UGANDA INDOOR RESIDUAL SPRAYING PROJECT PHASE 11 QUARTERLY PERFORMANCE REPORT

January 1 – March 31, 2016 Contract No. AID-617-C-12-00004

April 2016 This publication was produced for review by the United States Agency for International Development. It was prepared by IRS Project Phase II, Abt Associates.

Recommended Citation: Uganda Indoor Residual Spraying (IRS) Project Phase II Quarterly Performance Report: January 1 through March 31, 2016 Uganda Indoor Residual Spraying Project Phase II , Abt Associates Inc.

UGANDA INDOOR RESIDUAL SPRAYING (IRS) PROJECT PHASE II QUARTERLY PERFORMANCE REPORT

Contract/Project No.: AID-617-C-12-00004

Submitted to: Mr. Joel Kisubi, Contracting Officer Representative United States Agency for International Development /Uganda

Abt Associates  4550 Montgomery Avenue, Suite 800 North  Bethesda, Maryland 20814  Tel: 301.347.5000. Fax: 301.913.9061www.abtassociates.com

Abt Associates  Uganda IRS Project Phase II P.O.Box 37443 / Plot 86 Luthuli Avenue Bugolobi Kampala, Uganda.  Tel: 256 (0).414.251.300

Abt Associates Uganda IRS Project Phase II, Tororo  Plot 20 Masaba Rd, Tororo Municipality Tel: 256 (0).392.177.264

In collaboration with: Communication for Development Foundation Uganda (CDFU)  EnCompass, LLC

Cover Photo: Vector Control Officers and facilitators at the end of their orientation training in Tororo March 14-15 , 2016

DISCLAIMER The views expressed in this document do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Table of Contents Table of Contents ...... iii List of tables...... iv List of figures ...... iv Acronyms ...... v Executive Summary ...... 1 1. Background ...... 2 2. Technical Management Including IRS Implementation, Capacity Development and M&E………… ...... 3 2.1 Result 1: High quality, safe and effective IRS program implemented ...... 3 A. Spray operations ...... 3 B. Logistics...... 8 C. Environmental Compliance ...... 9 D. Behavior Change Communication activities ...... 9 2.2 Result 2: Capacity building and innovative approaches in IRS implemented ...... 11 A. Capacity dashboard ...... 11 B. IRS exit strategy and malaria control sustainability plan ...... 12 C. National and district in-service training ...... 13 Development of the private sector capacity to engage and conduct IRS activities...... 13 2.3 Result 3: Comprehensive monitoring and evaluation of the IRS program performed ...... 14 A. Monitoring and Evaluation ...... 15 3. Business Management ...... 18 4. Successful Interventions ...... 19 5. Project surveillance ...... 19 6. Cost considerations ...... 20 7. Challenges ...... 20 8. Lessons learned/recommendations ...... 20 9. Plans for next reporting period ...... 20

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List of Tables Table 1: Result 1: Summary of output indicators for quarter two, January – March 31, 2016 .... 3 Table 2: Number of participants who attended the planning and review meetings for group B districts ...... 5 Table 3: Spray teams recruited in the group B districts ...... 7 Table 4: Summary of output indicators for quarter two, January 1- March 31, 2016 ...... 11 Table 5: Number of in-service trainings conducted by category ...... 13 Table 6: Result 3: Summary of output indicators for quarter two January 1- March 31, 2016 . 14 Table 7: Summary of Bionomics study results: Female malaria vectors collected using various sampling techniques by sentinel district during Bionomics studies in January - March 2016...... 16 Table 8: No of female anopheline mosquito species collected during outdoor HBNC by hour, January- March 2016 ...... 16

List of Figures

Figure 1: Uganda IRS project Phase II target districts ...... 2 Figure 2: The new insecticide stacked in store...... 8 Figure 3: The packaging of the new insecticide, each box contains 12 bottles ...... 8 Figure 4: Community dialogue meeting in Agwatta sub-county, District………………13 Figure 5: Capacity transfer of group A districts from round five to seven ...... 12 Figure 6: Capacity transfer of group B districts from round six to seven ...... 12 Figure 7: Percentage of malaria vectors biting before and after midnight by district in 4 sentinel districts: Apac (former IRS district), Lira and Tororo (current IRS district) and (a non- IRS district), March 2016...... 16 Figure 8: Number of malaria vectors collected during pre-IRS PSCs in group B IRS districts in Northern and Eastern Uganda in March 2016 ...... 17

