 3%

6 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Partnerships and Collaborations

Members of the USAID/SUSTAIN Team

Integrated Community Based Initiatives (ICOBI) Uganda Muslim Medical Bureau (UMMB) The AIDS Support Organization (TASO) Uganda Episcopal Conference (UEC)/ Initiatives, Inc. Uganda Catholic Medical Bureau (UCMB) Health Research, Inc./HealthQual AIDS Information Centre (AIC) ACLAIM Africa Limited Children’s Chance International (CCI) Uganda Protestant Medical Bureau (UPMB)

Collaborations

Strengthening TB and HIV & AIDS Responses Ministry of Health (MoH) in Eastern Uganda (STAR-E), STAR-SW, and National Medical Stores (NMS) STAR-EC Joint Medical Stores Baylor University (Rwenzori, Soroti and Central Public Health Laboratories (CPHL) Karamoja Regions) The Targeted HIV/AIDS Laboratory Services Infection Disease Institute (IDI-Kibale), IDI- (THALAS) Project Kiboga, and IDI-Nile Supply Chain Management Systems (SCMS) Project RHITES-SW, RHITES-EC, and RHITES-E Healthcare Improvement Project Uganda Cares Applying Science to Strengthen and Improve Protecting Families Against HIV/AIDS (PREFA) Systems (ASSIST) Project AMREF Health Africa Securing Uganda’s Right to Essential Medicines Rakai Health Services (SURE) Project Makerere University Walter Reed Project Uganda Health Supply Chain Project

September 30, 2018 | Final Report 7 Sr. Helen Okwii, In-Charge Maternal Child Health unit with USAID/SUSTAIN project mentors review antenatal and PMTCT data during a Data Quality 8 USAID | SUSTAIN Strengthening Uganda’sAssessment Systems for exercise Treating at AIDS Mbale Nationally Regional Referral Hospital. How We Worked

Table 1. Main strategies implemented and achievements per strategy

Main Strategies Achievements

Integrating HIV service delivery USAID/SUSTAIN integrated HIV services into hospital systems to promote their long-term into hospital systems sustainability and country ownership

Institutionalizing quality Supported hospitals to improve their quality of care by training service providers to utilize data and improvement methods analyze systems and processes, identify gaps in achieving standards of care, and implement and measure changes toward improvement.

Planning and implementation Promoted ownership and built consensus for long-term sustainability plans with stakeholders Project workplans were developed and implemented with stakeholders

Utilizing a sustainable health Supported the printing of revised tools for the supported hospitals system strengthening approach Supported a skilled and expanded health workforce Improved the commodity/supply chain management system and the quality of laboratory services

Strengthening the use of data Supported the automation of data processes and on-time entry of data to support quick decision analysis and utilization for making service delivery improvement Health facilities were supported to organize quarterly data performance reviews

Knowledge management Dedicated its efforts toward the documentation and dissemination of best practices and lessons learned in addition to QI change packages. Promoted learning and information-sharing activities across facilities by facilitating and organizing learning sessions and on-site mentorships

Collaborating, learning, and Learning: SUSTAIN’s efforts to share lessons learned adapting and sustain development in the health sector were driving factors for its operational research studies (client satisfaction Collaboration: USAID/SUSTAIN established partnerships with surveys, eMTCT, LTFU, MDR-TB, and nutrition studies); international and local organizations to provide quality HIV abstract development; presentations at international prevention, care, and treatment; TB; and laboratory services. AIDS conferences, USAID, and MoH; development and Additionally, the project collaborated with other partners of the dissemination of best practices; change packages; and U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), success stories. which provided support to the government to improve service delivery and strengthen the health care system both Adapting: USAID/SUSTAIN’s ability to take on several at central MoH, district, and sub-district levels. The project transitions with changing mandate, while ensuring team collaborated with MoH mentors to conduct integrated uninterrupted services to clients, showcased how mentorships and data quality assessments in the various collaboration with other partners and local institutions ensure technical support areas and used QI approaches to identify adaptability to changes in resources, management, and and address gaps in service delivery. policy.

September 30, 2018 | Final Report 9 Focus Areas

HIV Testing Services Introduction of Targeted Testing To further improve the identification of HIV-positive clients, To improve access and the scale-up of provider-initiated as stipulated in the PEPFAR-supported Uganda Country testing and counseling (PITC)—as opposed to voluntary Operational Plan 2016, USAID/SUSTAIN incorporated counseling and testing as was the case before 2011—the targeted testing into the PITC approach to enable increased project and health facility management agreed to decentralize identification through eligibility screening using a tool that HTS to multiple hospital entry points, with Senior Principal estimates the risk of HIV exposure. This tool was used at triage Nursing Officers (SPNOs/PNOs) taking the lead. The SPNOs locations and points of care to screen for most-at-risk clients played a key role in championing attitude change, ownership, (most likely to have been exposed to HIV) attending services implementation, and performance monitoring of HTS after at the health facilities and in the community. The results of scale-up to multiple testing units. To measure the progress targeted testing are shown in Figure 5 and Figure 6. of these activities, SUSTAIN supported the integration of HTS service data into the facility’s 24-hour nursing report, staff appraisals, supervision, and departmental meetings. “Conducting on-the-ward testing has

This change did not come without its challenges; the workload increased identification and enrollment increased at point-of-care units. Volunteer linkage facilitators of HIV positive children into care.” were assigned to the testing points to meet the increase in --Sr. Akurut Mary Margaret, Acting Senior Principal responsibilities. Nursing Officer, Soroti RRH

Table 2. Increasing access to HIV testing services

What did we set out achieve? Key Achievements

Institutionalize provider-initiated Ownership of HIV testing services by hospital top and middle management that enabled scale-up testing and counseling and institutionalization. A PITC coordination structure instituted under the leadership of the head of the nursing division. Expanded annual HTS access from 104,925 people in FY 11 to a peak of 445,109 people in FY 15.

Enhance provider knowledge and 231 staff trained in customized PITC. skills in HIV testing Onsite mentorships conducted to ensure adherence to national guidelines.

Decentralize HIV testing and HIV testing shifted from the main lab and conducted at the different service delivery points counseling services

Linking all identified HIV positive Linkage enablers enhance improvement of successful linkage of newly identified HIV positive individuals to HIV care clients from 42% in 2013 to 93.5% in 2017 98.5% of all HIV positive individuals identified in SUSTAIN supported sites were initiated onto antiretroviral therapy by FY 17 and 85.5% in Northern Uganda supported facilities

10 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Figure 5. Results of HTS services provided over the life of the project

which which of of

70,245 HIV positive Over 2,381,059 101,172 people people were linked million people newly tested to HIV Care and tested for HIV HIV positive Treatment Services

Figure 6. Key HTS results by financial year

500,000 PTC scaled Focus on 405,000 up to all targeted 400,000 departments testing

305,000

300,000

205,000 Number 200,000

150,000

100,000

50,000

0 FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 FY 17 FY 18

Tested & received 104,925 122,453 253,702 399,789 445,109 354,133 272,255 428,693 results for HIV Tested HIV 11,468 12,979 14,830 15,275 14,299 10,932 9,068 12,348 positive

Seropositivity 10.9% 10.6% 5.8% 3.8% 3.2% 3.1% 3.3% 2.9%

USAID/ SUSTAIN expanded its support from 104,925 people in FY 11 to a peak of 445,109 people in FY 15. The dip in FY 17 was because of a shift to targeted testing. The figures in FY 18 represent reached by districts taken over by SUSTAIN for comprehensive support in Northern Uganda where targeted testing was people not yet used an approach for increasing identification of HIV infected clients. Results include data from 18 sites that were consistently supported over the years, except for FY18 that includes Pader District.

September 30, 2018 | Final Report 11 Parents at a Young Child Clinic receiving information about prevention of mother-to-child transmission.

Prevention of Mother-to-Child Table 3. Achieving elimination of mother-to-child transmission of HIV Transmission What did we set USAID/SUSTAIN supported the transition from Option out achieve? Key Achievements A to Option B+, as recommended by the World Health Support delivery 95% of target met for the proportion of Organization (WHO) and the MoH, with a goal of achieving of comprehensive women attending ANC who knew their HIV virtual eMTCT by 2015. The project’s support to the health and quality status from FY12 to FY17. units focused on strengthening the capacity of health workers PMTCT and EID Improved access to ART for newly to integrate PMTCT services at various entry points, including services identified HIV positive pregnant women ANC clinics; YCCs; and maternity, nutrition, and outpatient from 78.7% in FY11 to 95% in FY17. departments. The project also helped to streamline linkages Reduction in vertical HIV transmission rates to established mother–baby care points. The following among HIV-exposed infants from 8.0% in interventions were made for PMTCT: FY11 to 2.5% in FY17. n Building the capacity of health workers through trainings Scale-up cohort Health workers trained and mentored on and mentorships monitoring for cohort monitoring. maternal ART Improved net retention of exposed infants n Establishing mother–baby care points within the antenatal retention and and negative HIV outcomes at discharge care units to work as one-stop centers for the duo infant outcome from 72.9% to 81.9% and 59% to 72.6% n Functionalizing family support groups to foster peer respectively between FY16 and FY17. support and positive attitudes toward living among HIV- Strengthened systems to track missed positive women appointments. n Ensuring increased access to family planning and Iimprove access Conducted onsite viral load trainings and integrating the FP services into the HIV clinics to viral load camps to improve client monitoring. testing. Improved access to viral load testing for n Actively involving males in PMTCT and reproductive health pregnant and lactating mothers. services for better mother and child outcomes

12 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Rosemary Celebrates: Baby Declared HIV-free on World AIDS Day

ull of emotion, Rosemary asked for The SUSTAIN project While Rosemary could not measure the a moment to catch her breath upon care and treatment support she has Fseeing her baby’s blood sample supported Uganda’s received at Mbale Regional Referral coming to rest on the negative edge of an Hospital during this time, she was more HIV test kit. On December 1, 2015, at the health facilities to move than happy to show her excitement and Mother-Baby HIV Care Point in Mbale RRH closer to achieving an thankfulness at the good news. in eastern Uganda, Rosemary’s child was The efforts of SUSTAIN to achieve eMTCT discovered to be free of HIV. AIDS-free generation. have thus far been incredibly successful. When Sr. Mukwana (pictured above) As for Rosemary? The Uganda national target for virtual enrolled the newborn in HIV-exposed infant elimination of mother-to-child transmission care, Rosemary was losing hope. She had “I am so excited for my is less than 5%, and the percent of infants only learned her HIV-positive status during born to HIV-positive mothers that are found the first antenatal visit. Although she was baby and my family.” to be HIV-infected at project-supported initiated on the Option B plus PMTCT, the sites was only 3.6% in FY17. The SUSTAIN next several weeks were a struggle to project supported Uganda’s health facilities accept her own status. Her biggest worry to move closer to achieving an AIDS-free was transmitting the HIV infection to her generation. As for Rosemary? “I am so unborn child. excited for my baby and my family.”

September 30, 2018 | Final Report 13 Enhancing the quality of prevention of mother to enable cross-learning between teams from different hospitals. child transmission of HIV Because of this learning, best practices for PMTCT service improvements were developed. Quarterly performance reviews On-site trainings and mentorships supported staff adherence engaged all health facility staff in discussing progress for to national PMTCT guidelines and addressed gaps specific PMTCT among other services and planning for improvement. to health facilities. A total of 424 staff were trained in (The PMTCT and early infant diagnosis [EID] cascades are PMTCT treatment guidelines. QI teams were formed to shown in Figure 7 and Figure 8.) track performance for identified gaps in data, systems, and processes. Several inter-facility learning sessions were held to

Figure 7. PMTCT Cascade

160 148% 140 125% 120 107% 107% 107% 103% 101% 100% 99% 94% 100 96% 80 93% 93% 90% 93%

Percent 69% 60

20 8% 6% 8% 8% 9% 9% 9% 8% 0 FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 FY 17 FY 18

Percent of pregnant women with a known HIV+ status Percent of HIV positive pregnant women who received ART Percent of pregnant women with a known HIV status

Figure 8. EID Cascade (Results include data from 18 sites that were consistently supported over the years, except for FY18 that includes Pader District.)

140 122.4% 120 94% 97% 98% 94.5% 100 88.3% 94.3% 93.7% 90.8%

80 88.2% 88.5% 90.5% 89% 89.1% 89.5% 81.8% 80.8%

Percent 60 69.3% 67.5% 69.3% 43.7% 60.1% 40 51.8% 46% 20 8.3% 7.6% 7% 6.7% 5.4% 4.5% 3.6% 2.5% 0 FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 FY 17 FY 18

Percent of infants born to HIV+ mothers and are found to be HIV-infected Percent of HIV-exposed infants given ARV prophylaxis (at birth) Percent of infants born to HIV+ women who had a virologic HIV test Percent of infants born to HIV-positive pregnant women who were done within 12 months of birth started on Cotrimoxazole (CTX) prophylaxis within two months of birth

14 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally HIV Care and Treatment Provision of HIV Care and Treatment Services Table 4. Enhancing quality and stewardship of HIV care and treatment services

What did we set out achieve? Key Achievements

Strengthen service provider skills All supported health facilities were trained on the revised prevention, care and treatment through competency needs- guidelines. based training and mentoring Targeted onsite mentorships were conducted as a follow on to the trainings to support adherence to the guidelines. guidelines. A total of 271 health workers at supported hospitals were trained on the basics of HIV care and treatment to offer HIV services as teams.

Provide antiretroviral treatment to 59,230 individuals started on ART all identified HIV positive clients

Improve viral load monitoring for Improved access and utilization of viral load tests from 18.1% in FY14 to 72.9% in FY17 clients on ART

Provide psychological support 88.1% of clients enrolled on treatment in FY 16 were alive and active on ART 12 months later. This and counseling services aimed was higher compared to patients enrolled in the year before FY 11 out of whom 73% were known at improving adherence to to be alive and on treatment. This demonstrates an improvement in retention for ART patients treatment and retention in care, over the years. and to address individual client 95% of clients on ART in FY17 recorded good adherence. psychological and social needs 352 health workers trained in intensified adherence counselling (IAC) for non-suppressed clients. 88% suppression rate observed at 14 high volume facilities in Northern Uganda with targeted support for counselling and intensive adherence counseling

Figure 9. The number of HIV positive clients who received ARVs and are virally suppressed n Development of HRH HIV care and management capacity and skills through on-site trainings and mentorships (targeted, 101,172 184,904 88% integrated, and peer-to-peer learning platforms); and Percent of HIV positive Number of individuals Number of individuals clients on treatment n The implementation of QI approaches, tested HIV positive diagnosed with HIV that achieved viral hinged on data utilization for process and on treatment suppression system improvement. Enhancing the quality and stewardship of HIV Working with specialist-led, multidisciplinary care and treatment services teams to meet 90-90-90 targets at 11 regional Working with the MoH, the USAID/SUSTAIN project supported referral hospitals the provision of comprehensive HIV care and treatment Multidisciplinary teams led by health facility specialists were services to achieve the UNAIDS 90-90-90 targets (Figure responsible for planning, implementing, and monitoring 9). Approaches used to improve the quality of HIV care and progress on the 90-90-90 targets at the supported hospitals. treatment services included: The multidisciplinary teams included physicians, gynecologists, n District, community, and facility leadership and client pediatricians’ clinicians, counsellors, laboratory technologists, involvement(self-management) for service delivery; client linkage officers, data officers, and expert clients.

September 30, 2018 | Final Report 15 Figure 10. Clients maintained on ART and Pre-ART since FY 11

70,000

60,000

50,000

40,000

30,000 Number of clients 20,000

10,000

0 FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 FY 17

Percent 74.5% 77.0% 78.8% 86.4% 91.3% 93.7% 99.9%

On Pre-ART 8,290 8,991 9,469 6,518 5,255 3,738 68

Active on ART 24,231 30,088 35,141 41,379 54,990 55,268 53,532

In FY 11, up to 31,521 clients were served by project supported sites (24,231 on ART and 8,290 on Pre-ART). This number increased to a peak of 60,245 clients in FY 15 (54,990 on ART and 5,255 on Pre-ART). After transitioning out some sites to other partners in FY 17, this number was 53,600 (53,532 on ART and 68 on Pre-ART). Following introduction of the test and treat interventions, the proportion of pre-ART clients reduced from 15% in FY 11 to less than 1% by the end of FY 17. Results include data from 18 sites that were consistently supported.

Figure 11. Proportion of clients enrolled 12 months ago Regional referral hospital initiatives to support known to be alive and on treatment clients’ chronic care 100 USAID/SUSTAIN supported RRHs to offer TB/HIV services 88.1 90 84.0 83.7 85.1 79.9 80.1 using the chronic care model as a critical approach for 80 73.1 meeting client needs (Figure 12). This model exposed key 70 limitations of the health system at the time especially in the 60 areas of client self-management support and organization 50 of health care in particular the design of the clinics and

Percent 40 management and utilization of the data in the information 30 systems. The health units lacked data analytics to support 20 decision making and the clients views were not taken into 10 consideration while designing the service delivery systems. 0 Frequently the client waiting times were very high and health FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 FY 17 workers rude. The proportion of clients enrolled 12 months ago known to be alive and on treatment improved from 73.1% in health facilities supported in FY 11 to 88.1% for health facilities supported in FY 17. Results include data from 18 sites that were consistently supported over the years.

