USAID’s Maternal and Child Survival Program (MCSP)

Uganda

Quarterly Report

October 1, 2016 to December 31, 2016

Assistant District Health Officer for MCH facilitating a group discussion during a Quarterly Review Meeting in

USAID/ Quarterly Progress Report (Program Year 3)

Project Name: USAID’s Maternal and Child Survival Program (MCSP) Routine Immunization (RI) Program

Reporting Period: October 1, to December 31, 2016

Obligation Funding Amount: $891,939 (Field Support)

Project Duration: July 2014 - March 2019

Program Year (PY3): October 1, 2016 to September 30, 2017

Person Responsible for this Report: Dr Ssekitto Kalule Gerald – Chief of Party MCSP

Project Objectives:

1. Strengthen UNEPI’s institutional/technical capacity to plan, coordinate, manage, and implement immunization activities at national level.

2. Improve district capacity to manage and coordinate the immunization program as guided by UNEPI leadership.

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Acronym List

CAO Chief Administrative Officer CBET Competence-Based Education and Training CH Child Health DHMT District Health Management Team DHO District Health Officer DHT District Health Team DTPC District Technical Planning Committees EPI Expanded Program on Immunization EPCMD Ending Preventable Child and Maternal Deaths GAVI Global Alliance for Vaccines and Immunizations Gavi PEF Gavi Partnership Engagement Framework HC Health Centre HF Health Facility HSD Health Sub-District ICHC Institutionalization of Community Health Practices Conference IIP Immunization in Practice ICHC Institutionalization of Community Health Practices Conference IPV Inactivated polio vaccines IRB Institutional Review Board JSI John Snow Inc. LC Local Council MACIS Malaria and Childhood Illnesses NGO Network Secretariat MCH Maternal and Child Health MCHIP Maternal and Child Health Integrated Program MCSP Maternal and Child Survival Program MNCH Maternal, Newborn, Child Health MOH Ministry of Health NCC National Coordination Committee OPL Operational Level PDSA Plan-Do-Study-Act cycles PHC Primary Health Care PY Project Year QI Quality Improvement QRM Quarterly Review Meetings QWITs Quality Work Improvement Teams REC-QI Reaching Every Community using Quality Improvement techniques RED Reach Every District RI Routine Immunization SAS Senior Assistant Secretary SS Supportive Supervision SS4RI Stronger Systems for Routine Immunization STPC Sub-county Technical Planning Committee TOT Training of Trainers TWG Technical Working Group UNEPI Uganda National Expanded Programme on Immunization UNICEF United Nations Children’s Fund USAID United States Agency for International Development

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USG United States Government VHT Village Health Team WHO World Health Organization

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Introduction

The Maternal and Child Survival Program (MCSP) is a global U.S. Agency for International Development (USAID) cooperative agreement to introduce and support high-impact health interventions in 24 priority countries with the ultimate goal of ending preventable child and maternal deaths (EPCMD) within a generation. MCSP engages governments, policymakers, private sector leaders, health care providers, civil society, faith-based organizations and communities in adopting and accelerating proven approaches to address the major causes of maternal, newborn and child mortality and improve the quality of health services from household to hospital. MCSP also tackles these issues through cross- cutting approaches that focus on health systems strengthening, household and community mobilization, equity, gender, eHealth, and others. MCSP carries forward the momentum and lessons learned from USAID’s Maternal and Child Health Integrated Program (MCHIP), which made significant progress in improving the health of women and children in over 50 developing countries throughout Africa, Asia, Latin America and the Caribbean from 2008-2014.

This quarter marked the beginning of a new Program Year (PY3). During this period, MCSP continued its efforts to strengthen the capacity of the Uganda National Expanded Programme on Immunisation (UNEPI) and to strengthen Routine Immunisation (RI) systems for better coverage and utilisation of quality RI services in the two districts of and Butaleja. These are referred to as PY1 districts because support to them was initiated in PY1 (October 2014 to September 2015). MCSP also continued to provide support to the four additional districts of Ntungamo, Mitooma, Bulambuli and Kibuku. These are referred to as PY2 districts in the report also based on the year when support was initiated i.e. October 2015 to September 2016.

During PY3, quarter 1, MCSP continued to focus on promoting REC-QI practices in the districts, health districts and health facilities. These REC-QI practices include: building capacity for data analysis and use, quarterly review meetings involving political, civic and opinion leaders (eg, non-traditional stakeholders), integrated supportive supervision visits, mapping of health facility catchment areas, micro-planning, community engagement, Quality Work Improvement Teams, and testing changes in Plan-Do-Study-Act (PDSA) cycles.