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Acronyms

AMELP Activity Monitoring, Evaluation and Learning Plan BCC Behavior Change Communication CAO Chief Administrative Officer CDC Centers for Disease Control and Prevention CDFU Communication for Development Foundation Uganda CDO Community Development Officer COR Contracting Officer’s Representative DEO District Environmental Officer DFID Department for international Development DHT District Health Team DSO District Supplies Officer ECM Environmental Compliance Manager EMMP Environmental Monitoring and Mitigation Plan FAQ Frequently Asked Question FC Field Coordinator FP Focal Person FY Fiscal Year HBNC Human Baited-Net Collections ICCM Integrated Community Case Management IEC Information, Education and Communication IPC Interpersonal Communication IRS Indoor Residual Spraying LC Local Council LLINs Long Lasting Insecticidal Nets M&E Monitoring and Evaluation MoH Ministry of Health MOP Malaria Operational Plan NDA National Drug Authority NMCP National Malaria Control Program OP Organophosphate PM Parish Mobilisers PMI President’s Malaria Initiative PMP Performance Management Plan PSC Pyrethrum Spray Catch SK Store Keeper SM Store Manager SMT Senior Management Team SO Spray Operator STTA Short Term Technical Assistance TB Tuberculosis UAHPC Uganda Allied Health Professionals Council UKAID United Kingdom Agency for International Development UPCA Uganda Pest Control Association

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USAID United States Agency for International Development VCD Vector Control Division VCO Vector Control Officers VCOA Vector Control Officers Association VHT Village Health Team

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Executive Summary This report covers the period January 1 - March 31, 2016 and presents the Uganda IRS Project- Phase II’s (also referred to as the ‘project’ in this report) activities, achievements and lessons learnt during this time frame. During the reporting period, the project together with its key stakeholders and communications partner, Communications for Development Foundation Uganda (CDFU), focused on implementing activities for the smooth transition from bendiocarb to pirimiphos-methyl (Actellic CS), a broad spectrum organophosphate (OP) insecticide, to spray the 14 districts. To facilitate this transition, the project closely coordinated with the Ministry of Health (MoH)/National Malaria Control Program (NMCP) and district stakeholders to ensure that all the required logistical, operational, and procurement requirements and systems are in place for spraying, safe handling, and disposal of the waste from this insecticide.

During the quarter, the project’s management and logistics staff carried out detailed planning to address the storage and transport challenges of the new insecticide. They were successful in securing storage facilities free of cost in all but three districts of Bugiri, Kaberamaido and Serere. These efforts helped secure a seamless transition and enable the implementation of all planned project activities as per schedule.

In preparation for spraying in the group B districts the project, in collaboration with the district health teams (DHTs) and MoH, conducted three-day district-level planning and review meetings to review performance in the previous spray round (October – December 2015), achievements, successes, challenges and to introduce the new insecticide and provide information regarding its safe handling. The project also conducted microplanning at the sub-county level. The information, education and communication/behavior change communication (IEC/BCC) team developed messages to focus on the new insecticide, and also incorporated messages on integrated malaria prevention and control. The project also sensitised district leaders and spray teams on gender sensitive communication strategy which is in line with the broader communication strategy developed by the NMCP.

In this quarter, the project also made important strides in building the capacity of the private sector. It worked with key stakeholders to spearhead the development of draft guidelines for regulating the private pest control sector. The project worked with the DHTs to initiate IRS exit strategy dialogue and malaria control sustainability planning. Meetings were held to discuss key strategies and develop draft plans for sustaining and increasing behavior change and service provision to ensure integrated malaria prevention and care. These strategies are intended to avert malaria upsurges and maintain low prevalence in the post-IRS period.

In line with the guidelines of USAID/Uganda’s Collaborative Learning and Adaptation Agenda, the project continued to implement proven innovations and put in place new cost-effective approaches. One such initiative to recycle plastic waste at Gentex Enterprises Ltd. saved the project almost 2,600 USD. The project prepared and submitted all necessary reports on-time, conducted all required entomological monitoring activities and shared results in a timely fashion with the relevant stakeholders at the national and district level. The project drafted a paper for publication titled: “Insecticide resistance status of the malaria mosquitoes Anopheles gambiae s.l. and An. funestus in eastern and northern Uganda.” It also provided key input to an unpublished research study by IDRC, University of California, San Francisco, CDC Atlanta, and Makerere University on the relationship between IRS, maternal malaria and pregnancy outcomes.

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1. Background The Uganda IRS Project-Phase II is a continuation of the President’s Malaria Initiative (PMI) IRS program in Uganda, building on the achievements attained in Phase I (July 2009 – July 2012). The Phase II, five-year project commenced on June 26, 2012, and will end on June 25, 2017. The overall objective of the project is to achieve the PMI Uganda targets in IRS. In particular, the Uganda IRS project contributes to USAID/Uganda’s Development Objective 3, a comprehensive effort to improve outcomes in health, HIV/AIDS and education in Uganda through the following project objectives: a. High quality, safe and effective IRS program implemented; b. National capacity to conduct IRS developed; c. Comprehensive monitoring and evaluation (M&E) of the IRS program performed.