16 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally RESEARCH STUDY LTFU of HIV-infected Patients from HIV Care and Treatment in Three RRHs in Uganda

Why was this study conducted? Patients disengaged or stayed in care for more than one reason: Structural barriers were a main driver for both USAID/SUSTAIN wanted to understand what the current transfer-out and stopping care. Patient experiences at the outcomes of lost patients were; how incorporating outcomes clinic seemed to drive both retention (good experiences) of the lost patients would change the estimates of retention, and stopping care (bad experiences). Patients stayed in care LTFU, death, and transfer-out in RRHs; and if the changes because they expected good outcomes. varied by age group. We also wanted to gain an in-depth understanding of reasons why some patients are lost to follow- What do these findings mean and what are some up while others remain in care. We sought this information to recommendations? guide possible interventions to improve retention. n Retention, deaths, and transfer-outs are underreported What did the researchers do and find? within the HIV program while LTFU is over-estimated. From a population of HIV patients who enrolled in HIV n Most of the resources for tracking lost patients could be care in 2015–2016 at Jinja, Lira, and Mubende RRHs and wasted tracking patients who are, in fact, in care elsewhere subsequently initiated ART, we selected a random sample or at the same site. These resources might be saved if of lost patients stratified by age group. Lost patients were referral systems were strengthened. traced, and their updated status was ascertained, which was n Inter-facility referral systems need to be strengthened by used to correct overall and age- and site-specific estimates of taking the following steps: retention, mortality, LTFU, and transfer-out. 1. Routinely educate patients on the process of Of 6,940 patients, 5,765 (83%) had initiated ART by August transferring care. 2017. Of the lost patients sampled (522 out of 1,683), we 2. Invest in the inter-facility communication of referrals successfully traced 209 (40%). We found 11% had died, and (e.g., sharing lists of transfer-ins and transfer-outs). 89% were alive. Among those who were alive and interviewed 3. Use QI to streamline the reporting of outcomes from in person, 65% were in care in another clinic or at the same routine tracking of LTFU patients into the patient files clinic, and 35% had stopped care. and EMR. Among ART users alone, incorporating outcomes of lost 4. Routinely update patient contact information. patients increased 24-month retention from 77.4% to 89.9%, n mortality from 3.6% to 7.5%, and transfer-out from 13% to A comprehensive approach is needed to improve the 23%. Also, incorporating outcomes reduced LTFU from 23% patient’s care experience as well as reduce structural to 2%. barriers to care. This approach must include the following steps: Outcomes varied by age group and health 1. Differentiate service delivery (to reduce structural facility. barriers and waiting time). About 50%–60% of outcomes of lost patients were resolved 2. Expand provider training to include customer care by checking with paper-based records in Jinja and Mubende training. For example, adapt approaches used by hospitals, which highlighted the disconnect between electronic corporate organizations to keep customers. (This medical record (EMR) reporting and community follow-up strategy could be piloted to determine its effect on systems. retention.)

Being male or widowed (compared to being married) were 3. Conduct regular patient satisfaction surveys to inform characteristics associated with death, while receiving care at clinic services. Mubende was associated with better survival compared to 4. Offer education to improve patients’ outcome Jinja RRH. expectations (e.g., on benefits of ART).

September 30, 2018 | Final Report 17 Chronic Care Team, Kawolo General Hospital, Buikwe District, Uganda

Figure 12. The chronic care model, a key approach for meeting clients’ needs. The Chronic Care Model

Community Health Systems Resources and Policies Organization of Health Care

Self- Delivery Decision Clinical Management System Support Information Support Design Systems

Informed, Prepared, Activated Productive Proactive Patient Interactions Practice Team

Developed by The MacColl Institute Improved Outcomes ® ACP-ASIM Journals and Books

18 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Intensive Adherence Counseling gives HIV-Positive Patients a Second Chance

kwany, a 56-year-old client, receives HIV care two IAC sessions, Okwany was not taking his medicines and services at Orum Health Centre IV. He tested HIV therefore did not qualify to have a repeat viral load test until he O positive in 2011 and enrolled on ART in June of the adhered to his treatment. same year. His viral load tests in Au- gust 2015 and August 2016 showed Denis says, “I did not want continued lack of suppression, indi- to give up on him, so I kept cating a need for an intervention stay counseling him to focus on his on 1st line ART. As a retired teacher and peasant farmer, Okwany was adherence and get better.” spending a lot of his time drinking at a The national guidelines require that local bar, giving little thought to man- a patient have three consecutive aging his HIV treatment. good adherence assessment scores “I wanted to be suppressed, during the three months of IAC. It was only after the first two IAC sessions but, at the time, I was not that Okwany reduced his alcohol taking my adherence seriously. intake and started adhering to his I would go to the bar and medication and regularly attending IAC sessions. He therefore qualified forget to take my pills,” said for a repeat viral load test. The viral Okwany. load test done in May 2017 indicated that Okwany had finally achieved viral Through USAID/SUSTAIN’s continued suppression. support to Orum Health Centre IV’s ART Clinic, Okwany was enrolled in Okwany’s overall health improved Okwany at an intensive adherence the streamlined intensive adherence following IAC. He even advises counseling session at Orum Health Centre IV. counseling (IAC) for non-suppressed other HIV-positive individuals in the clients. He was counseled on the im- community to adhere to their drug portance of taking his antiretroviral drugs, benefits of viral regimens suppression, dose timing, and nutrition. “I thought if I can suppress this virus, then I want Denis (ART Clinic In-charge at Orum Health Centre IV) to help others do the same. I’m not afraid to talk to assisted Okwany in developing an adherence plan that was tracked by monitoring his pill count. He noted that despite them about it,” Okwany says.

Implementation of Chronic Care Model in Uganda; The Kawolo GH Experience

USAID/SUSTAIN participated in the MoH led chronic client education, reduced client waiting time, client data care model pilot activity in Buikwe district in November management, adherence support, client follow-up and 2010. A collaborative approach was used to conduct the management of other chronic illnesses among HIV clients. pilot at Kawolo GH and involved training health workers, Best practices from the exercise informed scale-up of the implementation, mentorships and learning sessions. chronic care model-based service improvement to other Significant improvements were noted in the areas of units.

September 30, 2018 | Final Report 19 TB/Multidrug-resistant TB

Table 5. Provision of quality TB services

What did we set out achieve? Key Achievements

Strengthen TB care, TB infection control, Identified 44,112 new and relapsed TB cases over the eight years of project pediatric TB care and enhancement of facility implementation team’s capacity to provide quality TB/HIV Improved TB treatment success rate from 51.8% in FY 11 to 95.8% in FY 18 services

Providing support in surveillance, diagnosis and Attained 71% treatment success rate in patients who were on MDR-TB treatment case notification, and strengthening infection control practices for DR-TB

Ensuring the provision of TB services n Establishing inter- and intra-facility linkages for patient care and support. USAID/SUSTAIN worked closely with the MoH’s National TB and Leprosy Program (NTLP) to strengthen the capacity of n Establishing TB/HIV one-stop service centers. public hospitals to effectively prevent, identify, and manage n Improving documentation/record keeping for TB-HIV and both susceptible and MDR-TB cases in Uganda (Figure 13). At MDR-TB care activities. the onset of the project, TB service provision was mostly left to n Improving TB infection control practices and physical a nursing staff that had limited experience and minimal support infrastructure for MDR-TB patient isolation. from other health facility staff. Stock-out of essential TB n medicines was common. Documentation of client details was Increasing surveillance for MDR-TB among presumptive incomplete, with no clear facility–client follow-up mechanisms. cases to help prevent MDR-TB. Missed opportunities for case identification were many, with n Strengthening supply chain management systems to avoid many pediatric TB cases undiagnosed due to inadequate stock out of TB commodities. skills. Community Tb support structures and client follow- n Provision of TB/HIV laboratory-related services and up mechanisms were weak. Client monitoring for treatment improved patient monitoring. outcomes was irregular with high LTFU rates. Though available, n Integrating nutritional assessments and interventions into laboratory services were underutilized, with delayed turnaround TB/HIV and MDR-TB care. times for TB sputum samples. n Provision of operational and logistical support for the Enhancing the quality of TB/HIV services coordination of drug-resistant TB (DR-TB) patient care To address the gaps in TB/HIV service delivery, the project between regional referral and peripheral follow-up health worked with the MoH and district TB focal persons to provide care facilities. technical assistance to hospitals to ensure the provision of quality services. The following approaches were implemented: Using quality improvement initiatives to improve TB/HIV services n Strengthening service provider knowledge and skills for TB and HIV management. In collaboration with the MoH, USAID/ SUSTAIN trained health care providers in TB care and the application of n Use of QI initiatives for TB-HIV and MDR-TB care indicator continuous QI (CQI) approaches to improve TB care. Hospital improvement. multidisciplinary process improvement teams, which included n Enhancing TB case detection and notification using experienced specialists or medical officers, were tasked to GeneXpert for TB screening, chest X-ray especially for monitor performance and support improvement. SUSTAIN pediatrics and TB index client contact tracing. and the MoH conducted on-site mentorships to address gaps

20 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Figure 13. SUSTAIN Performance with TB/HIV co-infection indicators tracked in the TB units

96.0% 97.6% 99.4% 100 94.5% 94.5% 90.4% 91.2% 88.3% 81.2% 82.4% 95.8% 78.3% 91.5% 80 67.9%

60 51.8% 51.3% 49.9% 46.0% 46.2% 44.3% 45.5% Percent 40 31.1%

0 FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 FY 17 FY 18

Percent of TB-HIV Co-infected clients TB/HIV Co-infected clients on ART Percent of TB patients with an HIV test result

Coverage of HIV testing among TB patients increases from 83.5% to 99.4% in Year 8. The yield for HIV positive cases among TB patients ranged between 31% and 51.3% in Year 3. However, the overall yield for HIV cases among TB clients was 45% over the years. The proportion of TB/ HIV co-infected clients also increases from 52% to 96% in supported health facilities over the years. Results include data from 18 sites that were consistently supported over the years, except for FY18 that includes Pader District.

Figure 14. Trends in TB treatment success rate in supported sites over the years

100

80 77.6% 76.0% 75.4% 72.2% 68.5% 71.1%

60 55.8% Percent 40 31.9%

0 FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 FY 17 FY 18

TB treatment success rate was also observed to have improved from 31.9% in FY 11 to 76.4% in FY 18. All the clients that were recorded as not completed would be followed up to establish the outcome however, the project would not adjust the numbers as they would have previously been reported in the system. The self-transfer outs to other TB treatment units closer to the clients’ homes was a leading factor in the low TSR figures. Results include data from 18 sites that were consistently supported over the years, except for FY18 that includes Pader District. in service delivery and to improve TB treatment completion training, assembling multidisciplinary teams, and mentoring rates (Figure 14). Key indicators for linkage to ART; sputum was maintained as a sustainable mechanism for supporting follow-up monitoring at two, five, and eight months; and improvements for TB/HIV services. treatment success rates were monitored. This process of

September 30, 2018 | Final Report 21 “If ever there was an appalling TB care system, Establishing one-stop-shop TB/HIV services it was here. We were below average as required In 2013, the MoH developed guidelines for TB/HIV one-stop by the Ministry of Health. We had lost many of model services in which health facilities were encouraged to utilize a patient-centered approach to provide TB and HIV our patients in the community because we had services at one care point, reduce multiple visits, and improve poor records and did not keep client contacts. coordinated care. The project established one-stop-shop TB/ USAID/SUSTAIN involved us in a performance HIV services at eight hospitals including Arua, Fort Portal, review process which helped us measure our Hoima, Kabale, Mbale, Lira, Gulu, and Mubende RRHs. USAID/ SUSTAIN supported client adherence to appointments as work against set indicators; we were not doing both HIV and TB treatment appointments were synchronized. well at all.” Improvements in access to HIV tests and ART were observed

Sister Betty Kihika, Focal Person, in TB clients, as were better treatment outcomes for HIV

TB & MDR-TB, Fort Portal RRH treatment.

Increasing the stewardship of the Ministry of

Prior to 2013, MDR-TB treatment was only Health to provide sustainable TB services available at three locations throughout Uganda: the To increase stewardship for TB services at supported health National Referral Hospital and two Medecins sans facilities, USAID/SUSTAIN worked with the NTLP, district Frontieres clinics. Regional Referral Hospitals (RRHs) TB/leprosy focal persons, community support structures, provided MDR-TB surveillance and referral, but not and facilities’ multidisciplinary teams to offer services. The project offered technical and logistical support, working with treatment. Better coverage of MDR-TB treatment was the different stakeholders while service provision and client urgently needed. care decisions were made by the health facility teams. This In 2013, SUSTAIN supported seven RRHs to roll-out a approach was used for the establishment of MDR-TB services, mixed (ambulatory and hospitalization approach) model with DR-TB expert panels established at health facilities of treatment for MDR-TB and assessed the clinical to oversee and support the provision of quality services in outcomes of the first cohort of 69 patients treated with coordination with the central MoH team and project technical these models. The study found that within six months staff. of treatment, fifty-nine (86%) patients had positive interim treatment outcomes – their sputum culture was Institutionalizing multidrug-resistant TB negative. Of the remaining ten patients, three (4.3%) management at selected public health facilities had died, three (4.3%) were lost-to-follow up, three Steps taken to establish MDR-TB services at selected health (4.3%) had unknown culture results, and one (1.5%) facilities (Figure 15) included the following: remained culture positive. Average time to culture n A rapid assessment was done to determine the caseload of conversion for those with favorable interim treatment confirmed DR-TB cases for all supported health facilities. outcomes was 2 months. n A study tour was conducted for TB clinic heads to Kitgum Less than half (46.4%) of patients receiving treatment Hospital, one of two DR-TB treatment centers in the country since 2009. at the RRHs experienced at least one severe drug adverse event; while 40 (67.8%) gained weight. n A renovation needs assessment was performed in These findings indicate that a mixed model of MDR- collaboration with the USAID TB Care I Project at selected hospitals. TB treatment at the RRH level can result in positive treatment outcomes. n Training was completed for DR-TB management at Mbale, Gulu, and Masaka RRHs and included the zonal and district

22 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Some of the patients admitted and receiving TB treatment at Mubende RRH TB ward. In the foreground, the TB nurse in-charge, Sr. Kitandwe talks with the patients.

TB and leprosy supervisors and health care workers from Figure 15. MDR_TB Cascade lower-level facilities. n DR-TB expert panels were selected and established at 533 MDR-TB each of the hospitals that developed hospital-specific cases implementation plans. detected n DR-TB management sites were set up at four pilot hospitals 364 Patients (Mbale, Gulu, Masaka, and Fort Portal RRHs), per MOH started on guidance and direction, and they were scaled up to seven MDR-TB RRHs by project closure. treatment n The project supported the coordination of DR-TB 71% Treatment management activities, including meetings, patient tracking, Success rate in monitoring, and support, as well as TB infection control MDR-TB patient activities. starting n DR-TB units were renovated and equipped for patient and treatment health worker safety.

Table 6. Results for DR-TB indicators

DR-TB Data element FY 13 FY 14 FY 15 FY 16 FY 17 FY 18

# of patients detected with DR TB 34 68 32 105 96 5

Number of patients detected with MDR TB 34 68 32 105 96 5

Number of DR-TB patients detected with malnutrition — 45 42 31 24 2

Number of DR-TB patients provided with RUTF — 65 40 30 21 2

Number of contacts of DR TB Patients screened for TB — — — — 749 11

Number of contacts of DR TB Patients diagnosed with TB — — — — 5 0

Number of DR-TB patients registered during the quarter — 47 63 94 85 5 with an HIV test result recorded

Number of DR-TB/HIV co- infected patients receiving CPT — 34 34 53 43 2

Number of DR-TB/HIV co- infected patients receiving ART — 33 33 50 43 2

September 30, 2018 | Final Report 23 Better Healthcare: With the Right Diagnosis, I Got the Right Treatment

Diagnosis and treatment “I was among the first patients on Above: Bernard—a 42-year-old construction worker—is one of the 24 n 2014, while on duty in South MDR-TB treatment in the region, patients who successfully completely Sudan, I felt feverish, [so I] went to a so I and my colleagues thought the MDR-TB treatment at Mbale RRH. medical doctor who recommended I nurses and doctors were conducting He is now a trained MDR-TB expert antibiotics for five days. I wasn’t getting client by the MOH and a change agent better. I tested for malaria and typhoid research on us; there were no people in his community. He tells his story too—results turned out negative. Then, to give us testimonies [of having been contending with MDR-TB. I decided to return to Uganda and cured of] the infection. What kept us continue investigations at home. going is that the side effects were After numerous investigations at different the day after I completed treatment. In reducing month by month.” health facilities, I received a phone call November 2016, I was selected and from a nurse at the Mbale RRH TB Financing my treatment trained by Ministry of Health as an MDR- ward inviting me to pick up my results. TB expert client. I now participate in My savings helped to facilitate my I confirmed the next day that I had health education for current patients to transport, accommodation, and medical contracted drug-resistant TB. It took share my story. I also sensitize people tests, including x-ray test while I was still only four days for my drugs to reach the in my community on the signs and conducting investigations. Fortunately, clinic. I was immediately called and told symptoms of TB and MDR-TB. to come with two treatment supporters the health workers explained that there to discuss my treatment plan. was a USAID-funded project called “For those who don’t know where to SUSTAIN, which was contributing start, I escort them to the TB ward to “When I heard of injections for six 120,000shs for each patient to cater for conduct tests.” months, I wondered how on earth transport and food during the treatment. This fund was such a relief because I I was going to receive over 180 don’t know how life would have turned injections without a break.” out.

I later started MDR-TB treatment after At last, I was a free man: I could not three days. believe that I was not given any drug 24 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Linkage facilitators, from L-R: Jackline Etap, Monica Community-Facility Linkages Amayo, Rose Awiiri (grandmother), Anna Alum and Esther Akello with the triplets at Dokolo HC IV.

Table 7. Implementing community-facility linkages

What did we set out achieve? Key Achievements

Address the linkage gap between testing points and In FY 17, 94.6% of newly identified HIV+ clients were linked to HIV care ART services services

Strengthen structures to improve clients’ retention in Intra and inter facility meetings instituted to support reconciliation of facility the HIV care and treatment program and self-initiated referrals to lower health units. Conducted a patient audit and client follow up exercise to track and return clients to care at all supported health facilities in FY17.