Summary of PY3 Quarter 1 Achievements

Immunization achievements for MCSP Uganda RI during PY3, Quarter 1 are summarized as follows:

National Level Achievements

Jointly, SS4RI and MCSP supported UNEPI in finalizing its official Immunization in Practice (IIP) Manual making it ready for printing. This manual will be used by health workers throughout the country and provides the essential content for UNEPI’s training materials. This long awaited activity paved the way for developing the Operational Level (OPL) training. Using the revised IIP Manual, MCSP and SS4RI supported Ministry of Health (MOH) /UNEPI in conducting a Training of Trainers (TOT) of 35 national trainers.

MCSP participated in the only Technical Working Group (TWG) held in this quarter and in a meeting of the National Coordination Committee (NCC) to prepare for the Meningitis A campaigns to be held in high-risk districts.

MCSP continued to facilitate organization of the Institutionalization of Community Health Practices Conference (ICHC), originally scheduled to take place in Uganda. MCSP is a key member in the

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Uganda country delegation to take part in that conference in March 2017. However, the venue for the conference has since been moved to South Africa, and MCSP’s involvement in the planning has ended.

District Level Achievements

PY1 Districts (Kanungu and Butaleja)

REC-QI is comprised of three main steps or phases, namely “Orient,” “Establish and Strengthen,” and “Sustain.” MCSP completed all scheduled activities in all of the two PY1 districts (Kanungu and Butaleja) except the sustainability forum meetings, which are planned for next quarter.

MCSP provided the last round of support to quarterly review meetings (QRMs) in the two PY1 districts at the district and health sub-district (HSD) levels. This provided a platform for the District Health Management Teams (DHMTs) together with district and sub-county political, religious and civil leaders to jointly reflect on performance in RI and other Maternal and Child Health (MCH) service areas, and develop strategies for improvement. A number of resolutions were made, namely: increasing involvement of leadership in supporting RI activities, strengthening vaccine forecasting and acquisition by health facility, and strengthening follow up to ensure primary health care (PHC) funds adequately facilitate staff and village health teams (VHTs) involved in RI activities.

MCSP provided technical assistance to a team of 28 district supervisors: 18 from Kanungu and 10 from . The aim was to consolidate their knowledge and skills in conducting Supportive Supervision (SS). During this activity, up to 72 health facilities (48 in Kanungu and 24 in Butaleja) that provide RI services were visited by the district supervision teams backstopped by the MCSP technical teams. Emphasis was directed towards addressing RI and REC-QI issues. However, support was integrated to include issues related to other service delivery areas e.g. Maternal and Child Health in general, and Malaria among others.

As shown in Figure 1 below based on results from an assessment conducted in October 2016, 67% of health facilities assessed in the PY1 districts had reviewed and completed new health facility micro-plans. Although this was slightly lower than the proportion observed in April 2016 (69%) it was still over ten times higher than the baseline level of 6% observed in July 2015. This showed that following MCSP technical assistance, health facilities had now developed REC micro-plans independently, an early indication of sustainability and a strengthened RI system process (i.e. micro-planning).

Up to 37% of health facilities assessed were found to be implementing REC-QI practices (e.g. had a micro-map, micro-plan, and a functional Quality Work Improvement Team that met at least once in the past 3 months) and were found working on at least one PDSA cycle. This was more than ten times higher than the 3% identified at baseline in June 2015.

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Figure 1: Proportion of PY1 health facilities with completed REC micro-plans (October 2016).

PY2 Districts (Ntungamo, Mitooma, Kibuku and Bulambuli)

In the PY2 districts (Ntungamo, Mitooma, Kibuku and Bulambuli), MCSP supported district health teams (DHTs) with QRMs. During this quarter, 58 supervisors were trained in SS including; 10 supervisors from Bulambuli, 10 from Kibuku, 12 from Mitooma, and 26 from Ntungamo.

PY1 and PY2 Districts

During this quarter, MACIS supported the collection and entry of data from 188 health facilities from the 6 PY1 and PY2 districts supported by MCSP. These data were analysed by MCSP and shared with the districts during the QRMs. MACIS also supported the entry of data on training using United States Government (USG) funds into MCSP data base.

Description of Activities for the Quarter

Objective 1: Strengthen UNEPI’s institutional/technical capacity to plan, coordinate, manage, and implement immunization activities at national level.

MCSP participated in a WHO regional capacity-building workshop on immunization data quality improvement, information system integration, and implementation of the vaccination cluster coverage survey held in , Uganda on 14-18 November 2016. The objective of the meeting was to build capacity of countries to assess data management systems (including data quality) and develop reliable data quality improvement plans. During the meeting, a key resolution by Uganda was that the Division of Health Information Systems will lead the coordination and implementation of sector-wide data quality coordination and implementation through a dedicated technical inter- programme working group comprised of program-based data managers, program managers and M&E staff. In a bid to further understand the challenge of the Child Register utilisation, the MOH, together with partners, plans to conduct a rapid assessment to identify challenges contributing to poor utilisation of the Child Register in the country.