PMI/Uganda has a five-year strategic plan (2015-2020) and an annual Malaria Operational Plan (MOP) which guides the implementation and scale-up of activities. IRS is one of the key components of the MOP, and is one of the four key interventions of the PMI/Uganda program. The aim is to reduce malaria-related mortality in Figure 1: Uganda IRS project Phase II target districts children under five and pregnant women.

Abt Associates, Inc. as the prime contractor of this program, manages and directs all technical component activities in support of IRS planning, procurement, implementation, monitoring, and capacity building. Two subcontractors support the project: CDFU provides support for IEC/BCC activities; EnCompass provides assistance in developing and upgrading IRS training materials.

Building on the project’s ongoing successes and ability to deliver innovative IRS programming that helped reduce the malaria burden in the north, the project transitioned in 2015 out of the 10 northern districts that it previously covered, to 14 high-prevalence and high-malaria burden districts in the northern and eastern regions (Figure 1).

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2. Technical Management Including IRS Implementation, Capacity Development and M&E

2.1 Result 1: High quality, safe and effective IRS program implemented Table 1 shows the targets and actual results for selected monitoring indicators for Result 1 according to the project’s Performance Management Plan (PMP)/Activity Monitoring, Evaluation and Learning Plan (AMELP).

Table 1: Result 1: Summary of output indicators for quarter two, January – March 31, 2016 INDICATOR January- March 2016 Target Actual Number of district level planning and introductory 14 14 meetings conducted with NMCP support

Number of district assessments conducted by DHTs and 14 14 NMCP with the support of project staff

Number of spray personnel trained to deliver IRS in the 0 0 IRS target districts

Number of IRS print materials disseminated in the IRS 10,887 10,887 target communities

Number of radio talk shows conducted 5 5

Number of radio spots aired 70 70

Number of community members mobilized and sensitized 23,406 23,709 about IRS

Number of community dialogue meetings held 411 411

Number of districts sprayed 0 0

Number of households sprayed with IRS 0 0

A. Spray operations Engagement with the district leadership During the reporting period, the Operations Manager, field coordinators (FCs), store managers (SMs), and BCC team conducted courtesy visits in all the 14 districts to inform the district stakeholders about the upcoming spray round, and the change in insecticide. During these courtesy visits, the team met the DHT members, Chief Administrative Officers (CAOs), local council (LC) V chairpersons and Resident District Commissioners.

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The project staff discussed with the district leaders the challenges and successes of the previous spray round, identified the gaps, and developed a plan for the next spray period. The team also requested for on-going support of the district leaders in sensitizing and mobilizing the communities for IRS.

Additionally, during these visits, the SMT introduced the newly assigned FCs and SMs (based on the recent reorganization of the district pairing) to their respective district leaders. The group B districts, which scheduled to start spraying on April 18, 2016, now include: Butaleja, Dokolo, Kaberamaido, Kibuku, Namutumba, Pallisa and Otuke. Group A districts:Amolatar, Alebtong, Budaka, Bugiri, Lira, Serere and Tororo will start spraying on June 6, 2016. Microplanning The project conducted microplanning at the sub-county level from February 22-26, 2016 in group B districts. The project field teams and DHT members held meetings with the leaders in all the sub- counties of the group B districts to verify the availability of previously-employed supervisors and store keepers (SKs). The team confirmed the availability of previously-used parish stores, solicited for new ones and shared the IRS activity work plan with the leaders. The team also took the opportunity to introduce the new insecticide to all the sub-county leaders, informing them of the measures required to ensure the safety of IRS workers and community members during spraying. Educating the sub-county leaders on the new insecticide enabled the project to preempt any misinformation or community resistance that might arise. Planning and review meetings In preparation for spraying, the project staff, in collaboration with the DHTs and MoH officials, conducted a three-day district level planning and review meeting from March 10-12, 2016 for the group B districts for the parish SKs, sub-county supervisors and DHT members ( Table 2). The project also invited 14 MoH supervisors and seven IRS focal persons from group A districts to be part of the training at the respective districts so as to learn more about the new insecticide. This quarter, the planning and review meetings were of longer duration (three days instead of the earlier two days) to ensure ample time to introduce the new insecticide and provide adequate information to ensure safety and correct use. These meetings provided an opportunity to review key areas such as data capture, logistics management, environmental compliance, spray pump maintenance, spray techniques and community mobilization.