Build the capacity of community linkage coordinators Provided mentorships to support client retention in care for targeted and volunteers in networking and collaboration to facilities with high client loss to follow up. ensure continuum of care for people living with HIV and orphans and other vulnerable groups

USAID/SUSTAIN implemented targeted activities to strengthen calls and home visits, and training and mentoring on gender community-facility linkages, including functionalizing mainstreaming. These activities focused on reducing the community health departments at the RRHs, conducting inter- gaps in the continuum of response, seeking to improve client and intra-facility meetings, providing outreach and training adherence to treatment and retain clients in care. to key populations, following up with clients through phone

September 30, 2018 | Final Report 25 Figure 16. Outcome of patient audit at 11 supported regional referral and general hospitals.

7,000 6,353 6,000

5,000

4,000 3,069

Number 3,000

2,000 1,543 836 1,000 315 130 120 175 87 73 0 Total Shifted to No contact/ Wrong Stopped Transferred Active Died Promised Total tested unknown address contact medication out to come unaccounted place on file

Patient audit for the period 2010–2017 To account for clients enrolled in care since the inception of Client follow-up mechanism USAID/SUSTAIN and to follow up with those that were lost, A standard operating procedure was developed in a data triangulation exercise was organized in July 2017 at response to significant client loss. The procedure supported facilities. It involved community peers, facility was based on shared facility experiences to guide staff, and volunteers. Figure 16 (on following page) shows client follow-up and included the following cascade the findings. of activities: Intra-facility meetings 1. Identify missed appointments weekly using the electronic database. USAID/SUSTAIN supported intra-facility meetings in which health facility staff reviewed retention data, identified and 2. Confirm missed appointments with the client files. listed all missed appointments, and designed mechanisms 3. Check for missed refills in dispensing logs. for tracing every client lost to follow-up. In the meetings, 4. Call clients using facility phones in case the client teams also reviewed performance and established CQI has the phone number saved in their phone’s initiatives to close any gaps in client tracking. memory. Strengthening facility–community referrals 5. Conduct home visits/physical tracking for the clients who are not tracked in Step 4. Intra- and inter-facility meetings—involving critical stakeholders from the District Health Office, community- 6. Conduct inter-facility meetings to harmonize self- based organizations, and client peer representatives—were referrals with other high-volume health units in the conducted to improve referrals for clients requiring services same catchment area. not available at the facilities as well as enhance linkages Health talks reinforced health education throughout between newly identified HIV clients and optimal care. The the process. For each of the steps, the ART register documentation of referrals was improved using triplicate was updated using outcomes of the follow-up referral forms, and linkages were confirmed at the monthly activities. intra-facility meetings.

26 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Improving client identification and referral among key and priority populations Retaining The project collaborated with the Most at Risk Populations Clients in Initiative (MARPI) to map hot spots and train key population peers to conduct joint outreaches with facility health workers. Care

These moonlight outreach events provided HTS, sexually Stella Kebirungi transmitted infection (STI) screening and treatment, condom Community Linkages education and distribution, and counseling and linkage Coordinator, Fort Portal services to the key population at the identified hot spots, RRH targeting priority populations. “We used to lose many clients, but when we adopted the electronic (Open MRS) system to Integration of sexual gender-based violence run client lists, we started tracing the lost clients. into HIV services We then introduced our own counter book, listing The project trained 330 health workers at the supported all lost HIV-positive clients with their contacts in hospitals in gender integration, conducted mentorships, the community for follow-up. First, the clients are and provided registers to document interventions. Working with clinic teams, USAID/SUSTAIN supported modifications followed up through phone calls; then home visits in the client flow to integrate assessment for gender- are conducted for clients without contacts or those based violence, support, and appropriate referrals. Client who cannot be reached by a phone call. We used involvement was enhanced using health talks at the triage to lose track of almost 60% of our clients; now we areas. track more than 90%.”

Voluntary Medical Male Circumcision

Table 8. Scaling-up voluntary medical male circumcision

What did we set out achieve? Key Achievements

Circumcise at least 287,001 Circumcised 79% of this males target

Follow up at least 80% of the Kept follow-up rate at over circumcised clients 80% for over 3 years

Keep adverse events rate Maintained adverse events below 2% rate below 1% for the last 5 years.

Right: A patient before voluntary medical male circumcision.

September 30, 2018 | Final Report 27 n March 2013, the USAID/SUSTAIN project scope was Figure 17. VMMC Cascade, FY13- FY18 expanded to support the MoH in scaling up VMMC services 160,000 in its supported facilities (Figure 17). SUSTAIN utilized two 143,072 I 140,000 approaches for VMMC service delivery, namely 127,786 120,000 n Static VMMC activities at hospitals, including conventional circumcision surgery, the Model for Optimizing Value and 100,000

Efficiency (MOVE), and device-based circumcision (e.g., 80,000

Prepex); and Number 60,000 n Targeted outreach and circumcision camps, specifically 40,000 targeting sites in priority regions with high demand and where no other implementers offer circumcision. 20,000 884 0 A total of 148,442 men were circumcised during the life of the Number Number Adverse project out of whom 127,786 (89%) were followed up and 884 Circumcised Followed-up Events (0.6%) had adverse events. Results include data from 18 sites that were consistently supported over the years, except for Figure 18. Trends in number of men circumcised and FY18 that includes Pader District. adverse events experienced in supported sites

Out of the 884 men who experienced adverse events (109 – Moderate Severe Adverse Events Adverse Events 12%) were severe while 775 – 88% were moderate. Results 775 109 include data from 18 sites that were consistently supported 12% over the years, except for FY18 that includes Pader District.

The safe medical male circumcision program begun in FY 13 with 16,944 receiving the VMMC service. The peak was 88% realized in FY 14 where 45,365 men were circumcised. This number later reduced and stabilized at around 24,600 men per year. The proportion of adverse events experienced also reduced from 1.84% in FY 13 to 0.27% in FY 18. Results include data from 18 sites that were consistently supported over the years, except for FY18 that includes Pader District.

Figure 19. Findings of the data review exercise

50,000 2.00 45,000 1.80 40,000 1.60 35,000 1.40

30,000 1.20 Percent 25,000 1.00 20,000 0.80

Males Circumcised 15,000 0.60 10,000 0.40 5,000 0.20 0 0 FY 13 FY 14 FY 15 FY 16 FY 17 FY 18 Circumcised 16,944 45,365 18,242 12,932 24,656 24,933 Adverse events 311 120 80 50 145 68 % Adverse events 1.84% 0.51% 0.44% 0.39% 0.59% 0.27%

28 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally A newly identified malnourished client undertakes an appetite test at Hoima RRH before receiving RUTF supplies.

September 30, 2018 | Final Report 29 SUSTAIN supported hospitals conducted nutrition Nutrition education in their communities.

Table 9. Integrating nutrition counseling and support

What did we set out achieve? Key Achievements

To integrate nutrition counseling Systems were established to provide nutrition service as routine service along the continuum and support into service delivery of care. in facilities The health facilities were equipped with nutrition equipment and IEC materials to improve service delivery. Nutrition best practices and change package developed to aid integration of nutrition services for other implementing partners. Advocating and collaborating with other IPs to ensure all health facilities received RUTF for management of acutely malnourished HIV infected clients.

In collaboration with the MoH, USAID/SUSTAIN supported The project integrated nutrition follow-up into routine contact facilities to establish systems and processes for integrating tracing activities, such as home visits and phone call follow- nutrition assessment, counseling, and support (NACS) up, to reduce the high default rates among HIV-infected, services. Nutrition services were integrated at various service malnourished clients enrolled on ready-to-use therapeutic delivery points at supported facilities, including EID/mother- food (RUTF) at the supported health facilities. SUSTAIN also baby care points, ANC units, and HIV and TB clinics, among engaged nutritionists to take the lead in the supervision of other entry points. nutrition services within the supported health care facilities for sustainability. (Results of the project’s nutrition interventions The project trained health workers in the revised MoH NACS are shown in Figure 20.) in-service training curriculum and supported the health facilities to revitalize the Baby Friendly Hospital Initiative framework.

30 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Figure 20. Coverage of nutrition services for PLHIV

98.9 94.2 100 92.9 PLHIV nutritionally assessed 89.6 91.1 90 PLHIV undernourished who received 80.4 80 supplimentary or therapeutic food

70 Cure rates for PLHIV given RUTF 56.5 57.4 60 54.8 63.4 50

Percent 36.9 52.1 40 39.4 30 20 26.3 10

0 FY 13 FY 14 FY 15 FY 16 FY 17

The proportion of PLHIV screened for malnutrition increased from 93% in FY 13 to 99% in FY 17. The proportion of undernourished PLHIV given RUTF also increased from 37% in FY 13 to a peak of 91% in FY 16. Cure rates for PLHIV given RUTF also improved from 26% in FY 13 to 63% in FY 16. Results include data from 18 sites that were consistently supported over the years.

Seven-step Model to Institutionalize NACS at All Service Delivery Points 1. Client assessment for nutrition status 2. Categorization where the nutrition status is recorded on the care card for each HIV-infected patient 3. Counseling, especially for malnourished clients 4. Food by prescription where identified malnourished clients who pass the appetite test receive RUTF 5. Follow-up of all malnourished clients given RUTF 6. Community links for all patients receiving RUTF 7. Health education on good nutrition and hygiene

Assessing nutritional status with a mid-upper arm circumference test.

September 30, 2018 | Final Report 31 A nurse takes inventory of HIV-related commodities. Supply Chain

Table 10. Strengthening supply chain management

What did we set out achieve? Key Achievements

Ensure uninterrupted supply of Reduced the stock out rate of key HIV commodities at SUSTAIN supported hospitals from HIV commodities 40% to 5%. Strengthened appropriate medicines use in health facilities through revitalization of the Medicine and Therapeutics committees at regional referral hospitals.

Strengthen supply chain Improved storage conditions and inventory management for medicines and related supplies. management systems at Strengthened the capacity of hospital teams to accurately quantify and submit timely reports and facilities orders to NMS for health commodities. On time commodity order submission increased from 54% (March 2011) to 98% (March 2018).

32 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally USAID/SUSTAIN improved logistics and inventory management related interventions and associated outcomes. Table 12 of health commodities at supported health facilities and demonstrates how the stocks of Pediatric Formulations ensured a continuous supply of HIV and essential commodities changed over time, increasing from low stocks to adequate from the national supply chain system. Table 11 describes stocks over the course of 10 reporting quarters.

Table 11. Interventions and outcomes to improve the supply chain for HIV-related commodities.

INTERVENTION OUTCOME IMPROVING SUPPLY CHAIN MANAGEMENT SYSTEMS

• Conducted visits under the Supervision, Performance • Increased accurate and timely reports and orders to NMS. Assessment, and Recognition Strategy (SPARS) with Order submission increased from 54% (March 2011) to 98% support from District and Regional Medicines Management (March 2018). Supervisors. • Improved storage conditions and inventory management for • Provided shelves, pallets, and hygrometers to supported medicines and related supplies. hospitals to improve storage management. • Reduced wastage of commodities due to expiry. • Supported 5S (sort, set, shine, standardize, and sustain) approaches in all the stores for the easy identification and retrieval of stock. • Installed Electronic Medicines Management software after provision of desktop computers to hospital stores, • Ensured utilization of laboratory management information system (stock cards, consumption logs, and stock books).

STOCK MONITORING AND REDISTRIBUTION

• Identified facility order focal person to monitor stocks. • Ensured timely submission of orders. • Supported stock status review meetings. • Implemented available monthly stock status reports that • Established Medicines and Therapeutics Committees. informed redistributions to mitigate stock-outs and prevent expiry of commodities. • Strengthened appropriate use of medical products in health facilities through the revitalization of Medicines and Therapeutics Committees at RRHs.

ENSURING UNINTERRUPTED SUPPLY OF HIV-RELATED COMMODITIES

• Delivered on-site trainings (SPARS, electronic medicines • 98.2% of the five HIV-related orders were submitted on time to management system (RX solutions). the NMS, up from 54% (March 2011). • Provided mentorships. • Key HIV commodities were available at an average rate of • Supported drug redistribution. 92.03% since the inception of the project. • Used cell-phone-based short message service (SMS) reminders to the order focal persons and hospital management, as per the order schedules.

September 30, 2018 | Final Report 33 Table 12. Percentage availability of Pediatric Formulations Low Stock 0-69 Moderate Stock Adequate Stock at 12 hospitals, Q2 of FY14 to Q3 of FY16. 70-89 ≥90

Commodity Type Percentage Availability

Q2-14 Q3-14 Q4-14 Q1-15 Q2-15 Q3-15 Q4-15 Q1-15/16 Q2-16 Q3-16

Children, ARVs 1st line 89 88 68 93 69 90 92 97 95 100

Children, TB 1st line 30 31 47 90 100 96 92 92 88 83

Cotrimoxazole 120 mg 47 46 55 70 83 85 92 100 92 100

Quarterly average 55 55 57 84 84 90 92 97 92 94

Laboratory Services

Table 13. Provision of quality laboratory services

What did we set out achieve? Key Achievements

Strengthen provision of HIV Improved laboratory working space through renovations for 18 laboratories related laboratory services 22 laboratories equipped with CD4, CBC, Chemistry, GeneXpert automated analyzers and other supportive equipment (centrifuges, refrigerators, pipettes, roller mixers

Enhance the provision of quality 18 Labs enrolled on EQA schemes i.e. UKNEQAS for CD4 and CBC and proficiency panels for laboratory services rapid HIV testing. 18 labs enrolled on the national SLMTA program and 17 attained between 1 and 3 stars. 98% of samples received in the laboratories were acceptable for testing.

Despite the rapid scale-up of HIV prevention, care, and Ensuring provision of laboratory services treatment interventions in Uganda, laboratory services in To ensure the provision of sustainable HIV services, the the public sector were limited by 2010. RRHs and general USAID/SUSTAIN project worked with the MoH to improve hospitals, which provided services to a large population of access to quality laboratory services in Uganda. Following a HIV positive clients, had poor laboratory infrastructure with joint needs assessment in December 2010—conducted in limited equipment that was inadequately maintained and had collaboration with the MoH, CPHL, and the USAID Targeted insufficiently trained laboratory staff. Routine monitoring tests— HIV/AIDS and Laboratory Services (THALAS) project— including CD4 counts (counts of Cluster of Differentiation 4 SUSTAIN set out to provide technical and operational support proteins), hematology, and chemistry for HIV-positive clients— for delivery of laboratory services aimed at addressing three had to be referred to other laboratories supported by other key areas of need: infrastructure, equipment, and human projects. These challenges negatively impacted evidence- resource. based clinical care service delivery.

34 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally A laboratory technician conducts syphilis tests at Fort Portal RRH.

Interventions included the following: Assessment Service [UKNEQAS] for CD4 and CBC and n Improving infrastructure, including renovations for 18 proficiency panels for rapid HIV testing). laboratories and 7 RMEMWs and the installation of n Supporting 34 hubs in the national laboratory sample and heavy-duty power back-up systems at the renovated and results transport network (Hub system), including 12 in equipped laboratories. northern Uganda. n Equipping 22 laboratories with CD4, complete blood count n Strengthening laboratory logistics management. (CBC), chemistry, GeneXpert, automated analyzers, and ancillary equipment. Conducting quality improvement activities n Conducting QI activities and set up of teams at each of the The project, in collaboration with the MoH, promoted the use hospitals supported. of QI approaches for laboratory services through training, n Enrolling 18 labs in the national Strengthening Laboratory on-site mentorships, and shared learning sessions. Some Management Towards Accreditation (SLMTA) program. of the QI indicators monitored included improvement of turnaround time for TB and CD4 tests, sample acceptability n Strengthening HR in the category of laboratory support for automated tests, and equipment uptime. See Table 14 through recruitment, placement, and capacity building. for the outcomes of lab QI interventions, and see Figure 21 n Enrolling 18 labs in external quality assurance (EQA) for data on the number of HIV-related lab tests conducted at schemes (United Kingdom National External Quality supported hubs.

Table 14. Lab quality improvement indicators at 18 supported facilities at the end of FY17.

QI measure Equipment/test Target Baseline (FY15) Performance (FY17) Sample acceptability CD4, CBC, & Chemistry tests 100% 89% 98%

Turnaround Time CD4 24 Hours (100%) 89% 94%

TB 3 Hours (100%) 63% 78%

Equipment Uptime Chemistry 100% 79% 87%

CBC 100% 88% 90%

CD4 100% 89% 77%

September 30, 2018 | Final Report 35 A laboratory technologist conducts chemistry tests for patient samples at Kabale RRH.

Figure 21. Number of HIV-related lab tests conducted at supported hubs.

Viral load 1,200,000 prioritization 1,135,814 Targeted 1,014,498 HIV testing 1,000,000 4,696,405 total 876,058 875,835 HIV-related 218,403 Syphilis 800,000 laboratory tests 145,180 tests TB sputum 627,521 541,527 tests CD4 600,000 tests 498,727

Number of Lab Tests 2,833,994 400,000 316,987 179,013 HIV antibody 159,601 Liver 249,950 618,687 tests Renal function CBC function tests 200,000 tests tests

0 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY 14/15 FY 15/16 FY 16/17 FY 17/18

36 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Enhancing the quality of laboratory services To improve laboratory quality management systems toward What was done? accreditation by international standards (ISO 15189), • Facilities enrolled in the SLMTA program in the USAID/SUSTAIN project supported 18 public health three cohorts: 5 in cohort 1 (2012), 9 in cohort laboratories in Uganda, allowing them to participate in WHO’s 2 (2013), and 4 in cohort 3 (2015) Africa Regional Office (WHO/AFRO) SLMTA program Figure( 22). Key challenges to be addressed included inadequate • Baseline data collected using the WHO/ quality management skills, limited supervision for lab teams, AFRO checklist from the Stepwise Laboratory poor documentation, and weak quality systems. Improvement Process Towards Accreditation (SLIPTA) program

“We used to be in a small multipurpose room, • Trainings completed in the three cohorts for the and we would lose samples on the way for 18 facilities advanced tests. The laboratory was remodeled • Facility management oriented on SLMTA for support and renovated, and staff were recruited. If there’s • Facility teams attended 3 structured workshops a project well done, it is the laboratory of Tokora. over 18 months There is value for money here.” • Ongoing on-site mentorships Dr. Peter Lokwang, In-Charge Medical Officer, • Mid- and end-term assessments conducted Tokora Health Centre IV

Figure 22. SLMTA cohort 3 end-line performance assessment.