Jointly, SS4RI and MCSP supported UNEPI in finalizing its official IIP Manual making it ready for printing. This manual will be used by health workers throughout the country and provides the

7 essential content for UNEPI’s training materials. This long awaited activity paved the way for developing the OPL training, the lack of which has been identified by MCSP to negatively affect RI service delivery.

MOH/UNEPI, MCSP and other partners, including SS4RI, conducted a TOT for 35 national trainers who were trained in OPL training using the revised IIP Manual. In addition, the trainers were oriented to Competence-Based Education and Training (CBET) as opposed to theory-based learning. The participants and UNEPI appreciated the CBET approach which focuses on the competencies needed by health workers to perform key tasks. It was resolved that the subsequent OPL trainings should follow CBET.

MCSP participated in the only TWG held this quarter and in a meeting of the NCC to prepare for the Meningitis A campaigns to be held in high risk districts. During the TWG meeting, MCSP presented the REC-QI approach and results to date to 23 members of the TWG to enable them to gain an in-depth understanding of the approach and inputs needed for scale up.

Objective 2: Improve district capacity to manage and coordinate the immunization program as guided by UNEPI leadership.

1.1. Technical Assistance for Integrated Supportive Supervision

a) PY1 Districts In October 2016, MCSP provided technical assistance to the two PY1 districts of Kanungu (in South Western region) and Butaleja (in Eastern region) to conduct integrated technical SS. This is the penultimate activity of the REC-QI approach supported by MCSP in the districts. During this activity, MCSP aimed to support the districts to consolidate efforts initiated during the first and second steps of REC-QI. Key areas for consolidation included: promoting recording of all children vaccinated in the Child Register; emphasising best practices for better management of vaccines and logistics to assure their availability across all health facilities in a district; and promoting practices to increase coverage of RI services. This was following a critical reflection and best practices learning meeting held in September 2016 in Kampala that included health workers drawn from different health facilities. A key product of that meeting was a list of minimum standard practices for immunization, based on the input of all participants.

Table 1: Number of district supervisors engaged in supervision and number of health facilities supervised during PY3/Quarter 1. District No. of district supervisors No. of health facilities visited for engaged in supervision supervision / total number of facilities in the district Kanungu 18 48 / 52 (92%) Butaleja 10 24 / 24 (100%) Total 28 72 / 76 (95%)

In addition to promoting REC-QI practices during SS, other areas addressed included infection prevention and control and follow up on recommendations from previous SS visits.

MCSP worked with district supervisors drawn from the DHT, HSDs and selected health facilities to jointly develop the terms of reference and SS checklist to guide the supervision;

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form supervision teams and allocate different sets of health facilities to visit; provide oversight to the actual visits to health facilities; facilitate joint review and analysis of findings; and support report writing and development of district level plans to facilitate follow up to ensure implementation of the targeted improvements.

In addition, supervision teams resolved that cold chain technicians should: conduct an all- round stock-taking exercise to ascertain vaccine availability in all health facilities and redistribute vaccines based on findings; map out mini-sub stores (eg, selected health facilities per HSD where health facilities without fridges can pick up vaccines); and develop and share distribution schedules with health facilities. b) PY2 Districts MCSP provided technical assistance in integrated SS to PY2 districts of Ntungamo and in South Western region, and Kibuku and in Eastern region. UNEPI and Expanded Program on Immunization (EPI) Regional Supervisors were involved in the SS to appreciate the REC-QI approach to SS for inputs and scale up. A total of 61 district supervisors were trained over two days on the topics of planning for SS, checklist development, SS scheduling and routing, and report writing. Supervisors then conducted SS in 102 of the 112 health facilities (91%) in the PY2 districts.

Areas of focus during SS visits included: RI service delivery (presence of an RI schedule); execution of planned RI sessions; cold chain and EPI logistics management; organisation of and sharing of RI information; Child Register utilisation; infection prevention and control; human resources for service delivery (e.g. assessment of cadres of staff participating in RI sessions); mobilisation of communities to demand for RI services; and implementation of REC-QI practices.

Health facility staff were supported to address some issues affecting RI identified during the SS visit itself, while other issues were referred to the relevant levels. All supervisors had a debrief meeting on the last day to reflect on the exercise, share experiences, and discuss possible solutions to challenges identified. Some of the resolutions made during the supervisors’ debrief meeting included: stepping up district support towards quantification and forecasting of vaccine requirements, compiling a report of all faulty fridges, supplying at least 2 registers per health facility, DHOs (District Health Officers) writing a circular to all facility in-charges to ensure the involvement of qualified staff involvement in delivery of RI service, emphasizing the importance of tracking of children per village by VHTs.