5 Cohort 1 Cohort 2 Cohort 3 4

Lira Arua Jinja Gulu Abim Mbale Soroti Hoima Kotido Kabale Masaka Moroto Kawolo Tokora Matany Fortportal Kaabong Mubende

Star status at Baseline/Midterm Highest Achievable Star

Star status at Endline/Midterm Target Star

September 30, 2018 | Final Report 37 38 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Adolescent-friendly Health Services

Table 15. Establishing adolescent friendly services

What did we set out achieve? Key Achievements

Address the unique challenges and Established Adolescent Friendly Health service clinics at 12 supported health facilities coping mechanisms of HIV-positive Trained 273 health workers on adolescent friendly services. adolescents Utilized a multisectoral approach to mentor and train facility staff involving the health, education and gender ministries of the Uganda government. Trained and involved peers in service provision and leadership at the clinics

Increase the number of new adolescents 27,791 new adolescents attended the clinics in FY17. using the AFHS centers

Increasing peer adolescent All supported adolescent friendly clinics had peers involved in service provision. involvement in planning and implementation of AFHS

To integrate adolescent transition Designed an adolescent transition mechanism with the MoH and established the services in adolescent service delivery systems at the clinics.

Unsung Hero: Gloria Akullo

loria Akullo (opposite) is a 24-year-old female Gloria currently coordinates activities of other adolescent volunteer at the forefront of enhancing AFHS in peer volunteers and ensures that each adolescent gets GLira District. She was diagnosed with HIV at the the right health information, is linked to the right clinician, age of three, following a persistent illness and the death and receives priority and quality care. Her roles include of her parents. Wondering shy she was subjected to daily creating awareness of the services offered at various pills, Gloria later learned from her aunt, who was also her entry points and identifying and physically escorting caretaker, that she was HIV positive by age 10. It was adolescents from all units to the center. Gloria also devastating news but not nearly as devastating as the participates in conducting health education talks on death of her aunt six years later. Gloria gave up on living topics like teenage pregnancies, STIs including HIV, and and quit her ARVs for a year. At the brink of death from family planning. She keeps adolescents engaged with the progression of her HIV disease, Gloria’s life was saved board games such as Snakes & Ladders and chess. by the dedicated ART clinic team at Lira Regional Referral By sharing her own experiences, Gloria gives hope and Hospital, who supported her to fight off stigma and motivates many newly identified HIV-positive adolescents discrimination from her relatives and later switched her to utilize the services at the ART clinic. Through building to a new drug combination. Because of the close bond trust with adolescents, she can actively follow up with shared with the ART clinic team, at 17-years-old, Gloria adolescent clients who are lost from HIV care and chose to be “a hero to the hero-less.” She became an personally ensure their return, remind those who are due adolescent peer volunteer to support other HIV-positive for a viral load of its importance, and support them to adolescents. access viral load testing services.

September 30, 2018 | Final Report 39 To address the unique challenges and coping mechanisms of HIV- positive adolescents, in November 2015, the MoH and USAID/SUSTAIN What worked? collaborated and initiated the process of establishing model adolescent- • Directly involving adolescents in the provision friendly health services (AFHS) clinics at six RRHs. The clinics were of AFHS established effectively in partnership with the senior hospital leadership • Offering holiday camps for the provision of teams. Many levels of stakeholders worked together to establish the comprehensive HIV services that targeted AFHS clinics, from MoH experts to the adolescents themselves. adolescents in school Health facilities were selected based on the high volume of adolescent • Conducting adolescent clinic days for HIV- clients served, poor AFHS indices, low access to viral load testing for positive adolescents adolescents, poor viral load suppression among adolescents, and • Involving management at health facilities low ANC attendance for adolescent girls and young women. The to support the establishment of special adolescent-friendly health centers were then scaled up to an additional adolescent clinic days at ANC and ART clinics four RRHs and one general hospital in FY17 and an additional 44 health • Utilizing a family-centered approach facilities in the Acholi and Lango Sub-regions by March 2018 (Table 16).

Table 16. Locations where clinics for adolescent-friendly health services were established, FY16–FY18.

Period Facilities where AFHS were established

FY 2016 Jinja RRH, Mbale RRH, Gulu RRH, Lira RRH, Moroto RRH, Kabale RRH

FY 2017 Fort Portal RRH, Hoima RRH, Mubende RRH, Arua RRH, Kawolo General Hospital

March 2018 44 sites in the Acholi and Lango Sub-regions

Figure 23. Stakeholders who collaborated with the project to create clinics for adolescent-friendly health services, and their respective outputs.

Reproductive Data collection tools Health Division, Development MoH

District health Data collection Tools office/teams Integration

Hospital/ Clinic Set-up of adolescent- teams friendly health services

Outpatient Triage and linkage of department adolescents 10–19 years

Peer support & health Adolescents education, mobilization of adolescents, filing, and Participation in registration of adolescents by a peer nutritional assessment volunteer.

40 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Health Management Information Systems

Table 17. Ensuring data quality and use

What did we set out achieve? Key Achievements

Improve data accuracy and completeness Median deviation of key indicators, selected by technical leads, from what was recorded vs. what was reported decreased from 9% in FY 11 to 1.3% in FY 17, Encourage staff at facilities to use their data indicating an improvement in data quality to improve service delivery

rior to 2010, project- and installing and utilizing supported facilities the new MoH electronic data Pwere using multiple management system (Uganda information systems devel- EMR). With these interventions, oped by previous partners, facility teams were able to which created bottlenecks generate reliable data to in patient monitoring and successfully respond to facility, central reporting by hos- central MoH, and USAID pitals. Poor filing made it information requirements, difficult to track clients’ as well as utilize data for appointment-keeping, planning and improving service treatment outcomes, and delivery Data management LTFU. USAID/SUSTAIN teams at facilities conducted aimed to enhance the data quality assessments, use of the MoH HMIS which often involved project tools, strengthen systems monitoring and evaluation A data officer searches for client files in preparation for a clinic day and health workers’ skills team, technical leads, and to improve data manage- MoH representatives. The ment and quality, and increase health care teams’ use of median deviation of key indicators, selected by technical leads, reliable data for decision making. from what was recorded vs. what was reported decreased from 9% in FY 11 to 1.3% in FY 17, indicating an improvement USAID/SUSTAIN, in collaboration with the MoH, enabled in data quality. facility teams to utilize the MoH’s client data collection and reporting tools for HIV services. Interventions included training The LTFU study revealed that cleaning up records, using all and supportive supervision for data management and clinical available record systems (community linkages facilitators’ services teams, improving filing systems for paper-based reports, appointment books, etc.), solved up to 90% of records, providing data collections tools, conducting regular erroneously reported LTFU clients. However, it also revealed on-site client data quality audits and validation, supplying that incomplete, wrong, or archaic patient details contribute computers for clinical and pharmacy/stores data management, significantly to the burden of finding patients reported as LTFU.

September 30, 2018 | Final Report 41 Student midwives assist in entering data at a SUSTAIN supported health facility.

42 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Human Resources for Health

Table 18. Establishing adolescent friendly services

What did we set out achieve? Key Achievements

Address staffing challenges for HIV service USAID/SUSTAIN provided HRH support for over 302 critical staff positions at the delivery supported hospitals.

Improve HR management practices Performance management training was done for 171 health facility managers Transitioned oversight of project supported staff to the health facility managers.

Support the absorption of PEPFAR HRH staff 153 PEPFAR HRH staff absorbed

Transition planning to ensure minimal service The project worked with hospital management and incoming IPs to prepare for the delivery interruption seamless transitioning out of USAID/SUSTAIN support.

Use HRH data to support decision making The project regularly gathered performance data on the health workers to ensure accurate reporting and planning.

Rationalizing human resources for health support based on the specific needs SUSTAIN Supported HRH Interventions At the onset, the SUSTAIN set out to establish workload- • Establishing provider: patient ratios based staffing needs. An HR capacity assessment was done • Supporting hospitals to directly manage HR to assess the HR staffing needs. Tasks and criteria for staffing • Ensuring HR sustainability for HIV clinics were established using data on client loads, staffing levels, – MOH leaders for HIV services and the time required for delivery of quality key HIV services – Core teams per client. These tasks and criteria were used to inform HRH – Provider capacity building staffing plans and the current need for support as well as to – Seconded staff salaries aligned to public forecast future needs. Workload-based staffing needs for the service scale ART clinics were determined for each hospital. The Average – MoH/Districts to transition some supported number for required staff per cadre was established as below staff to public service Health workforce support • Maximizing staff efficiency and productivity In line with the SUSTAIN’s stewardship objective, over 302 Outcomes: Improved leadership and HR project-supported staff positions were directly managed management capacity for HIV services and supervised by the hospital management teams. The project provided HRH grants to pay salaries in light of HRH Integrating quality improvement and human constraints, enabling the hospitals to attain the right HRH numbers and skills mix for providing HIV services. Also, resource management to improve productivity the project worked with hospital management, supporting In 2013, SUSTAIN conducted a human resource performance leadership training to ensure adherence to benchmarks for improvement (HRPI) activity to improve productivity and HR management. efficiency. While the methods used may be applied to any aspect of care, HIV testing and counseling (HTC) services

September 30, 2018 | Final Report 43 Figure 24. Patient to clinician ratio

3 Counseling Staff HCT PMTCT

0.6 Clinic with 1.2 10,000 1,000 Dispensing 1,000 HIV+ Clinical General Pregnant Clients Clients Staff Clients Staff

3.7 0.1 1.0 Counselors Counselor Laboratory Staff

Collaboration with the Ministry of Health By the end of the support, 153 health workers of and districts for the absorption of PEPFAR’s a possible 262 at public facilities (approximately human resources for health by the Ugandan 60%) were absorbed, and their salaries were Government taken on by the districts and RRHs. In Year 7, the project coordinated the PEPFAR HRH activity on behalf of USAID. The project supported 686 health were offered at three hospitals: Entebbe, Fort Portal, and workers at government and PNFP health facilities and Mubende. Through the HRPI, these hospitals focused on districts. SUSTAIN regularly engaged with the district a QI indicator for HTC: reaching the target number of HTC stakeholders to ensure they were supported toward this goal. conducted. The activity focused on the HR performance The districts were tasked to identify funds and commit to framework, which describes that employees who are engaged absorbing the supported health workers. are more likely to be productive and perform well. The HRPI demonstrated that integrating HR improvement strategies Engaging hospital management in the with QI methods can be employed successfully to improve preparation for transition productivity and clinical outcomes. Following the HRPI, the USAID/SUSTAIN worked with stakeholders to prepare for supported hospitals utilized simple steps for achieving QI the transitioning-out of SUSTAIN. Transition activities were targets for HTC including setting targets as a team, involving coordinated to ensure minimal disruptions to service delivery. all team members; addressing staff motivation; and rewarding, Several meetings were held on- and off-site to ensure the recognizing, and regularly sharing data and feedback. transition processes were seamless. All project-supported facilities and the scope was transitioned-out to new implementing mechanisms.

44 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Building Performance Management Competencies for Managers and Supervisors

Group work session during the performance management training at Ishaka Hospital n 2018, USAID/SUSTAIN worked sessions were conducted during each in collaboration with the Intrahealth week, at a total of six regionally based IStrengthening Human Resources for venues. The training exercise had the supervisor had that affected the Health project to conduct a performance cost-sharing aspects: SUSTAIN asked implementation, and agree on ways to management training exercise. that PNFP and GOU host the activity. implement performance management Participants were the supervisors of the The venues included Gulu, Kabale, plans at their own institutions. The PEPFAR HRH for both PNFP and public and Jinja RRHs; the Aber Hospital; highly interactive sessions included facilities. The training aimed to build Ishaka Adventist Hospital; and Cure group work with assignments to ensure leadership capacity and orient leaders Hospital. The host venues provided optimal learning for the participants. and supervisors of health workers the training spaces and were facilitated From the feedback collected at the end in performance management. They by SUSTAIN to prepare and serve the of the training, the participants found included HR officers, doctors, nurses, refreshments. The specific objectives the training to be highly relevant and and administrators. The three-day were for the teams to identify common applicable for the daily supervisory training program was implemented over performance management gaps, agree tasks. In total, 160 supervisors attended a two-week period. Three concurrent on interventions, detect gaps that the training at the six venues.

September 30, 2018 | Final Report 45 Quality Improvement

Table 19. Institutionalizing quality improvement

What did we set out achieve? Key Achievements

Institutionalize QI in service delivery The project supported the establishment of hospital QI teams

Improve the quality of HIV delivery services QI approaches were applied to improve the quality of health services.

Conduct a client satisfaction survey at 11 95% of the respondents agreed that the quality of services being offered at the supported health facilities. project supported HIV clinics were satisfactory.

Strengthen QI structures at various levels Participated in the National QI Coordination meetings held quarterly Established and supported up to seven RQI Committees that are now functional and supporting QI work.

USAID/SUSTAIN supported QI at the national (MoH) level by routine technical support through coaching and clinical participating in QI policy formulation through membership in mentorship, and the National QI Framework and Strategic the national QI coordination committee, chaired by the MoH’s Plan 2016–2020 to redesign and increase the quality of HIV/ Quality Assurance Department. The project also actively AIDS service delivery and improve providers’ performance as participated in national conferences by presenting QI-related well as clients’ health outcomes. abstracts. At the hospital level, SUSTAIN established and functionalized By equipping service providers with the knowledge and QI structures (facility, department, units). Health care technical skills to deliver services according to standards providers from each HIV service delivery point within the and with the utilization of QI approaches, SUSTAIN built the hospitals formed QI and work improvement teams, and the capacity of service providers to deliver quality care (Figure 25). teams identified key changes in systems and processes Providers were trained on the application of QI approaches, aimed at improving select performance indicators.

46 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Fort Portal’s Quality Improvement Excellence

hen it comes to QI, thanks to systems put in place by SUSTAIN, the Fort Portal regional maintenance workshop continues to excel, ranked as the best W in the country and among the best in 5S. The maintenance workshop runs differently from the rest of the hospital departments; they have grasped how to implement QI projects and documentation properly.

The lab has taken the same approach. In fact, it is due to be accredited by the South To crown it African National Accreditation System (SANAS); the only item not yet in place is a smoke detector. For all of the regional hospitals, HR support was essential to making all, SUSTAIN improvements. It was what really boosted the scale-up of HIV services. The hub rider has made system extended services to the lowest-level health facilities, which was especially me a better important for exposed infants who need access to the DNA-PCR and viral load tests. manager. The development of local capacity enabled staff to be trained in the management of TB on the ward. It is no longer seen as a punishment to be deployed to the TB unit. Rather, it Dr. Florence is seen as an area where one can serve and even make patients better. TB management Tugumisirize gives hope. It bridges the gap between the patients and the community. The regional TB treatment centers demystify TB and DR-TB. The patients are reached and integrated back into the community

Finally, leadership and governance: the management teams that were supported by SUSTAIN improved greatly in their management practices. When it comes to staff appraisals, management is now creative with the process as opposed to routinely checking boxes.

September 30, 2018 | Final Report 47 Figure 25. SUSTAIN’s QI journey

• Training of 55 trainers in QI • Initiation of QI institutionalization process • Baseline survey of QI practices 2010/11 • 1st client satisfaction survey • Client flow, waiting, and contact-time surveys

• QI training for lab, management, and staff • Formation of QI teams 2011/12 • Recruitment of QI Advisor • Support for National QI conference

• QI training: VMMC, Care & Treatment, and Lab • Formation and supervision of QI structures and implementation • Implementation of QI at top- and mid-level 2012/13 management • Dissemination of National QI Framework

• Further training in QI 2013/14 • Incorporation of QI into service delivery (VMMC follow-up)

• Pilot of the QI documentation web-based database with Mildmay Health Centre Uganda • Documentation of best practices and 2014/15 success stories with submission of abstracts

• Support to the functionality of 2015/16 hospital QI structures • Harvesting of QI innovations and writing of change packages

• Functionalized regional QI structures • Learning through QI learning sessions 2016/17

48 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Challenges

Table 20. Challenges encountered, and the approaches USAID/SUSTAIN used to address them.

Overarching Challenges Approaches for Addressing Challenges

The great divide between the RRHs and the local The project worked with other programs that were pursuing integrated government health units does not enable implementation of outreach to lower-level facilities and supported inter-facility forums for the RRH mandate to support service delivery improvements systems improvement, though in a limited scope. in the regions.

The project noticed high rates of undocumented LTFU The project encouraged and supported the active transfer of clients clients due to self-transfers to lower health care facilities to lower health care facilities after the decentralization of service from the regional referrals that were supported. delivery. Working with CDC mechanisms and projects under the USAID Strengthening TB and HIV & AIDS Responses (STAR) program, the accredited health facilities were identified, and inter-facility meetings were initiated to enable the RRHs to communicate to the lower units for client data triangulation.

The project conducted a fully approved LTFU study to determine the outcomes and predictors of LTFU among clients that were accessing care at RRHs in Uganda.

Understaffing and staff attrition continued to affect the The project supported secondment of critical staff positions at coordination and delivery of client care. the heavy-volume facilities and worked with the District Service Commission, Health Service Commission, and hospital leadership to prioritize absorption of the same into the government payroll system.

Health workers did not support a good culture of using data USAID/SUSTAIN supported performance reviews and QI project to drive decisions. The poor culture was worse among high- implementation, encouraging the review of data to identify gaps in the cadre clinicians and better with nurses. systems and processes.

Contextual Opportunities

1. Decentralizing HIV/TB service delivery support through accreditation, plus equipping lower-level health units, was shown to work. These strategies should be supported to decongest the RRHs and to bring about better client experiences that lead to better clinical outcomes.

2. The RRHs have been equipped to work as centers of excellence for HIV/TB service delivery. The regional implementing mechanisms should tap into these rich resources and use them to support local governments in the different regions.

3. The improved laboratory infrastructure can be utilized as an income-generating unit for the hospitals and health units if good business models are thoughtfully applied.

September 30, 2018 | Final Report 49 A caretaker with a child at the nutrition ward, Hoima RRH

50 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally ANNEX 1 Lessons Learned

USAID STRENGTHENING UGANDA’S SYSTEMS results as part of performance assessment scored well in most FOR TREATING AIDS NATIONALLY of performance indicators, including those for quality of care. (USAID SUSTAIN) This was further evidenced when top leadership for RRHs was changed; the hospitals that received strong leaders performed USAID/SUSTAIN has been part of major policy, program design better than before, even in a short period of time. and service delivery changes in the HIV/AIDS response in Uganda over the eight years of its implementation. The project Ownership and stewardship has played a major role in supporting the MoH to continually Consistent engagement of healthcare facility management and update knowledge and application of new guidelines and service service provider teams in stewardship of delivery of previously delivery protocols. USAID/SUSTAIN worked with 12 of 13 RRHs parallel HIV and TB services created a strong sense of ownership in the country, to varying depth and periods of time.; 53 General for the services and improvements, as opposed to a previous Hospitals with different levels of complexity of organization of scenario where the services were managed and delivered by service delivery systems; and provided HRH strengthening project teams. To achieve this, USAID/SUSTAIN used a mixed support to 58 district local governments. model of support to hospitals, where personnel were seconded to fill-up critical staffing positions while lobbying for deployment of TRANSITION OF SERVICE DELIVERY AND government staff to take over the roles as they were mentored to SYSTEMS STRENGTHENING SUPPORT be effective in those roles. Data show that in most cases, service BETWEEN IMPLEMENTING PARTNERS delivery units mostly staffed with government contracted health Transition care workers as opposed to project-seconded staff scored higher on select sustainability indicators. A very close working relationship with the various hospitals and districts; frequent transitions of roles between USAID/SUSTAIN Structural barriers to full implementation of the and other USAID and CDC partners coupled with related changes RRH mandate in the scope of work for the project provided an opportunity for USAID/SUSTAIN to document the type of technical support and The divide between management structures for RRHs and district mentoring necessary to ensure effective and seamless handover local governments and their healthcare facilities presents a of roles and responsibilities between implementing partners that complexity in enabling the RRHs to fully implement their mandate support government structure to foster un-interrupted service to support service delivery improvements at lower levels of the delivery. Key elements for such a transition include: developing health care system in respective regions. There is urgent need a joint facility plan with the incoming implementing partner for the government to streamline this relationship and provide (IP) detailing work achieved and work that has yet to be done, resources (human and others) to optimize the role of RRHs conducting site visits with incoming IP, and discussing how a in supporting and strengthening district health management facility operates. structures, including lower level healthcare facilities. Sustainability of maintenance of medical equipment and LEADERSHIP AND OWNERSHIP other infrastructure in public sector healthcare facilities Leadership and performance Maintenance of medical equipment and infrastructure is very Strong leadership at healthcare facility level is associated expensive and requires a deliberate and well-thought-out plan. with good performance across the entire facility. Healthcare Relying on donor-funded projects to cover maintenance and facilities whose leadership demanded for accountability and servicing costs for laboratory equipment is unsustainable. The

September 30, 2018 | Final Report A–1 MoH and individual healthcare units must be supported to develop Management of electronic management information business models that will foster servicing and maintenance of systems and databases their infrastructure. Such models could include agreements The health system staffing structure in Uganda does not include where suppliers of equipment commit to service and repair the information technology experts; a relevant labor category as equipment and income generation through provision of private the country migrates to electronic data management systems. services. This position must be incorporated in the structure to ensure BUILDING SERVICE PROVIDER SKILLS AND this transition is successful and sustainable without relying on COMPETENCES seconded experts from donor-funded projects. Capacity building Absorption of project-seconded personnel by PNFP hospitals Capacity building approaches in today’s fast-changing implementation environment should be rethought to focus on Absorption of project-seconded health workers by private-non-for- measurable, self-learning models as opposed to a didactic/ profit hospitals (PNFP) has proven to be rather difficult, for some classroom training approach. of these hospitals have more seconded healthcare workers than they can afford to take on within their current business models. A lot of productive time is spent on refresher training courses Some of the units have been requested to go beyond the mandate due to frequent changes in policies/ guidelines. This method of for which they were created by mainstreaming HIV and TB service delivering the courses assumes the same learning capacity for delivery components into their scope. A business model shift all trainees. Training can be made more efficient with e-learning needs to be thought out carefully to enable sustainability. modules and tailoring the learning to specific gaps in knowledge and skills, ascertained through an assessment. This modality of Strengthening health worker efficiencies and training reduces the time away from actual service delivery. performance HRH planning needs to address staff absenteeism, redundancies, Building service provider skills in HIV counselling and slack time to enable increased productivity. District Local Clinicians, nurses and midwives acquire very limited counseling Governments need to have proper analyses of their HRH needs skills during pre-service training. This impacts retention of HIV after accounting for the absenteeism, redundancies, and slack clients in care, ultimately affecting treatment outcomes. Investment time. Health workers’ job assignments need to be based on in on-job skilling of service providers in HIV counseling is vital for workload and not structural provisions, as is currently the case. improving patient experience, adherence to ART and treatment outcomes. HEALTH MANAGEMENT INFORMATION SYSTEMS AND DATA MANAGEMENT AND USE THE HEALTH WORKFORCE Use of data Bridging staffing gaps The culture of data utilization for decision making is still rather Understaffing and attrition of essential health cadres, especially for weak among health workers. Coupled with and related to this, the laboratory services, medicines management, data management/ uptake of use of QI methods in routine service delivery is gradual, HMIS, and clinical services continue to affect delivery of quality variable, and dependent upon consistent technical support from client care. Over the project cycle, USAID/SUSTAIN seconded donor-funded projects. It has taken a lot of effort to change the additional personnel, through staffing needs assessments, culture and perceptions of managers and service delivery teams to support service delivery at high-volume hospitals, and concerning data analysis and data-driven decision making. subsequently worked with District Service Commissions, the Inspiring a culture change is especially difficult given that there Health Service Commission, and hospital leadership to prioritize is no built-in accountability framework for high quality service absorption of the same personnel into the government payroll delivery nor are there highly functional management structures system. Cross-cutting service areas are important because in place throughout the health system to facilitate guidance, without proper staffing within these essential areas, the system support and accountability throughout all levels of the system. An does not function efficiently. accountability framework and related management structures and leadership that cut across all levels are essential in cultivating and sustaining a data use culture.

A–2 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Triangulation of HIV testing and linkage data to confirm Male partner involvement successful linkage to care Male partner involvement in eMTCT services is important in Some of the identified HIV clients at RRHs prefer seeking care supporting adherence to treatment for the mothers. However, and treatment from lower health facilities. It is thus important to it should not be a condition for prioritizing service delivery. periodically triangulate data and confirm that clients referred to Success in involving male partners require catering for their own these lower health facilities are still in care, but not lost to follow- health needs such as screening for non-communicable diseases up. at the ANC service units. Capturing and documenting client contact information LTFU of clients in HIV care Contact information for clients preferably should be obtained While the national program is implementing the test-and-start before or during pretest counseling. The project noted that mandate toward the virtual elimination of HIV in Uganda, the over 60% of the clients that were lost to follow up were not level of engagement among HIV-positive patients at the point traceable either by phone or through physical tracking because of first diagnosis is insufficient to keep them engaged in care. the telephone numbers and physical addresses provided were The project noticed high rates of undocumented LTFU clients not correct. Many clients, once identified HIV positive, need time due to self-transfers to lower health care facilities from the to prepare themselves psychologically and start on treatment, regional referrals that were supported. After conducting a fully and thus do not provide accurate contact information if this is approved LTFU study, the project determined the outcomes and requested after testing. predictors of LTFU among clients that were accessing care at RRHs in Uganda. Furthermore, active transfer of clients to lower Interpretation of PMTCT HMIS codes and indicators health care facilities after the decentralization of service delivery Interpretation of PMTCT HMIS codes and indicators by midwives should be encouraged and supported. remains a challenge and investment, through ongoing orientation Integration of TB services into other service delivery of midwives on indicator definitions and codes is critical for sustained improvement. This is also further aggravated by high Integration of DR-TB and TB/HIV support is feasible and turnover of midwives due to shifts to other units. considered an effective way of strengthening the quality of DR-TB care as well as the entire cascade of TB services. The INTEGRATED SERVICE DELIVERY two should not be considered separate and all health workers Integration of HIV with other services should be skilled to identify and appropriately manage and/or refer both susceptible and DR-TB cases. The integration of HIV service delivery in all service areas of healthcare facilities eliminates missed opportunities for the Coordination and management of DR-TB activities is identification of at-risk or HIV-positive individuals and providing resource-intensive and calls for close collaboration and appropriate services. The introduction/integration of HTS at all partnership with all stakeholders, especially district and sub- service delivery units at RRH and GHs (including entry points such county TB service resource personnel. as postnatal services, YCCs, ANC clinics (males), and in inpatient wards) has been shown to increase yield when coupled with Achieving TSR targets at Regional Referral Hospitals requires targeted testing through the screening for HIV exposure before collaborating with District TB and Leprosy Supervisors from testing. within the region to supervise the TB units, follow up and track patients as well as monitoring lower level ambulatory sites. Reducing missed opportunities for identifying exposed infants IMPROVING QUALITY OF CARE Reducing missed opportunities to identify exposed infants at Quality Improvement RRHs has been successful through integration of EID services The uptake of use of QI methods in routine service delivery is at various entry points, including YCC, and linking identified gradual, variable, and requires consistent technical support. mother-baby pairs to the Mother-Baby Care Points for quality It is also paramount to involve the hospital management for services. Simple verification of EID codes on child health cards leadership, ownership and sustainability of QI approaches. at immunization (YCC) clinics significantly reduces the number of children that would otherwise be missed.

September 30, 2018 | Final Report A–3 Clearly established quality goals are vital to support management SUPPLY CHAIN and tracking of performance in addition to processes and Stock monitoring systems improvements. What is unwritten is not easily tracked. All health units should have clear quality goals that are measured Monthly stock monitoring at stores and user-department levels periodically for improvement. The National QI Framework in each hospital reduces losses due to expiry, prevents stock- provides a strong basis from which the MoH can operationalize outs and enables re-distribution. This also informs accurate such quality goals. With the strong presence of USAID and CDC order submission and pulling of the right commodity types and partners working across all regions of the country, this step will quantities from the central/ national supply warehouses. contribute strongly to institutionalizing a culture of quality among Utilization of credit line budget all healthcare providers. Functionalizing the multidisciplinary MTC prevents wastage, Scale-up and dissemination of best practices inappropriate procurement planning, poor prescribing and It is critical to facilitate deliberate collaboration with other dispensing practices, hence saving funds for other critical implementing mechanisms to achieve quick learning through commodities from an already constrained budget. The MTC is the exchange of best practices. The implementing environment responsible for setting up the hospital formulary/ list of medicines in Uganda is similar across regions; what works in one region and supplies that meet the needs of the patients accessing care can be scaled up in another. The USAID/SUSTAIN and ASSIST at the said facility. Without this, the procurement plan is derived projects developed a substantial body of documented best from data that is not accurate and leads to wastage. practices and QI change packages that could be implemented to scale by other implementing entities. LABORATORY SYSTEMS Laboratory service units To promote rapid and effective scale-up, regionally-based projects need a platform to regularly share best practices, which Laboratory service units for large hospitals have historically helps to reduce the time involved for each project to learn from worked independent of/parallel to the mainstream hospital the start. The Ministry of Health can and ought to play a critical supervision structure, leading to increased staff absenteeism and role in establishing the sharing and ensuring that best practices poor service delivery. The USAID/SUSTAIN project demonstrated are indeed implemented and measured, that regular supervision, oversight and support from healthcare facility management teams is critical in motivating laboratory staff to improve productivity, set and achieve performance goals and sustain results.

USAID Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) Project

+256 (0) 312-307-300 / +256 (0) 312 -202-045/6 Plot 7, Ntinda Crescent, Naguru, Kampala, Uganda www.sustainuganda.org

A–4 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally 371 371 539 539 986 986 17,404 51,358 19,953 86,928 86,928 45,680 88,824 1,776,723 1,952,366 Grand total 47,576 (53.6%) 31 31 120 216 216 120 FY17 8,701 8,701 8,323 3,235 3,295 9,068 8,690 10,476 (95.8%) 246,548 272,255 Oct-2016 Sep-2017 90 90 162 162 323 323 FY16 3,576 9,605 5,592 11,705 10,180 10,357 10,357 10,932 (93.1%) 354,133 322,903 Oct-2015 Sep-2016 0 0 27 27 235 235 FY15 4,517 3,696 11,002 14,037 14,037 12,999 13,261 14,299 411,857 (92.7%) 445,109 Oct-2014 Sep-2015 0 0 46 46 223 223 FY14 9,801 3,082 3,309 14,753 15,006 15,006 15,275 15,022 (98.3%) 399,789 368,591 Oct-2013 Sep-2014 0 0 0 177 177 246 246 423 FY13 8,374 3,527 3,528 (2.9%) 14,380 14,380 14,803 253,702 223,893 Oct-2012 Sep-2013 0 0 0 0 0 0 FY12 12,979 12,979 12,979 109,474 122,453 Oct-2011 Sep-2012 0 0 0 0 0 0 FY11 11,468 11,468 11,468 93,457 104,925 Oct-2010 Sep-2011 NA NA NA NA NA NA NA NA NA NA Positive Negative postnatal 1st test1st during Breastfeeding mothers testing HIV+ Number of DNA PCR results that returned from the lab that are positive Breastfeeding mothers testing HIV+ Male partners tested and received HIV results who tested HIV+ in PMTCT Exposed infants tested for HIV months below 18 (by PCR) 1st Number Individuals of who tested HIV positive Number individuals newly of tested HIV positive Number of Individuals who received HIV test results disaggregated by age and sex Breastfeeding mothers tested HIV for Male partners tested and received HIV results who tested HIV+ in PMTCT Number of DNA PCR results that returned from the lab that are positive Number Individuals of who tested HIV positive Male partners tested and received HIV results in eMTCT Name in the database

Number of individuals tested HIV + HTS_TST_POS Number of Individuals HIV+ tested newly HTS_TST_POS Performance Indicators HIV TESTING AND COUNSELING Number of individuals who received Testing and Counselling (T&C) services for HIV outside PMTCT-settings and received their test results HTS_TST - ANNEX 2 – FY 2017 FY 2010 Summary Table Indicator Performance

September 30, 2018 | Final Report A–5 289 6,143 6,315 5,307 87.2% 22,198 14,622 52,771 39,700 306,307 306,307) Grand total 8.6% (26,361 / 0 0 15 FY17 9.5% 1,457 1,095 6,420 8,323 2,589 94.6% 38,821 38,821) (3,699 / Oct-2016 Sep-2017 0 0 35 FY16 9.3% 2,718 1,734 1,264 6,733 9,605 88.2% 43,299 (4,017 / 43,299) Oct-2015 Sep-2016 0 74 150 FY15 9.6% 7,573 1,470 9,477 2,541 74.1% 12,999 42,689 (4,085 / 42,689) Oct-2014 Sep-2015 0 62 9% FY14 1,739 1,921 1,990 8,706 11,151 89.1% 41,481 14,753 41,481) (3,722 / Oct-2013 Sep-2014 0 0 103 984 FY13 8.9% 7,091 1,681 5,919 2,216 83.5% 45,138 45,138) (4,000 / Oct-2012 Sep-2013 0 0 0 FY12 6.2% 2,860 45,888 45,888) (2,860 / Oct-2011 Sep-2012 0 0 0 FY11 8.1% 3,978 48,991 48,991) (3,978 / (3,978 / Oct-2010 Sep-2011 NA NA NA NA NA NA NA NA they were facility other Successfully Successfully identified identified HIV+ than one where where than one linked to another Number of HIV positive pregnant women attending ANC 1st visit with a known HIV positive status (Count only TRRK) HIV+ Pregnant women who knew their HIV status before ANC the 1st (HIV+ TRRK) Pregnant women tested HIV+ for time the 1st during this pregnancy (TRR) at any visit ANC visit 1st for women Number individuals newly of tested HIV positive Individuals successfully linked to same facility where they were identified HIV positive Individuals that tested HIV+ linked to care and treatment at same facility that were enrolled into HIV care Pregnant women testing HIV+ on a retest (TRR+) Name in the database Newly identified HIV+ clients that did not reach the same facility ART clinic (for enrollment) after referral who are followed up and had a documented outcome Performance Indicators PMTCT % of pregnant women who tested HIV positive in ANC - PMTCT_STAT_POS Percent of newly newly of Percent identified HIV+ clients linked to HIV care services