Table 2: Number of district supervisors engaged in supervision and number of health facilities supervised during PY3/Quarter 1. District No. of district supervisors No. of health facilities engaged in supervision supervised / total number of facilities in the district Bulambuli 10 19/19 (100%) Kibuku 10 16/16 (100%) Mitooma 12 24 / 28 (86%) Ntungamo 29 43 / 49 (88%) Total 61 102 / 112 (91%)

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1.2. Technical Assistance to District QRMs

a) PY1 Districts MCSP facilitated the last QRMs in the two districts of Kanungu and Butaleja. In both districts, the process was that HSD-level QRMs were first conducted and then immediately followed by district-level QRMs (e.g., DHMT meetings). At the HSD-level QRMs, the performance of individual facilities was reviewed and plans for improvement discussed. HSD representatives then made presentations of the key resolutions during the DHMT QRM that followed immediately at the district headquarters with the participation of the Regional EPI supervisors for guidance, support and scaling up of best practices. In Kanungu District, the meetings (HSD and DHMT) were attended by a total of 123 participants (72 females and 51 males) while 72 participants attended in Butaleja District (38 females and 44 males). These included health facility staff, DHMTs, political, religious and civil leaders at sub-county and district levels.

The resolutions in these meetings included: the DHOs developing a monthly vaccine distribution budget and schedule for the districts in order to ensure more consistent availability of the required vaccines; Chief Administrative Officers writing to health facility in-charges to ensure that all staff conducting RI outreaches are paid their allowances from the PHC fund (of which 40% is allocated for immunization), and DHT meeting being conducted to address the same; Cold Chain Technicians compiling reports of non- functioning fridges and submitting to UNEPI; the District Local Council Level 5 (LC V) chairperson calling on-site meetings with all health facilities graded as RED (Reaching Every District) Category 4 (e.g. having poor access and utilisation of RI services); and health facility in-charges including VHT facilitation in budgeting PHC funds for outreach allowances and ensuring that VHTs are paid. Generally given the gaps identified, the districts were implored to strengthen SS to all health facilities with a specific focus on addressing management issues.

b) PY2 Districts QRMs were supported in 3 out of the 4 PY2 districts with 71 participants in Kibuku, 8 in Mitooma, and 144 in Ntungamo District. The main resolutions were centred around strengthening follow up to ensure PHC funds are well utilised to facilitate both health workers and VHTs in conducting RI activities, allocating some funds to support vaccine distribution; re-organisation at health facility level to ensure RI sessions have adequate numbers and the right cadre of staff to support RI; revitalising SS activities that had become infrequent and encouraging health facility staff to ensure all opportunities at health facility level are exploited to yield greater use of RI services (e.g. sensitising mothers who come for other services); conducting daily RI sessions for health facilities with fridges; asking for Child Health Cards during outpatient attendance and providing appropriate doses of vaccines to eligible children who are seeking other services. All resolutions were aimed at increasing access to and utilisation of RI services. The action plans developed will be followed up during the next QRMs.

MCSP learned from last quarter’s QRMs that both district CAO (Chief Administrative Officer), Chairperson LC V, Secretary for Health and Resident District Commissioner (RDC) and sub-county leaders (e.g. Senior Assistant Secretary (SAS) & Local Council III Chairperson) were not involved in planning and monitoring immunization services and the SAS are not given reports on RI performance in their sub-counties to enable effective monitoring and support of RI. Therefore, MCSP has initiated a process of strengthening the

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links between the DHO’s office and the District Leaders at district level and between the HC III In-charges and sub-county leaders. The leaders at both levels of government recommended that the DHT and HC III In-charge regularly inform leaders of the status of EPI through presentations at the meetings of the District Technical Planning Committees (DTPC) and Sub-county Technical Planning Committee (STPC). This will facilitate leaders in prioritizing RI challenges to address themselves or to lobby other partners and central government to address.

II. Challenges, Solutions and Actions Taken

Actions taken to address the Results of actions Challenges faced during the quarter challenges taken

National Level The core UNEPI team gets Continuously reviewed the plans and With this approach, overwhelmed with many activities timelines with UNEPI team and MCSP managed to (government and support to maintained a higher degree of implement most of the partners). This makes it difficult for flexibility to gain access to a slot for planned activities, MCSP to get UNEPI to participate in some activities. Some activities were though outside the MCSP planned activities leading to done in a stepwise manner such that originally planned delays or complete failure to if a partner misses the drafting, they timelines. implement the activities, given that can participate in the review meeting almost all national level activities are or finalization of the given document. supposed to be done with UNEPI However, this requires more time team. Over the years, there has and resources. been expansion in MCSP’s scope and the number of districts it supports, yet the UNEPI team has remained the same size. This puts strain on the team, thus scattering it. Most national MCSP-supported activities had to be delayed because the UNEPI team was busy. Additionally, the timeline for national UNEPI activities keeps changing making it unpredictable, hence difficulty in harmonizing MCSP-supported activities with those of MOH. This problem coupled with heavy schedules on the side of partners, such as WHO and UNICEF, led to them missing some of the activities supported by MCSP. This is because the key party is UNEPI: once UNEPI has assigned a slot to organize an activity, if the date is not convenient for WHO or UNICEF and has to be changed, the opportunity to engage UNEPI is lost.