A–6 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally 371 289 796 7,014 9,747 6,143 7,407 5,307 71.1% 92.6% 17,404 11,431 14,622 10,233 16,078) 26,361) (11,431 / (11,431 (24,418 / / 26,361) Grand total 103.9% (27,387 (27,387 103.9% 0 0 0 15 31 83 FY17 2,515 1,020 1,095 1,233 2,589 3,295 89.1% 1,224) 95.6% 3,699) 3,699) 100.7% (1,233 / (3,535 / (3,295 / Oct-2016 Sep-2017 0 0 0 35 90 110 89% FY16 1,114 2,718 1,264 1,350 3,576 2,604 90.1% 4,017) 4,017) 1,499) 92.6% (3,718 / (1,350 / (3,576 / Oct-2015 Sep-2016 0 0 0 74 27 152 FY15 1,470 1,501 2,541 1,348 3,696 2,343 87.1% 1,723) 90.4% 90.5% 4,085) 4,085) (1,501 / (3,691 / (3,696 / Oct-2014 Sep-2015 0 0 62 46 170 289 93% FY14 1,619 1,727 1,739 1,921 1,843 3,309 2,017) 3,722) 3,722) 85.6% 88.9% (1,727 / (3,462 / (3,309 / Oct-2013 Sep-2014 0 0 177 103 473 281 79% FY13 1,152 2,195 1,681 2,216 3,528 2,082 92.7% 92.7% 2,777) 88.2% 4,000) 4,000) (2,195 / (3,707 / (3,528 / Oct-2012 Sep-2013 0 0 0 0 0 0 0 0 FY12 4,244 3,501 2,055 2,860 71.9% 2,860) 2,860) 2,860) 122.4% 148.4% (4,244 / (3,501 / (2,055 / Oct-2011 Sep-2012 0 0 0 0 0 0 0 0 FY11 3,513 1,370 3,978 5,030 34.4% 3,978) 3,978) 3,978) 88.3% 126.4% (1,370 / (3,513 / (5,030 / Oct-2010 Sep-2011 NA NA NA NA NA NA NA NA NA NA retest retest 1st time and1st 1st time and1st Pregnant women tested HIV+ for time the 1st during this pregnancy (TRR) at any visit Number of HIV positive pregnant women attending ANC 1st visit with a known HIV positive status (Count only TRRK) Pregnant women testing HIV+ on a retest (TRR+) Exposed infants tested for HIV months below 18 (by PCR) 1st HIV+ Pregnant women who knew their HIV status before ANC the 1st (HIV+ TRRK) Breastfeeding mothers testing HIV+ Infants born to HIV positive women who received an HIV-test months within 12 of birth by test type (count only first test) Number of pregnant women enrolled into care reporting the during period Name in the database HIV positive pregnant women Initiated on ARVs for EMTCT (ART) Number of mothers tested HIV positive in maternity Number of HIV positive pregnant women who received antiretrovirals to reduce risk of mother- transmission child to HIV positive pregnant women already on ART before ANC 1st visit (ART- K) Performance Indicators EARLY INFANT DIAGNOSIS INFANT EARLY infants of Percentage born to HIV+ women who had a virologic HIV test done within months 12 of birth - PMTCT_EID Percent of HIV-positive HIV-positive of Percent newly pregnant women enrolled in HIV care services % of HIV-positive who pregnant women received ART to reduce the risk of mother- to-child-transmission (MTCT) during pregnancy - PMTCT_ART

September 30, 2018 | Final Report A–7

371 289 796 986 563 7,014 6.3% 6,143 5,307 62.7% 93.6% 17,404 17,263 14,622 24,650 26,326 27,528) 26,326) (17,263 / (17,263 (24,650 / Grand total (1,549 / 24,418)

0 0 0 15 31 83 120 FY17 3.6% 1,095 3,429 2,589 2,644 3,295 3,660 (120 / (120 3,813) 93.7% 69.3% 3,295) 3,660) (3,429 / (2,644 / Oct-2016 Sep-2017

0 0 0 35 90 110 162 FY16 4.5% 2,718 4,214 1,264 3,576 3,981 2,845 (162 / 67.5% 4,217) 4,214) 3,576) 94.5% (3,981 / (2,845 / Oct-2015 Sep-2016

0 0 0 74 27 152 235 98% FY15 6.4% 1,470 4,078 2,541 2,956 3,696 3,998 (235 / 69.3% 4,078) 4,264) 3,696) (2,956 / (3,998 / Oct-2014 Sep-2015

0 0 0 62 46 170 223 97% FY14 6.7% 1,739 1,921 3,768 2,366 3,309 3,656 (223 / 60.1% 3,768) 3,938) 3,309) (3,656 / (2,366 / Oct-2013 Sep-2014

0 0 0 7% 177 103 281 246 94% FY13 2,310 1,681 2,216 3,528 3,466 3,686 (246 / 51.8% 3,528) 4,458) 3,686) (2,310 / (3,466 / Oct-2012 Sep-2013

0 0 0 0 0 0 0 272 FY12 7.8% 2,311 2,860 3,461 3,501 3,669 3,501) 80.8% 94.3% (272 / 3,669) 2,860) (2,311 / (3,461 / Oct-2011 Sep-2012 0 0 0 0 0 0 0 291 46% FY11 8.3% 3,513 1,831 3,978 3,251 2,659 (291 / 3,513) 81.8% 3,251) 3,978) (1,831 / (2,659 / Oct-2010 Sep-2011 NA NA NA NA NA NA NA NA NA NA NA NA NA Pregnant women tested HIV+ for time the 1st during this pregnancy (TRR) at any visit Breastfeeding mothers testing HIV+ Number of mothers tested HIV positive in maternity Number of HIV exposed infants started on CPT within two months of birth Pregnant women testing HIV+ on a retest (TRR+) Number of HIV positive pregnant women attending ANC 1st visit with a known HIV positive status (Count only TRRK) HIV+ Pregnant women who knew their HIV status before ANC the 1st (HIV+ TRRK) Exposed infants tested for HIV months below 18 (by PCR) 1st Infants born to HIV positive women who received an HIV-test months within 12 of birth by test type (count only first test) Name in the database Number of DNA PCR results that returned from the lab that are positive HIV exposed babies given ARVs Live births to HIV+ mothers in unit Number of infants born to HIV- positive women who received an HIV- test months within 12 of birth and their test result was positive Percentage of infants infants of Percentage born to HIV-positive pregnant women who were started on Cotrimoxazole (CTX) prophylaxis within two months of birth Performance Indicators D.3. Percent of HIV- of Percent D.3. exposed infants given ARV prophylaxis (at birth) infants of Percent D.4. born to HIV-positive mothers and are found to be HIV-infected - PMTCT_EID_POS

A–8 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally 89 710 106 288 383 383 2,374 2,757 0.69% 37,396 81,056 118,139 118,139 118,835 Grand total 0 0 12 133 327 327 327 265 FY17 0.59% 24,467 24,656 24,794 24,656 Oct-2016 Sep-2017 5 47 23 56 56 56 45 FY16 0.39% 12,876 12,932 12,929 12,932 12,985 Oct-2015 Sep-2016 5 75 89 143 143 FY15 0.44% 18,242 18,621 18,621 18,242 Oct-2014 Sep-2015 17 213 442 442 FY14 0.51% 45,366 45,365 45,365 45,366 Oct-2013 Sep-2014 67 244 FY13 1,789 1,789 1.84% 17,069 17,069 16,944 16,944 Oct-2012 Sep-2013 FY12 Oct-2011 Sep-2012 FY11 Oct-2010 Sep-2011 NA NA NA SMC Clients Counseled, and Tested Circumcised SMC Clients Counseled, Tested, and Circumcised for HIV at SMC site and test result negative is Number of clients counseled, tested, and received HIV results as part of MMC package SMC clients who experienced one or more adversesevere events (AE) SMC Clients Counseled, Tested, and Circumcised for HIV at SMC site and test result positive is Number of clients counseled, tested, and received HIV results as part of MMC package HIV+ tested who SMC Clients Counseled, Tested, and Circumcised for HIV at SMC site and test result positive is Number of Clients whose HIV test results is positive and were linked to care Number of males circumcised, by age group and technique for HIV at SMC site who had a positive test result and where linked to care SMC clients who experienced one or more moderate adverse events (AE) Name in the database Individuals counselled and tested for HIV as a first step before surgery Number of males circumcised surgically or by medical device that experienced at least one moderate or severe adverse event(s) (AEs) tested who Individuals positive and were linked care to Tested positive Tested Performance Indicators VOLUNTARY MEDICAL MALE CIRCUMCISION (VMMC) Number of males circumcised as part of the voluntary medical male circumcision (VMMC) for HIV prevention program within the reporting period - VMMC_CIRC

September 30, 2018 | Final Report A–9 5 63 1,117 8,687 37,231 15,521 12,062 20,227 33,990 127,786 Grand total FY17 36,156 13,836 22,320 Oct-2016 Sep-2017 FY16 1,117 6,391 11,670 18,061 Oct-2015 Sep-2016 5 63 FY15 8,687 15,521 24,276 Oct-2014 Sep-2015 FY14 43,178 10,395 32,783 Oct-2013 Sep-2014 FY13 6,115 1,667 4,448 Oct-2012 Sep-2013 FY12 Oct-2011 Sep-2012 FY11 Oct-2010 Sep-2011 Second follow Second follow Second follow Second follow First follow up First follow up First follow up First follow up visit/ 48 Hours visit/ 48 Hours visit/ 48 Hours visit/ 48 Hours up visit / 7 days up visit / 7 days up visit / 7 days up visit / 7 days Name in the database Number of clients circumcised who returned for follow up visit within 6 weeks of MC procedure (Prepex) Number of clients circumcised who returned for follow up visit within 6 weeks of MC procedure (Surgical) Number of clients circumcised who returned for follow up visit within 6 weeks of MC procedure (Surgical) Number of clients circumcised who returned for follow up visit Number of Clients Circumcised who Returned for Follow Up Visit at 7 days after a device-based SMC Procedure Number of clients circumcised who returned for follow up visit Number of clients circumcised who returned for follow up visit within 6 weeks of MC procedure (Prepex) Number of Clients Circumcised who Returned for Follow Up Visit within 6 weeks of SMC Procedure Number of Clients Circumcised who Returned for Follow Up Visit within 6 weeks of SMC Procedure Performance Indicators Individuals who were followed up in the first 48 hours and at 7 days

A–10 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally 88 292 938 308 2,193 1,023 4,842 66.7% (8.2%) 59,230 20,238 38,992 59,230 88,824) (59,230 / Grand total 81 115 171 367 FY17 3,160 5,771 8,931 8,931 (4.1%) 98.5% 9,068) (8,931 / Oct-2016 Sep-2017 133 109 164 406 FY16 4,303 2,283 6,586 6,586 60.2% (6.2%) 10,932) (6,586 / Oct-2015 Sep-2016 191 202 798 405 FY15 6,142 3,324 9,466 9,466 66.2% (8.4%) 14,299) (9,466 / Oct-2014 Sep-2015 567 223 200 990 FY14 7,108 3,378 68.6% (9.4%) 10,486 10,486 15,275) (10,486 / Oct-2013 Sep-2014 184 245 276 705 FY13 2,607 6,828 9,435 9,435 63.7% (7.5%) 14,803) (9,435 / Oct-2012 Sep-2013 88 247 190 283 808 FY12 4,971 8,067 3,096 8,067 (10%) 62.2% 12,979) (8,067 / Oct-2011 Sep-2012 0 118 768 292 358 FY11 6,259 3,869 2,390 6,259 54.6% 11,468) (12.3%) (6,259 / Oct-2010 Sep-2011 NA <1 <2 Male 1-<2 1-<5 2-<5 5-<15 Female Number of new clients started on ART at this facility quarter the during Number of new clients started on ART at this facility quarter the during Number of new clients started on ART at this facility quarter the during Children Number of new clients started on ART at this facility quarter the during Number of new clients started on ART at this facility quarter the during Number of new clients started on ART at this facility quarter the during Number of new clients started on ART at this facility quarter the during Name in the database Number of new clients started on ART at this facility quarter the during Number of new clients started on ART at this facility quarter the during % of all HIV positive individuals identified in SUSTAIN supported onto initiated sites therapy antiretroviral Performance Indicators (ART)Anti-Retroviral Therapy Number of adults and children newly enrolled on antiretroviral therapy (ART) - TX_NEW

September 30, 2018 | Final Report A–11

0 0 3,701 1,040 6,056 17,672 89.2% 15,257 34,778 53,532 53,532 38,995 35,860 38,995) (34,778 / Grand total 26,054 (48.7%) 26,054 146 534 FY17 3,324 4,004 (7.5%) 17,672 89.2% 34,778 53,532 53,532 38,995 35,860 38,995) Oct-2016 (34,778 / Sep-2017 147 598 FY16 3,553 4,298 88.7% (7.8%) 31,981 18,328 28,352 55,268 55,268 36,940 31,981) Oct-2015 (28,352 / Sep-2016 244 900 FY15 3,540 4,684 (8.5%) 18,352 36,638 54,990 54,990 Oct-2014 Sep-2015 213 840 FY14 2,646 3,699 27,897 41,379 41,379 (8.9%) 13,482 Oct-2013 Sep-2014 829 290 FY13 2,194 3,313 11,712 35,141 35,141 (9.4%) 23,429 Oct-2012 Sep-2013 FY12 3,247 3,247 10,780 19,308 30,088 30,088 (10.8%) Oct-2011 Sep-2012 FY11 8,571 2,809 2,809 24,231 24,231 15,660 (11.6%) Oct-2010 Sep-2011 NA <1 NA <2 ml) <15 Male 1-<5 2-<5 5-<15 Female Undetectable (<1000 copies/ (<1000 Number of adult and paediatric ART patients with a viral load result documented in the patient medical record within the months past 12 Number of adult and paediatric ART patients with a viral load result documented in the patient medical record within the months past 12 Children Number of adults and children receiving ARVs, by age and sex Number of adults and children receiving ARVs, by age and sex Name in the database Number of adults and children receiving ARVs, by age and sex Number of adults and children receiving ARVs, by age and sex Number of adults and children receiving ARVs, by age and sex Number of adults and children receiving ARVs, by age and sex Number of adults and children receiving ARVs, by age and sex # of adults and children with HIV infection (ART) therapy antiretroviral receiving Number of adults and children receiving ARVs, by age and sex Number of adults and children receiving ARVs, by age and sex Performance Indicators laboratoryor information systems (LIS) within the past months 12 with a suppressed viral load (<1000 copies/ml), TX_PVLS Number of adults and children with HIV receiving infection therapy antiretroviral (ART) - TX_CURR Percentage of ART of Percentage patients with a viral load result documented in the medical record and/

A–12 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally 77% 95% 15,418 11,873 41,321 41,321 14,652 16,992 16,992 53,600 53,532 53,600 (41.1%) 15,418) 15,418) (11,873 / (11,873 (14,652 / Grand total 98% FY17 2,479 2,087 5,275 5,275 2,479 2,280 2,234 (47%) 91.5% 2,280) 2,280) 53,600 53,532 53,600 (2,087 / (2,234 / Oct-2016 Sep-2017 FY16 2,156 2,615 2,478 2,445 5,985 5,985 2,445 2,615) 2,615) 82.4% 94.8% 59,006 59,006 55,268 (2,156 / (2,478 / (40.9%) Oct-2015 Sep-2016 FY15 7,189 7,189 3,125 2,537 2,991 2,985 2,985 2,985 3,125) 3,125) 81.2% 95.7% 60,245 60,245 54,990 (41.5%) (2,991 / (2,537 / Oct-2014 Sep-2015 FY14 6,316 6,316 2,478 2,478 3,025 2,962 2,368 97.9% 3,025) 78.3% 3,025) 47,897 47,897 41,379 (2,962 / (2,368 / (39.2%) Oct-2013 Sep-2014 FY13 2,170 6,120 6,120 2,170 1,942 2,758 2,860 67.9% 96.4% 35,141 2,860) 2,860) 44,610 44,610 (1,942 / (2,758 / (35.5%) Oct-2012 Sep-2013 783 FY12 1,513 1,229 2,400 5,380 5,380 2,400 (783 / 1,513) 1,513) 81.2% 51.8% 39,079 39,079 30,088 (1,229 / (44.6%) Oct-2011 Sep-2012 FY11 2,035 5,056 5,056 2,035 32,521 32,521 24,231 (40.2%) Oct-2010 Sep-2011 NA NA NA NA NA NA Number of new bacteriologically confirmed TB cases, PTB (P-BC) Number of TB patients recorded in the TB reporting the during register period Number of TB patients registered in the TB register during the reporting period who are started or continued with ARV Number of TB patients registered during the reporting period with a recorded HIV+ result who started or continued receiving Cotrimoxazole prophylaxis Name in the database Number of TB patients recorded in the TB register during the reporting period that had an HIV+ test result Number of HIV-positive children and adults receiving a minimum of one HIV clinical service, by age and sex Total number of registered new and TB cases, relapsed during the reporting period # of new sputum smear positive pulmonary TB cases registered Number of HIV positive adults and children who received at least one of the following during the reporting period: clinical assessment (WHO staging) OR CD4 count OR viral load Performance Indicators CARE HIV Number active on ART TB/HIV TB/HIV of Percent co- infected clients receiving CPT Percentage of HIV- of Percentage positive new and TB registered relapsed cases on ART during TB treatment - TB_ART

September 30, 2018 | Final Report A–13 5 749 142 159 142 156 165 106 164 289 271 335 335 8,702 8,244 6,325 3,593 16,946) Grand total 58.5% (9,918 / 0 5 24 24 21 95 95 96 85 96 43 43 749 76% FY17 1,428 1,878 1,878) (1,428 / Oct-2016 Sep-2017 0 31 70 31 70 30 50 53 94 105 105 FY16 1,462 2,057 71.1% 2,057) (1,462 / Oct-2015 Sep-2016 0 42 32 42 32 40 46 33 63 34 46 FY15 1,332 1,944 1,944) 68.5% (1,332 / Oct-2014 Sep-2015 0 47 65 68 54 45 45 68 33 54 34 FY14 1,180 1,634 1,634) 72.2% (1,180 / (1,180 Oct-2013 Sep-2014 6 0 6 34 34 923 FY13 1,189 (923 / 1,189) 77.6% Oct-2012 Sep-2013 0 0 0 FY12 4,027 2,248 4,027) 55.8% (2,248 / Oct-2011 Sep-2012 0 0 0 FY11 4,217 1,345 4,217) 31.9% (1,345 / Oct-2010 Sep-2011 NA NA NA NA NA NA NA NA NA NA NA NA NA NA Number of patients detected with MDR TB Number of DR-TB patients detected with malnutrition Number of DR-TB patients provided with RUTF Number of DR TB cases with negative sputum smear at month 5 or 6 of treatment # of patients detected with DR TB Number of contacts of DR TB Patients screened for TB Name in the database Number of contacts of DR TB Patients diagnosed TBwith Number of persons started on TB treatment 8 months before the reporting period New Smear positive TB Patients registered 12- months15 before end of reporting period Number of DR TB cases with negative sputum smear at 6 months of treatment Number of DR-TB/HIV co- infected patients CPTreceiving Number of DR-TB/HIV co- infected patients ARTreceiving Number of DR-TB patients registered during the quarter with an HIV test result recorded Number of TB patients who got cured or completed TB treatment New Smear positive TB Patients registered 12- months15 before end of reporting period who completed treatment cured or Performance Indicators TB Drug-Resistant Number of patients detected with DR-TB Contacts identified and screened MDR-TB patients had severe acute malnutrition and all were enrolled on ready-to-use-therapeutic feeding Contacts identified, screened and diagnosed with TB TB Treatment Success Success TB Treatment Rate (for new sputum smear-positive TB cases) DR-TB/HIV co-infected patients started on CPT DR-TB/HIV co-infected patients started on ART MDR-TB patients with a HIVdocumented status Sputum conversion of DR TB cases