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Actions taken to address the Results of actions Challenges faced during the quarter challenges taken

District Level Since it was rainy season in some No action was taken to address this N/A districts, some roads were challenge. impassable. Some health facilities could therefore, not be reached for

technical SS. It was worst in Kanungu and Bulambuli Districts, where the road terrain is especially poor.

Staff in some health facilities were District supervision teams were No results observed found busy attending to long queues again urged to keep in touch with yet of clients. This delayed the start of the health facility staff to obtain the

some supervision sessions. most suitable and least busy time slots to be able to interact with health workers. Some of the top leaders (civil and These leaders were represented by No results observed political) were out of the district other delegates, with the yet attending to other official duties and expectation that they would convey

could therefore, not participate in the resolutions agreed upon to the the QRMs. leaders.

In some health facilities, RI issues are Districts were encouraged to closely No results observed left to the EPI focal person with very follow up and nurture PDSAs related yet little involvement of health workers to re-allocation of qualified staff to from other sections / departments in support RI activities. This could the facility. This was the main reason offer numerous benefits in improving behind the low recording in the documentation of immunised Child Register and poor reported RI children and scaling up vaccination. performance in some health facilities.

Minimal sharing of information by Continued to promote SS to ensure More staff were staff who attended trainings. This left that more staff are reached with reached with several staff who had not attended a information about REC-QI. More information on REC- training with little knowledge of what staff will be reached during the QI during SS visits, was shared (e.g. trainings in the key planned OPL training, since the than those who could tools like micro-plans, PDSAs, etc). REQ-QI approach has been be reached during incorporated in the IIP Manual. trainings. As much as sites actively implement Continued to mitigate this challenge No results observed PDSAs, some still had challenges of through mentoring health workers yet comprehension, and did not take and continuously emphasizing the time to analyse the results arising importance of analysing data for a from their PDSAs in order to make given PDSA and on taking decisions meaningful decisions on whether to whether to “adopt, adapt or “adopt, adapt or abandon”. abandon”. Tried to lighten up the

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Actions taken to address the Results of actions Challenges faced during the quarter challenges taken language used to ease comprehension and application of the PDSA concepts. Matters of vaccine distribution and Raised the challenge with UNEPI No results observed logistics management, such as through sharing of field report; plans yet shortage of gas in districts, were not to write a policy brief for the

well-addressed because district Minister of Health (Primary Health officials had no clear channel to raise Care). the challenges.

III. Lessons, Best Practices and Recommendations

National Level By working closely with UNEPI management in planning activities and continuously consulting with them while setting timelines, MCSP has improved the coordination and harmonization of UNEPI and MCSP activities. Sharing field experiences and learnings with the TWG has helped to enable adaptation of the model and increase the likelihood of scale-up by partners and the MOH. Field reports that highlighted district program challenges were shared with UNEPI, which helped to ensure bottlenecks, such as cold chain repairs, were addressed by MOH.

However, there is no clear communication channel to address challenges with vaccine stock outs and gas cylinder shortages that affect vaccine and logistics management. MCSP has future plans to share briefs with UNEPI management, highlighting the challenges that UNEPI-MOH and National Medical Stores can address. MCSP recommends regularizing the sharing of 1-2 page summary briefs with UNEPI to ensure faster action in addressing the highlighted gaps. Additionally, MCSP has future plans to develop a Policy Brief for the Minister of State for Health (Primary Health Care), since many matters have policy implications.

District Level • During QRMs, it was found that splitting the entire group into smaller groups per sub-county to engage in performance discussions and action planning created a better platform for all parties to appreciate the joint role in improving health performance at that level. • A strategy is needed under REC-QI to strengthen the community component of the RI system and better understand why, despite the increase in the number of RI sessions conducted, utilization and coverage of RI services in some districts remains lower than expected. • Based on discussions held with districts, the strength of the leadership has a strong bearing on the RI performance. Discussions revealed that districts that had several performance gaps also reported low levels of proactivity on the part of district leaders and managers at all levels, both in communities and at health facilities. It is recommended that sub-county leaders task health facility teams to submit periodic reports on RI performance to them as a way of ensuring accountability with communities. • Proper management of PHC funds is needed to facilitate staff doing outreach, among other key activities, to ensure continuity of RI service delivery. The political leadership beginning with CAO has a vital role to play in following up more closely on the use of the PHC funds that are designated to support RI and other health services.

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• During QRMs, it was found to be important to consolidate feedback from SS with periodic REC- QI assessments and RED categorisation performance. This should help to ensure performance is more broadly analysed from coverage to systems, which is a practice recommended for a good RI system. • Efforts should be made to link the DHO’s office with district leaders in the form of sharing reports and challenges regularly, while Health Facility In-charges should do the same with sub- county leaders. • Involvement of district leaders in SS is recommended to further expose them to the existing RI challenges and garner their support in solving them. For example, some districts have indicated they would be well-positioned to facilitate replacement of gas cylinders for powering the vaccine refrigerators or to purchase a replacement tyre for a motorcycle/vehicle to run outreach sessions. This is a developing story and work in progress that will be reported on more in the next quarterly report.

IV. Success Story

None developed this quarter due to short period of implementation after workplan approval.

V. Management Issues

To enhance the capacity of the MCSP team to carry out district supportive activities, a new vehicle was procured to supplement the existing pick-up truck that was getting old with high maintenance costs.

Staff provided support for start-up of the MCSP Maternal, Newborn and Child Health (MNCH) program, which has since evolved into the MCSP Child Health (CH) program. The support was mainly in the area of consultation and conceptualization of the program, and recruitment of program staff.

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VI. Monitoring and Evaluation

Data collection and entry with MACIS

During the quarter, MACIS collected data to inform REC-QI implementation from a total of 188 health facilities across the 6 districts supported by MCSP. Data was also collected from the 6 and 8 headquarters of the districts and health sub-districts, respectively.

Table 3: Number of HSDs and health facilities visited for assessment during PY3 Quarter 1. No. of HSDs No. of Health facilities District headquarters visited visited PY1 districts Kanungu 2 / 2 52 / 52 Butaleja 1 /1 24 / 24 PY1 Sub Total 3 /3 76 / 76 PY2 districts Bulambuli 1 / 1 19 / 19 Kibuku 1 / 1 16 / 16 Mitooma 1 / 1 28 / 28 Ntungamo 3 / 3 49 / 49 PY2 Sub Total 5 / 5 112 / 112 Grand Total 8 / 8 188 / 188

Findings from these assessments were shared during QRMs, workshops for planning for REC-QI implementation, and trainings on selected REC-QI tools. This is aimed at ensuring that plans for improving uptake of REC-QI practices and strengthening of the RI system are developed. Findings from this assessment will be shared with staff and the districts next quarter.

Program Learning

Learning Question 1: What are the tangible results of the REC-QI approach and the principle enablers/drivers of change along the REC-QI continuum from “Orient” to “Sustain”?

The protocol for this assessment was submitted to USAID for review and approval on December 19, 2016.

Learning Question 2: What are the enablers and inhibitors of uptake and sustainability of REC- QI practices in ?

The protocol for this assessment was reviewed by the local Institutional Review Board (IRB) at Makerere University School of Public Health, which shared feedback with MCSP to be addressed prior to resubmission. The process of international IRB review in the United States by Johns Hopkins University / JSI was initiated.

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VII. Summary of Quarterly Results

The following table shows the compiled MCSP Uganda RI performance indicators for data available from the six districts where MCSP implemented in Quarter 1.

No Indicators Districts Quarterly Quarterly Achievement Target Numerator Denominator Percentage Comments (Percentage) (%) 1 Number of deaths in the under five Data collected by Uganda DHS and children per 1000 reported every five years live births (context) 2 DTP 3 coverage Indicator reported annually nationwide 3 DPT 3 coverage by Indicator reported annually district PY1 districts Percentages above 100% imply that 4 Kanungu 90% 2,344 2,962 79% more children were vaccinated than Number of children Butaleja 90% 2,889 2,868 101% targeted. This may be largely because who at 12 months Total 90% 5,233 5,830 90% of issues around the have received three PY2 districts denominator/target or population doses of DPT/Penta movements. Ntungamo 90% 5,753 5,684 101% vaccination from a Mitooma 90% 1,397 2,155 65% USG- supported immunization Kibuku 90% 2309 2,373 97% program. (Standard Bulambuli 90% 1,206 2,050 59% 3.1.6 – 61) 90%

Total 10,665 12,262 87% 5 The main reasons for not conducting Kanungu 91% 1,315 1,630 81% some planned RI sessions were vaccine Butaleja 91% 1,084 1,083 100% stock outs and inadequate funding for % of planned RI PY1 districts Total 91% 2,399 2,713 88% outreach activities as a result of low sessions that were Primary Health Care (PHC) grant and delay in its release. Lack of transport conducted in the Ntungamo 91% 1,597 2,143 75% for the outreach (e.g., lack of fuel for year (IP custom) Mitooma 91% 812 798 102% the motor cycle) compounded the Kibuku 91% 791 1,031 77% problem. PY2 districts Bulambuli 91% 964 2,081 46% Total 91% 4,164 6,053 69% No Indicators Districts Quarterly Quarterly Achievement Target Numerator Denominator Percentage Comments (Percentage) (%) 6 # of national level No new documents scheduled for guidelines, review this quarter. However, MCSP manuals, and tools supported finalization of the IIP manual in which REC-QI which had been targeted for review concepts are last financial year. The document is incorporated (IP now ready for printing. custom) 7 Kanungu 100% 0 40 0% Number of people Butaleja 100% 0 40 0% trained in child PY1 districts Total 100% 0 80 0% health and nutrition The OPL training for immunization was

through USG- delayed due to a delay in completion of Ntungamo 100% 26 66 39% supported IIP Manual, which provides the training Mitooma 100% 12 52 23% programs (IP content for the OPL training. Thus, custom) Kibuku 100% 10 48 21% training in OPL in PY1 districts was not PY2 districts Bulambuli 100% 10 50 20% conducted. Total 100% 58 216 27% 8 % MoH / UNEPI 100% TWG coordination meetings held where Routine Two EPI TWG meetings were held with 2 3 67% Immunization was one combined/converted into an NCC. discussed in a year (IP custom)