A–14 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally

57 667 19% 4,739 1,996 3,630 3,668 57.1% 41.8% 18,149 34.3% 98.9% 42,892 52,930 53,600 18,149) 52,987) 53,600) (18,149 / (18,149 (10,365 / (52,987 / Grand total (4,335 / 10,365) / (4,335 57 6% 750 FY17 5.9% 1,143 3,137 1,052 3,137) 57.4% 57.4% 1,802) 63.4% 63.4% 98.9% 52,930 53,600 (1,143 / (1,143 (3,137 / (3,137 (1,802 / 52,987) 53,600) Oct-2016 (52,987 / Sep-2017 6% 787 FY16 3,174 6.2% 1,875 3,313 1,504 3,313) 91.3% 80.4% 56.5% 2,662) 50,694 59,006 (1,504 / (3,313 / 59,006) 53,868) (2,662 / Oct-2015 (53,868 / Sep-2016 9% 475 FY15 2,114 8.8% 1,021 4,972 52.1% 39.4% 4,972) 94.2% 2,589) 56,759 60,245 (1,021 / 56,759) 60,245) (4,972 / (2,589 / Oct-2014 (56,759 / Sep-2015 0 667 543 11% FY14 1,996 4,630 (667 / 10.8% 89.6% 26.3% 54.8% 4,630) 2,539) 47,897 42,892 47,897) 42,892) (4,630 / (2,539 / Oct-2013 (42,892 / Sep-2014 0 0 5% 773 FY13 5.1% 2,097 (773 / 2,097) 92.9% 36.9% 41,459 44,610 41,459) 44,610) (2,097 / (41,459 / Oct-2012 Sep-2013 0% FY12 39,079 Oct-2011 Sep-2012 ( / 39,079) 0% FY11 32,521 Oct-2010 Sep-2011 ( / 32,521) NA NA NA NA NA NA NA NA NA Cured Number of HIV+ clients with severe malnutrition given RUTF during the quarter 3 months ago documented to have cured Number of HIV+ clients with severe malnutrition given RUTF during the quarter 3 months ago with documented a outcome Number active on ART assessed for malnutrition at their visit in quarter Number active on pre-ART care assessed for malnutrition at their visit last in quarter Number of HIV+ clients who have been MUAC using malnutrition assessed for Number of HIV-positive children and adults receiving a minimum of one HIV clinical service, by age and sex Name in the database Number of HIV+ clients newly identified with RUTF given malnutrition moderate Number of HIV+ clients newly identified with severe malnutrition given RUTF Number of clients under HIV care identified malnourished and provided with RUTF Number of HIV+ clients newly identified with moderate and severe malnutrition Cured Performance Indicators Nutrition People of Percentage Living with HIV (PLHIV) in care and treatment who were nutritionally assessed Percent of HIV-positive HIV-positive of Percent clients identified to be malnourished acutely Proportion of clinically undernourished PLHIV who received therapeutic or supplementary food

September 30, 2018 | Final Report A–15

25% 74,113 74,113 74,113 46.7% 98.4% 98.4% 11,806 27,901 18,720 18,692 18,558 33,851 34,406 39,707) 34,406) (18,558 / (33,851 / Grand total 30% FY17 7,961 3,468 6,205 40.1% 11,342 15,490 10,843 26,333 26,333 26,333 104.6% 15,490) 10,843) (6,205 / (11,342 / (11,342 Oct-2016 Sep-2017 26% FY16 9,165 5,675 4,026 9,323 6,223 50.1% 12,411 9,323) 98.3% 21,734 21,734 21,734 12,411) (9,165 / (6,223 / Oct-2015 Sep-2016 21% FY15 4,171 7,996 8,725 3,977 8,206 3,534 94.1% 7,996) 8,725) 52.2% 16,721 16,721 16,721 (4,171 / (4,171 (8,206 / Oct-2014 Sep-2015 16% FY14 5,138 5,515 3,810 1,522 1,959 9,325 9,325 9,325 3,694 51.4% 5,515) 3,810) 93.2% 93.2% (5,138 / (1,959 / Oct-2013 Sep-2014 FY13 3,555 Oct-2012 Sep-2013 FY12 Oct-2011 Sep-2012 FY11 Oct-2010 Sep-2011

<6 m >6 m above feeding Exclusive No longer breastfeeding breastfeeding 6 months and Complementary Number of infants born to HIV-Positive pregnant care point, attendingwomen mother-baby the typedisaggregated by feeding of Number of infants born to HIV-Positive pregnant care point, attendingwomen mother-baby the typedisaggregated by feeding of Number of infants born to HIV-Positive pregnant care point, attendingwomen mother-baby the typedisaggregated by feeding of HIV+ mothers initiating breastfeeding within 1 hour after delivery Number of infants born to HIV-Positive pregnant care point, attendingwomen mother-baby the typedisaggregated by feeding of Number of infants born to HIV-Positive pregnant care point, attendingwomen mother-baby the typedisaggregated by feeding of Number of infants born to HIV-Positive pregnant care point, attendingwomen mother-baby the typedisaggregated by feeding of Number of infants born to HIV-Positive pregnant care point, attendingwomen mother-baby the typedisaggregated by feeding of Number of infants born to HIV-Positive pregnant care point, attendingwomen mother-baby the typedisaggregated by feeding of Name in the database Number of infants born to HIV-Positive pregnant care point, attendingwomen mother-baby the typedisaggregated by feeding of Introduced to foods complementary No breastfeeding longer Initiated breasfeeding within an hour after birth Performance Indicators Exclusively breastfeeding Exclusively

A–16 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally ANNEX 3 Project Publications

Technical area Posters and abstracts AFHS Establishing Adolescent Corners Increases Uptake of Health Services AFHS Establishing Adolescent-friendly Support Groups for Youths Living with HIV/AIDS: Experiences from Jinja and Soroti Hospitals AFHS Establishing Adolescent Corners Increases Uptake of Health Services: Experience from Moroto Regional Referral Hospital AFHS Provision of adolescent friendly services increases access to HIV Testing services at public health facilities: Experience of Mbale Regional Referral Hospital AFHS Functionalizing adolescent friendly services through collaborative learning: A case of six regional referral hospitals in Uganda AFHS Transitioning HIV-positive Adolescents to Adult Care at Public Health Facilities AFHS Establishment of Adolescent Friendly Health Services Enhances Health Service Accessibility and Utilization: Experience from Kabale Regional Referral Hospital Grants Grants to Support Hospital Operations and Human Resources for Health HIV Care and Reducing Client Waiting time at Lira RRH HIV Clinic Treatment HIV Care and Improving Retention Rates of HIV Clients in Hoima RRH Treatment HIV Care and Actualization of Test and Treat Policy at Lira Regional Referral Hospital Treatment HIV Care and Approaches to strengthening follow up and retention in care at public health facilities in Treatment Uganda HIV Care and Building Capacity of Health Facilities’ Multidisciplinary Teams to Manage Non-suppressed HIV Treatment Positive Clients Through Provision of Intensive Adherence Counseling (IAC) HIV Care and Improved Retention of HIV+ Patients on ART (Mubende Regional Referral Hospital) Treatment HIV Care and Improving HIV Service Delivery -Use of a Client Flow Survey Treatment HIV Care and Building Capacity of Health Facilities’ Multidisciplinary Teams to Manage Non-suppressed HIV Treatment Positive Clients Through Provision of Intensive Adherence Counseling (IAC) HIV Care and Approaches to strengthening follow up and retention in care at public health facilities in Treatment Uganda HIV Care and Implementing the “Test and Treat Policy:” Increasing Access to Quality HIV Care Services at Treatment 11 USAID/SUSTAIN Supported Hospitals in Uganda

September 30, 2018 | Final Report A–17 Technical area Posters and abstracts HIV Care and Reducing daily clinic workload using a client appointment system at Kabale Regional Referral Treatment Hospital HIV Care and Scaling up access to highly active anti-retroviral therapy among children at Lira Regional Treatment Referral Hospital HIV Care and Improving access to ART in HIV-positive children using collaborative learning Treatment HMIS How a streamlined file flow system improves estimates for identifying lost clients: The case of Mubende Regional Referral Hospital HRH Identifying and Addressing Human Resources Requirements for Sustainable and High-Quality HIV/AIDS Care and Treatment in Uganda HRH Assessment of workload and workforce in addressing availability of health workers HRH Retention of Health Workers Seconded to Government Health facilities in Uganda following Transition to Public Service Pay Scales HRH Reducing daily clinic workload using a client appointment system at Kabale Regional Referral Hospital HTS Improving the numbers of children accessing HIV testing and Counseling (HTC) at Soroti Regional Referral Hospital (RRH) in Uganda HTS Improving the numbers of clients accessing HIV testing and Counseling (HTC) at Regional Referral Hospitals in Uganda LAB Improving Medical Equipment Maintenance through Strengthening Workshops in Uganda Lab Improving the Quality of laboratory services in Uganda through SLMTA implementation Lab Increasing Participation of Public Hospital Laboratories in External Quality Assurance Schemes: Small Changes Yield Improvement Lab Using Quality Improvement Interventions to Improve Laboratory Services at Public Healthcare Facilities in Uganda LAB Improvement in ISO15189 quality standards rating towards laboratory accreditation at regional referral hospitals in Uganda through SLMTA implementation Nutrition Increasing Proportion of Clients Assessed for Nutritional Status at the ART Clinic (Jinja Regional Referral Hospital) Nutrition Building capacity of hospitals in Uganda to integrate nutrition assessment and management of malnourished clients into HIV care Nutrition Growth Monitoring and Promotion to Prevent Malnutrition Among HIV Exposed Infants Nutrition Strengthening Nutrition Systems at Mother-Baby Care Points to Contribute to Elimination of Mother-To-Child Transmission of HIV Nutrition Growth Monitoring and Promotion to Prevent Malnutrition Among HIV Exposed Infants eMTCT Improving HIV exposed infants’ final outcome through birth cohort enrollment and monitoring at regional referral hospitals in Uganda

A–18 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Technical area Posters and abstracts eMTCT Improving HIV exposed infants’ final outcome through birth cohort enrollment and monitoring at regional referral hospitals in Uganda eMTCT Increasing Male Partner Engagement in Elimination of Mother-To-Child Transmission of HIV (eMTCT) in Uganda: Case Study of Mbale Regional Referral Hospital eMTCT The 24–Month Incidence of HIV Infection, Loss to Follow-up and Mortality Among Exposed Infants at Referral Hospitals in Uganda QI Quality Improvement interventions improve the Quality of Laboratory services at public health facilities in Uganda Quality Using Multi-Disciplinary Quality Improvement Teams to Strengthen the Continuum of Care for Improvement HIV Services at Hospital Level in Uganda Supply Chain Engaging public healthcare facilities to improve the availability of HIV-related commodities among children at regional referral hospitals in Uganda Supply Chain Use of Simple, Low Cost Innovations to Improve Availability of HIV-related Commodities at Public Hospitals in Uganda TB Improving Sputum Follow-up Among TB Patients on Treatment at Moroto RRH Using Continuous Quality Improvement TB Improving Sputum Follow-up Among TB Patients on Treatment at Moroto RRH Using Continuous Quality Improvement TB Using Continuous Quality Improvement Approaches to Identify Facility-Based Innovations for Increasing Retention of TB/HIV Co-Infected Patients on Treatment in Uganda TB Early Treatment Outcomes for the First Cohort of Patients Initiated on Pulmonary Multi-drug Resistant Tuberculosis Treatment at Public Regional Referral Hospitals in Uganda VMMC Improving Delivery and Quality of Voluntary Medical Male Circumcision Services at 14 Public Hospitals in Uganda VMMC Leveraging QI Approaches to Improve Follow-up of Safe Male Circumcision VMMC Improving post-operative follow-up in the circumcision program at Masaka Regional Referral Hospital VMMC Reducing Adverse Events for Clients Receiving Safe Male Circumcision Services (Gulu Regional Referral Hospital) VMMC Improving Delivery and Quality of Voluntary Medical Male Circumcision Services at 14 Public Hospitals in Uganda VMMC Use of Quality Improvement Methods to Increase Utilization of Health Services: A Case Study of VMMC Post-Operative Client Follow-up at Gulu Regional Referral Hospital

September 30, 2018 | Final Report A–19 Technical area Operational Research Studies MDR TB Early treatment outcomes for the first cohort of MDR-TB patients managed at the regional referral hospitals using the mixed model of care in Uganda MDR TB Perspectives of Healthcare Workers and Managers on Implementing a Mixed-Model of Multi-Drug Resistant Tuberculosis Care in Regional Referral Hospitals in Uganda eMTCT Prevalence and risk factors for HIV transmission among exposed infants at regional referral hospitals in Uganda: a retrospective study eMTCT Predictors and outcomes of perinatal HIV transmission in the PMTCT program at regional referral hospitals in Uganda HIV Care and Outcomes of HIV patients lost to follow up from HIV care and treatment Treatment Nutrition Measures of dietary intake among undernourished and normal nutritional status HIV patients participating in antiretroviral therapy (ART) programs in Uganda: a case- control study

Technical area Technical Briefs eMTCT Realizing a Continuum of Care in Elimination of Mother to Child Transmission of HIV Health Strengthening Uganda's Health Management Information Systems at Selected Management Public Healthcare Facilities Information Systems HIV and Improving Systems for Delivery of Quality Tuberculosis Control Tuberculosis HIV Care and Supporting Delivery of Quality HIV Care and Treatment Services Treatment HIV Testing Increasing Access To And Delivery Of HIV Testing Services Human And Counseling Services In Uganda Resources for Health Laboratory Addressing Human Resources Requirements for Sustainable and Quality HIV Care and Treatment Nutrition Improving the Quality of Laboratory Services at Uganda's Public Healthcare Facilities Supply Chain Integrating Nutrition Assessment, Counseling, and Support into Routine Service Delivery VMMC Engaging Public Health Facilities to Improve Supply Chain Management Systems

A–20 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Technical area Quality Improvement Change Packages HIV Care and HIV Care and Treatment Services Change Package Treatment Laboratory Laboratory Services Change Package eMTCT Prevention of Mother to Child Transmission Services Change Package Supply Chain Supply Chain Management Change Package Health Monitoring and Evaluation Change Package Management Information Systems Nutrition Nutrition Services Change Package TB TB Care Change Package VMMC Voluntary Medical Male Circumcision Change Package AFHS Adolescent Friendly Health Services Change Package Quality Quality Improvement Change Package Improvement

Technical area Best Practices Handbooks HIV Care and HIV Care and Treatment Best Practices Handbook Treatment Laboratory Laboratory Best Practices Handbook eMTCT Elimination of Mother to Child Transmission Best Practices Handbook HRH Human Resources for Health Best Practices Handbook Supply Chain Supply Chain Management Best Practices Handbook Health Health Management Information Systems Best Practices Handbook Management Information Systems Nutrition Nutrition Best Practices Handbook HIV and Tuberculosis Best Practices Handbook Tuberculosis VMMC Voluntary Medical Male Circumcision Best Practices Handbook HTS HIV Testing Services Best Practices Handbook

September 30, 2018 | Final Report A–21 Hospital Profiles

Lira Regional Referral Hospital

Moroto Regional Referral Hospital

Mubende Regional Referral Hospital

Mbale Regional Referral Hospital

Gulu Regional Referral Hospital

Hoima Regional Referral Hospital

Kabale Regional Referral Hospital

Jinja Regional Referral Hospital

Kawolo General Hospital

Arua Regional Referral Hospital

Fort Portal Regional Referral Hospital

Kaabong General Hospital

Soroti Regional Referral Hospital

A–22 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally ANNEX 4 Stewardship Assessment Checklist*

Score**

Stewardship Elements 0 1

Workplan and budget

Any evidence of HIV service delivery activities and inputs incorporated in the hospital workplan 1 and budget

Leadership for HIV services

2 The head of HIV clinic is MoH staff (public servant)

3 PMTCT focal person is MoH staff (public servant)

4 HTC coordinator is MoH staff (public servant)

5 VMMC focal person is MoH staff (public servant)

Staff performance management by senior hospital management

6 Evidence of staff appraisal(s) conducted by senior management

7 Evidence of disciplinary action taken on staff

8 Evidence of allocation of responsibilities (duty rosters in place)

9 Presence of well-maintained HR records (staff files in place)

HIV care commodities

10 ARVs and OI drugs are only provided by MoH/NMS

11 Laboratory reagents (CD4, hematology, and chemistry) are provided only by MoH/NMS

12 HIV test kits are provided only by MoH/NMS

Monitoring and evaluation

Evidence of hospital management participating in performance review meetings (any member of 13 senior management known to have attended a performance review meeting during the last three months)

Evidence of internal support supervision for QI (any visits made by the QI focal person to the 14 service units during the past three months)

* A hospital is said to have achieved stewardship if it scores 60% on the stewardship assessment checklist. * * The score is 0 if the stewardship element has not been achieved and 1 only if it has been completely achieved.

September 30, 2018 | Final Report A–23 ANNEX 5 Success Stories

“I have learned the ethical and legal issues related to adolescent HIV care.” Dr. Mutaka Winfred, a doctor in the HIV Clinic.