9 % of planned Kanungu 100% 3 3 100% quarterly Butaleja 100% 1 1 100% The QRM scheduled in Bulambuli was review/coordinatio PY1 districts Total 100% 4 4 100% n meetings held postponed for January 2017 due to

where routine busy activity schedule set up by the Ntungamo 100% 4 4 100% immunization was district health office towards the Mitooma 100% 1 1 100% discussed in a December festive season. district per year (IP Kibuku 100% 1 1 100% custom) PY2 districts Bulambuli 100% 0 1 0% Total 100% 6 7 86%

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No Indicators Districts Quarterly Quarterly Achievement Target Numerator Denominator Percentage Comments (Percentage) (%) 10

% of planned Kanungu 100% 3 1 33% The SS scheduled in Bulambuli was integrated Butaleja 100% 1 1 100% postponed for January 2017 due to the supportive PY1 districts Total 100% 4 2 50% busy activity schedule set up by the supervision visits district health office towards the conducted in a Ntungamo 100% 1 4 25% December festive season. The district in a year (IP Mitooma 100% 1 1 100% supervisions scheduled to be custom) Kibuku 100% 1 1 100% conducted by HSDs in Ntungamo and Bulambuli 100% 0 1 0% Kanungu were not done due to funding PY2 districts Total 100% 3 7 43% challenges. 11 For the PY1 districts, the percentage is Kanungu 40% 35 52 67% slightly lower than the percentage in Butaleja 40% 16 24 67% April 2016 (70%) but still higher than 44% in October 2015 and 6% at % of health PY1 districts Total 40% 51 76 67% baseline. The key reasons for absence facilities with of micro-maps includes health facilities complete REC Ntungamo 40% 19 49 39% submitting the micro-plans to the micro-plans (IP Mitooma 40% 16 28 57% district without keeping copies, and custom) Kibuku 40% 6 16 38% health facilities lacking adequate Bulambuli 40% 12 19 63% knowledge of how to fill sections of the PY2 districts 40% micro-plan. Total 53 112 47%

Reporting rates are as follows; 97%, 99%, 100%, 100%, 98% and 100%% by 8th October 2016 for Bulambuli, Butaleja, Kanungu, Mitooma , Kibuku and Ntungamo districts respectively

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VIII. PY3 Quarter 2 Planned Activities

The following are the activities planned for next quarter, January to March 2017:

National Level Activities • Participate in UNEPI quarterly RI review meetings with partners to share REC-QI lessons learned by presenting/discussing different topics at each meeting and in subcommittee work; • Participate in UNEPI TWG meetings, Quality Assurance Department Meetings, and WHO/EPI Eastern and Southern African (ESA) Managers’ meeting on March 20-22, 2017; • Presentation of technical briefs to MOH/UNEPI for RI challenges beyond the mandate of MCSP and districts that need to be addressed; • Presentation of lessons learned from REC-QI in Uganda at the Institutionalization of Community Health Conference (ICHC) in Johannesburg, South Africa on March 27-30, 2017.

District Level Activities

PY 1 Districts (Kanungu and Butaleja) • Conduct end of support sharing meetings in the two districts of Kanungu and Butaleja; • Potentially provide technical assistance, if requested by the district, to strengthen sustainability.

PY2 Districts (Mitooma, Bulambuli, Kibuku and Ntungamo) • Conduct OPL training, once the new IIP Manual is published and distributed.

PY3 Districts (Mbarara, Bushenyi, Serere and Mayuge) • Conduct initial visits to sensitise district leadership about MCSP activities (pre-visit); • Complete situation analysis assessment; • Facilitate planning for REC-QI implementation; • Train health workers in selected key REC-QI tools; • Conduct OPL training, once the new IIP Manual is published and distributed.

Monitoring and Evaluation • Collect, enter and analyse REC-QI monitoring data from MoH/UNEPI, district health offices and HSD headquarters across all the 10 supported districts (e.g., PY1, PY2 and PY3 districts); • Compile quarterly progress report; • Share findings from the data collected from PY2 districts with the DHMT and other district and national level stakeholders, during other REC-QI activities e.g. QRMs, workshops for planning for REC-QI implementation, etc.; • Develop and begin operationalising a web-enabled database to track REC-QI performance; • Follow up on USAID review/ approval of the protocol for the program learning study on Tangible results of the REC-QI approach and the principle enablers/drivers of change along the REC-QI continuum from “orient” to “sustain”; • Revise and resubmit the protocol to the local Ugandan IRB for the program learning study on Enablers and inhibitors of uptake and sustainability of REC-QI practices in Kapchorwa District based on local IRB feedback, and also complete US IRB review.