A–24 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Meet Benon Baguma: 2017 PEPFAR Hero

ince 1992, Baguma Benon has While trying to convince men was been supporting the health difficult on its own, finding them was Seducation and health promotion even harder. Benon worked late nights department as a film van driver with the targeting popular places like drinking Uganda MoH. His experience spans joints and landing sites just to create years of creating awareness for the demand for VMMC services. His car AIDS Control Program when entire broke down many times. It is evident populations and families were wiped what keeps Benon going despite the out due to misconceptions and myths. challenges: He has also raised awareness for cholera and Ebola epidemic information “I worked in an era of a high HIV sessions in the most affected regions, prevalence and painfully nursed where no one would ever imagine going, so many of my relatives and with the biggest incentive being the Benon Baguma receiving a PEPFAR Award friends to the grave. And from lives that needed saving with the right from the U.S. Ambassador to Uganda, then, I chose to change the information. Deborah Malac. lives of the current and future In 2013, Benon took on a daunting assignment promoting VMMC services generations through the right with the USAID/SUSTAIN project with support from village health teams information about lifesaving and community mobilizers of VMMC. across the catchment of 11 RRHs services like VMMC.” countrywide. It proved to be one of “Previously, I hadn’t experienced the most difficult health-promoting Benon’s film van is known countrywide tasks because interfacing with various what VMMC was all about and as the “circumcision van.” Young men communities and individuals, who had a few doubts myself, which look forward to hearing messages on perceived the practice as negative and made it difficult to convince other VMMC and finding out where to receive unacceptable to their cultures, resulted men; however once I’d done it, I services. in insults, physical resistance, items could speak more confidently USAID/SUSTAIN nominated Benon thrown at his film van, and criticism Baguma as an unsung hero for leading from his fellow colleagues who shunned and extensively about its benefits, health promotion and mobilization the practice. Despite the obstacles, and I saw how much belief and efforts for VMMC and increasing its he continued using his megaphone to confidence all the men I reached uptake in Uganda to reduce new communicate key messages in remote out to had in me,” Benon says. HIV infections in the country. He was and suburban towns, and he continued honored with a PEPFAR award by the setting up health promotion sessions U.S. Ambassador to Uganda.

September 30, 2018 | Final Report A–25 Scaling up access to highly active antiretroviral therapy among children at Lira Regional Referral Hospital

Background ccording to the Uganda Demographic Health Survey A2012, Uganda has more than 190,000 children under 15 years of age estimated to be living with HIV, but only 32% of these children are enrolled on highly active antiretroviral therapy (HAART). These statistics are comparable to the global picture of 34% (WHO, 2014). In 2013, Uganda released its revised HIV care and treatment guidelines, which recommended that all children under 15 years of age must be initiated on HAART to reduce mortality and morbidity. USAID/SUSTAIN worked closely with the MoH to support 13 A mother collects drug refills for herself and her child at Lira RRH ART pharmacy. hospitals to provide quality HIV services. Lira RRH (one of the 13 hospitals) is the Objective pediatric formulations, guardian-only HIV referral point for eight districts of visits that prevented assessment of Lango Sub-region in the northern part To increase the number of children under the children, non-disclosure among of Uganda. 15 years old on HAART from 72.4% in children, an absence of an eligibility June 2014 to 95% by March 2015 at Lira screening mechanism, and information Problem Description RRH. gaps on new policy among parents and Prior to the roll-out of the revised MoH Intervention health care providers. treatment guidelines, Lira RRH had initiated up to 821 children under 15 A multidisciplinary QI team comprised The teams planned, tested, and years who were active in care. However, of clinicians/nurses, data officers, implemented intervention changes as only 604 (73.6% of all children) were counselors, and the community linkage follows: on HAART. With the new criteria, an coordinator was instituted to achieve • Oriented staff on the revised estimated 217 (26.4%) children were the objective. Gaps identified by the guidelines. eligible for treatment (Figure 1). team included an inadequate stock of

A–26 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally • Intensified health education sessions Figure 1. Number of children enrolled/initiated on antiretroviral with new policy requirements for therapy across quarters, 2014–-2015 parents and caretakers. 1000 120 • Generated a list of all eligible children 882 875 878 822 860 and their contact details to be tracked 739 100 800 97.5 99.7 for enrollment on ART. Retrieved 87.6 595 children’s clinic files and marked them 80

72.4 Percent with a sticker. 600 647 60 • Requisitioned pediatric formulations 400 from the NMS, including the projected 40 new enrollments. Number of Children 200 20 • Made phone calls and conducted home visits (during school holidays) to 0 0 trace the eligible children and initiate 1-Jun 1-Sep 1-Dec 1-Mar them on HAART. 2014 2014 2014 2015 • Started initiating new enrollments on Number of children receiving ARVs HAART immediately. Number of HIV-positive children reciving a minimum of one • Involved a pediatric counselor to HIV clinical service facilitate the disclosure process where Percentage this was not yet done.

September 30, 2018 | Final Report A–27 Identifying TB cases in underserved populations: Experience of a community-led initiative for TB contact tracing, screening, and sputum collection in Nwoya District

ulmonary TB accounts for approximately 80% of all TB Pcases in which a presumptive diagnosis can be made through screening suspected cases in a community and facility setting. Until recently, the procedure(s) for diagnosing TB was mainly carried out on patients with symptoms who reported to the health facility on their own (Manual for Management and Control of Tuberculosis and Leprosy, March 2017). In October 2017, USAID/SUSTAIN started supporting Nwoya District, located in northern Uganda, to provide comprehensive HIV prevention, care, and treatment services, including A patient provides a sputum sample at the TB clinic. services concerning TB. Health workers in Nwoya were mainly using passive contact tracing to identify new TB among the TB clients,” said a packaging. During the mentorship, the cases in the region but realized that health worker at Nwoya hospital. team mapped and generated lists of opportunities were missed to identify contacts of current TB cases at the more TB contacts through more In October 2017, USAID/SUSTAIN district’s Anaka Hospital and assigned comprehensive care approach. set out to pilot the active case-finding specific community health workers to approach. The strategy involves conduct active case-finding for 22 TB “We would receive individuals working with community-level health index cases within the district. suspected with TB and, when service providers to screen contacts Nightie, a sub-county health worker at [they were] confirmed to have the of TB patients within their homes. In collaboration with the Nwoya District Anaka Town Council, was one of the bacteria, encourage them [to] TB & Leprosy Supervisor, the project health workers mentored on active bring their family members to the conducted on-site mentorships to equip case-finding and sputum sample health facility for testing. However, community health service providers collection. Among her assigned areas this approach was ineffective with skills in intensified TB case-finding, of operation was Lukai, a village in mainly due to transport constraints sputum sample collection, and safe Lungulu Sub-county which is located

A–28 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally 20 km away from the town of Anaka. “All three of Okecha’s family members while his brother was counseled on HIV She visited over 11 homes, among prevention. tested positive for TB. Immediately, which was Okecha’s home (name With support from other community has been changed to protect identity). I made a phone call to Okecha, health workers like Nightie, in October Okecha was a 49-year-old man requesting him to bring his family 2017, Nwoya District screened 353 receiving care at Anaka Hospital’s members to the hospital. They came contacts through contact tracing. Sixty- ART Clinic. Nightie discovered that one (61) of these were presumed TB three of Okecha’s household members the next day, were counseled, and cases and were referred to the facility for (a brother, a sister, and the sister’s started on TB treatment.” testing. Eight (8) tested positive for TB. two-month-old daughter) had been coughing and experiencing night — Nightie, a community health worker, Empowering community health sweats for more than two weeks. Giving Anaka Hospital providers with skills in TB identification them quick instructions, she collected and contact tracing is highly likely to their sputum samples and took them yield more positive cases that may back to Anaka Hospital for GeneXpert otherwise be missed at health facilities. testing. Active case-finding is a new strategy being advocated by the NTLP to Okecha’s sister and her daughter increase the screening and identification also tested HIV positive and were of TB clients in Ugandan communities. immediately enrolled into PMTCT care

September 30, 2018 | Final Report A–29 Using peer mobilization to increase uptake of HIV testing services among fisherfolk at the Kayei landing site in Apac District

riven by compassion and the desire to make an impact in her Who are peer leaders? community is Monica, an owner D Peer leaders are members of the of a drug shop in the Kayei landing site community with influence from in Akokoru sub-county (Apac District) their work or position and often who is devoted to the challenging task interface with several members of mobilizing fisherfolk and their families, especially men, to test for HIV. Selected of the community. They are by the beach management community selected by the community or as a peer leader, she was mentored are volunteers from the fisherfolk on the signs and symptoms of HIV and (boat owners, fishers, barias, AIDS and oriented on how to assess fishmongers, service providers, individuals for their perceived high restaurant owners, and shop A group of fishermen mobilized for HTS at risk for HIV using the HTS screening Kayei landing site. owners) and could be members tool. The mentorship was conducted of the beach management unit or by the Akokoru Health Centre III staff in Village Health Team. collaboration with the USAID/SUSTAIN “Initially, I lived and worked with these project-supported staff. people, but I had no idea that they What is perceived high risk? The need for peer mobilizers like Monica were at risk of HIV; some of them Behavior traits are considered is evident by the estimated 15%–40% even had the signs that the health high risk if they increase one’s HIV prevalence among the transient workers showed me while others fell risk of acquiring HIV. These traits population of “fisherfolk,” who are under the categories I learned about include having multiple sexual categorized as those who reside at in the screening tool. As a peer, I’m partners, increased mobility, wife fish landing sites. The term includes motivated to bring these services inheritance, and unexplained fishermen, fishmongers, female sickness. These traits are relative commercial sex workers, boat owners, closer to most of these individuals, and usually are determined by etc., which is attributable to the high- who would rather go fishing or spend risk sexual behaviors and low access to their money on alcohol and women,” comparing one’s previous and HIV testing and ART treatment (https:// said Monica. current behavior and health status. www.ncbi.nlm.nih.gov/pmc/articles/ PMC5507699/).

A–30 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Since October 2017, Monica has been “One of the fishermen whom I spoke a convenient time and place near their using her free time moving from home to with had three wives and was so communities. home, informing people about the need While the fisherfolk are difficult to for HIV testing. Upon visiting the homes, resistant to testing because he didn’t convince to get testing, they have she speaks with the heads of household think it necessary as he was strong come to trust Monica because of her (mostly men) and inquires when all the and healthy; but while he refused to compassion for making a difference in members of each household last tested have the test himself, I convinced him her community and the information she for HIV and if they all know their HIV shares on the importance of HIV testing. status, which most confess that they to allow his wives and children [to Peer-led mobilization and HIV testing do not. While at her shop, which also get tested], which he did. When they sells class C drugs (painkillers), Monica within the fisherfolk communities have returned, two-thirds of his wives had gets the opportunity to interact with increased access to testing in this individuals and explains to them the a positive test while the other one was high-risk group. Between October and benefits of knowing their HIV status. negative. It was shocking to him and November 2017, 398 fisherfolk were Using the screening tool, Monica further tested for HIV in Apac District, with 21 compelled him to test for HIV himself. assesses the men and their family men (yield of 7.9%) and 12 women (yield members for their perceived high risk, [His results turned out positive.] of 16%) identified as HIV positive and identifies those who are eligible for Although it was a difficult outcome all linked to care. From this experience, the peer approach was shown to be testing, and encourages them to test. to believe, he expressed a sense of When she has mobilized over 20 eligible effective and can be replicated to identify testers, Monica calls the HTS focal awareness and relief.” —Monica and link more high-risk populations such person at the health center, who then as fisherfolk at landing sites to HIV care. organizes testing for these individuals at

September 30, 2018 | Final Report A–31 Overcoming Adversity: Christine’s Story

Christine is HIV positive; despite her status, she has delivered three negative babies. The community which had at one time labelled her a walking coffin, has now recognized her as one of their own upon realizing that the battle against HIV&AIDS can be won. Christine and her HIV-free children receive care at Moroto RRH

hristine and her three children missing her medication. Her hope was “My mother cried uncontrollably, live in the outskirts of Moroto kept alive by a nurse at Moroto RRH who lamenting how I betrayed her. It Ctown, Karamoja Sub-region. Her consistently counseled and encouraged story began when she was discovered her to live a normal life as long as she had was no longer a secret because bedridden in 2007 during an outreach her medication. passersby, neighbours got to initiative. It was then that she learned about her status. She had TB also was HIV “It is because of her counsel that know. This was the hardest positive. Christine started TB treatment I managed to deliver my three time for me especially dealing and, after two months, was given ARVs. babies; all of them turning HIV Like many other clients that are HIV with stigma and discrimination. negative until discharge from positive, Christine felt that disclosing her care.” said Christine. I was called names such as status could result in losing family support, friends, or even her husband. Another ‘AIDS person, walking coffin’ With this new dawn of her family’s HIV- of her nightmares came true when her free generation, most women in her and self-isolation was the only mother discovered she was HIV positive. community who have not disclosed alternative to help me cope.” Christine receives HIV care at Moroto their HIV-positive status find comfort in RRH. Before (2008–2010), the hospital Christine’s counseling and home visits. Christine was grappling with challenges of frequent She volunteers with a community home- medicine stock-outs and long wait times. based organization that works with Moroto However, the delays have been corrected, RRH to empower HIV-positive women with and Christine no longer worries about skills in counseling and craft-making.

A–32 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally Use of Linkage Facilitators in Following-Up Clients in HIV Care

eft to support her daughter’s now 16-month-old triplets, is 45-year-old L Rose Awiiri, who is also caring for her five school aged children with help from her husband. Rose believes her 18-year- old daughter abandoned her husband and babies, from fear of becoming pregnant again when she discovered that multiple births were not uncommon in their lineage. Because the triplet’s mother is HIV positive, they received nevirapine syrup at Dokolo Health Center IV for six weeks to prevent mother to child transmission (PMTCT) of HIV. The twins then received their first deoxyribonucleic acid poly-merase chain From L-R: Jackline Etap, Monica Amayo, Rose Awiiri (grandmother), Anna Alum and Esther reaction (DNA PCR) test at six weeks old Akello with the triplets at Dokolo HC IV. which showed they were all negative for HIV. The triplet’s mother left home when they Who are linkage facilitators? confident, I’m ready for the HIV rapid were 13 months old, one month after she Members of the community selected by District test.” said Rose had stopped breastfeeding, and they were Health Management Teams to support access Linkage facilitators build trust with yet to undergo their second DNA-PCR test. to health services by helping facilities and caretakers like Rose to ensure clients Jackline Etap, the Maternal, Neonatal, health workers manage client affairs enrolled in HIV care are not lost by and Child Health In-charge, and Esther associated with their treatment. regularly following up clients who miss Akello, the midwife who helped deliver appointments. Without treatment, the likelihood of HIV passing from mother-to- the triplets, heard about Rose’s situation given Ready-to-use Therapeutic Food to child is 15% to 45%. However, antiretroviral through Monica Amayo and Anna Alum, the supplement the triplets’ nutrition. linkage facilitators supported by the USAID/ therapy and other effective PMTCT SUSTAIN project. Knowing the triplets did Monica and Anna stopped by Rose’s interventions can reduce this risk to not have their second DNA PCR, Jackline home to remind her of the triplet’s below 5%.1 USAID/SUSTAIN supports and Esther asked the linkage facilitators to appointment and check on the family’s delivery of comprehensive PMTCT/early encourage Rose and her husband to come welfare. On the date of the appointment, infant diagnosis interventions across all to the facility for counselling. During the Rose brought the triplets to Dokolo Health supported facilities in Northern Uganda counselling session, the grandparents were Center IV for their second DNA PCR and with the aim of reducing the risk of mother- given a health talk on HIV transmission and results for all three babies were negative. to-child transmission among HIV-exposed strongly advised to return the triplets to the “I’m glad the linkage facilitators came children to less than 3%. health center for their second DNA PCR in and checked on me. I felt stranded, I 1 World Health Organization (WHO) ‘Mother-to- didn’t know what to do but now I feel three weeks. The grandparents were also child transmission of HIV’

September 30, 2018 | Final Report A–33 ANNEX 6 Awards and Recognitions

The Uganda Medical Laboratory Technology Association (UMLTA) selected the USAID/SUSTAIN project as a winner of the Khadil Award of Excellence in Medical Laboratory Service. This was in recognition of the enormous contribution the organization has made in promoting excellence in medical laboratory service delivery in Uganda.

The USAID Global Health Bureau Office of Health Systems (GH/OHS) had a global call for health systems strengthening cases. Over 145 cases were submitted to GH/OHS and USAID SUSTAIN was selected among the top ten best cases in 2014.

USAID/SUSTAIN’s HSS case can be accessed at: https://hssglobalcall.hsaccess.org/top-cases.

A–34 USAID | SUSTAIN Strengthening Uganda’s Systems for Treating AIDS Nationally ANNEX 7 Financial Summary

Total Estimated Amount: $84,231,254 Cost Sharing Amount: $2,240,935 Total Program Amount: $86,472,189 Total Final Obligation: $79,357,804

Cost Categories Total Estimated Costs Total Expenditures Remaining Funds

Total Direct Costs $45,543,873 $43,089,971 $2,453,902

Subcontracts / Sub awards $24,636,020 $23,216,095 $1,419,925

Total Indirect Costs $13,959,043 $11,972,613 $1,986,430

Construction $92,318 $0.00 $92,318

Total Federal Funds $84,231,254 $78,278,679 $5,952,575

Cost-Share $2,240,935 $2,240,935 $0.00

Total Program Amount $86,472,189 $80,519,613 $5,952,575 (+cost share)

Obligated Amount: $79,357,804 Obligated Spent to Date: $78,278,679 Obligated Amount Remaining: $1,079,125

September 30, 2018 | Final Report A–35

USAID Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) Project

+256 (0) 312-307-300 / +256 (0) 312 -202-045/6 Plot 7, Ntinda Crescent, Naguru, Kampala, Uganda www.sustainuganda.org