Program Management • Hold regular meetings between the USAID/Kampala Activity Manager and MCSP staff to update him on progress and to solicit guidance as needed.

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Annex A: EMMR Quarterly Update

List each Mitigation List of any Measure from outstanding issues Status of Mitigation Measure Remarks Column 3 in the relating to required EMMP Mitigation conditions Plan Utilization of auto- Vaccinators will be trained in vaccine Training in OPL will be Overall, MCSP disable syringes and and immunization logistics conducted in Q2 after Uganda aims to needles for all management, including ordering from the IIP manual is finally discuss immunization the health sub-district vaccine printed environmental activities. store/district vaccine store that impact includes bundling of auto-disable as part of syringes (ADs) with vaccines to ensure technical available stock of vaccines doses at the assistance, health facility at any time have equal training and number of ADs, stock management other materials. and the use of only ADs for MCSP only gives immunization. technical Training of assistance to vaccinators to avoid management of recapping of needles auto- disable after vaccination and syringes (ADs), use of safety boxes MCSP Uganda will contribute to does not procure following guidelines, efforts aimed at avoidance of recapping nor distribute with the motto “no syringes by promoting proper use of them to districts safety box, no the AD syringes (provided through and health vaccination.” MOH/UNEPI) through project facilities (this is trainings, quality improvement responsibility of activities, and supportive supervision the National Reduction in waste visits. Medical Store generation and (NMS)). segregation of wastes during vaccination. Through the trainings, quality Sharps to be improvement activities, and supportive separated from other supervision visits that it supports, wastes. Sharps MCSP Uganda promotes segregation containers which of waste by proper use of safety boxes puncture-proof, for sharps disposal during vaccination impermeable and sessions. tamperproof with fitted covers should be used. Put in place a system MCSP Uganda builds local capacity to MCSP has not Overall, MCSP to identify expired ensure systems are in place to identify conducted the Uganda aims to vaccines and expired vaccines and remove them Operational level discuss consumables, remove from the cold storage (EPI fridges) at training that could environmental them from shelves, health facilities and drugs for district partly contribute to impact place them in well retrieval and disposal, locked storage addressing this. This is as part of

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List each Mitigation List of any Measure from outstanding issues Status of Mitigation Measure Remarks Column 3 in the relating to required EMMP Mitigation conditions Plan labeled boxes, and place for filled safety boxes exist are scheduled for Q2, technical forward them to communicated and monitored in (delayed due to delay assistance, incineration / disposal project trainings, quality improvement in the IIP finalization). training and points. activities, and supportive supervision other materials. visits conducted. Identification of expired drugs and their removal from drug stores for disposal. Training, quality improvement activities, and supportive supervision Before final disposal are geared towards building local of filled safety boxes, capacity to properly use incinerators, they should be stored where they exist and the ‘burn and in a secure place that bury’ method recommended by is inaccessible to MOH/UNEPI is known and practiced people and animals. at health facilities where incinerators do not exist. Construction of incinerators to be used for burning of safety boxes and other wastes.

Fencing of the MCSP Uganda works to ensure that disposal sites. mercury thermometers are destroyed and fridge tags are disposed of Ministry of health Where incinerators according to WHO protocols. /UNEPI now uses are unavailable, use alcohol burn and bury thermometers methods in areas with for its EPI fridges limited access that is and other cold adequately protected storage from ground equipment as contamination. clarified by UNEPI. Mercury thermometers will be disposed of in a safe place where the mercury will not contaminate the ground water. They should not be burned

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List each Mitigation List of any Measure from outstanding issues Status of Mitigation Measure Remarks Column 3 in the relating to required EMMP Mitigation conditions Plan in open spaces where the fumes will destroy the environment.

Once expired, fridge- tags should be disposed of in a safe place such as a landfill or designated trash area.

Capacity building of health care providers on proper commodity management systems to minimize expiries or wastage.

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Annex B: Photo Gallery

Assistant District Health Officer for Environmental Health facilitating a discussion during the Quarterly Review Meeting in Butaleja District

Assistant District Health Officer for Maternal and Child Health facilitating a session during the Quarterly Review Meeting in Butaleja District

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MCSP staff engaging Mac Neil HF staff during Supportive Supervision in Ntungamo District

Supportive Supervision session in progress in

Nyamirama HC III staff in discussion with supervisors in Kanungu District

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District supervisor mentoring Rushaka HC II staff on temperature charting

Action planning sessions in progress for countries during the WHO Regional Workshop on Data Quality

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