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Table 2: Number of participants who attended the planning and review meetings for group B districts

CATEGORY

DHT MoH Supervisors Store Keepers Police Prison Army

# M F M F # M F Old New VHT # M F Old New VHT

S/No. Districts

1 Butaleja 8 5 3 2 0 12 3 9 7 5 0 26 20 6 18 8 6 0 0 0

2 Kibuku 10 8 2 2 0 10 6 4 10 0 0 26 21 5 23 3 7 0 0 0

3 Namutumba 13 12 1 1 1 7 6 1 6 1 0 18 15 3 14 4 18 0 0 0

4 Pallisa 11 8 3 2 0 19 16 3 18 1 0 42 32 10 37 5 38 0 0 0

5 Kaberamaido 12 10 2 2 0 12 10 2 9 3 3 29 23 6 26 3 17 0 1 0

6 Dokolo 6 5 1 2 0 11 10 1 6 5 3 28 24 4 25 3 28 0 0 0

7 Otuke 10 10 0 2 0 9 6 1 7 0 2 25 20 5 20 5 23 0 0 0

Total 70 58 12 13 1 80 57 21 63 15 8 194 155 39 163 31 137 0 1 0

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Verification and recruitment of the spray team The project, in collaboration with the district staff, assessed the availability and medical fitness of the previous spray team members in the group B districts and recruited new spray team members to replace those who dropped out or were unavailable. The project also recruited one parish mobilizer for each parish store to lead the daily community mobilization activities at the village level ahead of the spray team.

Sensitization meetings of the sub-county leaders and LCI chairpersons were conducted concurrently with the recruitment of the spray teams. The meetings with both the sub-county and LCI leadership were crucial for sharing experience and working together as a team to mobilize the community about IRS. These joint meetings with the LCIs and sub-county leaders enhanced the vetting and identification of competent and trustworthy spray team members. To encourage large turn-out during the recruitment and especially participation of women, the project aired radio announcements to inform communities about the recruitment schedule in all districts, and encouraged women to apply. As per the MoH policy, village health team (VHT) members were given priority to be recruited as spray operators (SOs), along with women. Since the local leaders are well aware of the capabilities and credentials of the VHTs, the DHT members, sub-county officials, sub-county supervisors and parish SKs led the verification and recruitment process.

The project recruited a total of 3,701 (27 percent women, 73 percent men) spray team members in the group B districts, of which 17percent were new, and 83 percent had previous spray experience with the project. Of the total, 68 percent were VHT members, and 32 percent other community members. (Table 3) for details regarding the recruitment of spray team members.

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Table 3: Spray teams recruited in the group B districts

S/No. Districts Supervisors Store keepers Spray Operators Wash persons Parish mobilisers Security Guards

M F Old New VHT M F Old New VHT M F Old New VHT M F Old New VHT M F Old New VHT M F Old New VHT

1 Butaleja 3 9 7 5 0 20 6 18 8 6 296 74 268 102 272 4 40 39 5 39 10 16 18 8 22 49 3 40 12 7

2 Kibuku 6 4 11 0 0 21 5 23 3 4 223 75 268 30 252 0 37 32 5 19 24 2 22 4 16 51 1 49 3 5

3 Namutumba 6 1 6 1 0 15 3 14 4 18 199 97 245 51 288 0 38 36 2 37 13 5 14 4 17 29 7 32 4 24

4 Pallisa 16 3 18 1 0 32 10 37 5 38 412 143 484 71 532 2 66 62 6 65 37 5 40 2 41 83 3 84 2 43

5 Kaberamaido 10 2 9 3 3 23 6 26 3 17 312 65 328 49 258 1 45 44 2 39 26 3 26 3 19 52 6 43 15 14

6 Dokolo 10 1 6 5 3 24 4 25 3 28 376 78 384 70 104 1 57 43 15 41 25 3 23 5 22 34 22 42 14 0

7 Otuke 7 2 7 2 2 20 5 20 5 23 147 29 121 55 123 1 24 13 12 14 25 0 20 5 19 46 4 27 23 30

Total 58 22 64 17 8 155 39 163 31 134 1,965 561 2,098 428 1,829 9 307 269 47 254 160 34 163 31 156 344 46 317 73 123

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B. Logistics Receipt of the new insecticide (Actellic) and collection of the remaining bendiocarb During this quarter under review, the project went through an exhaustive ordering and clearance process to ensure that the new insecticide reaches the districts. In preparation for spraying the group B districts, the SMs working with the District Supplies Officers (DSOs) received a total of 13,560 cartons (162,720 bottles) of the new insecticide (Figures 2-3).

All the 14 districts provided additional storage space to accommodate the new insecticide, while the project completed the necessary renovations to the parish stores in a timely manner.

Figure 2: The new insecticide stacked in Figure 3: The packaging of the new Butaleja district store insecticide, each box contains 12 bottles The logistics team collected all the leftover sachets of the previous insecticide (bendiocarb) from respective district stores for safe custody in the store. A total of 12,854 sachets with an expiry date of May 2017 are in Dokolo district store, awaiting USAID’s guidance on their usage. The project has prepared and submitted to USAID, draft estimates of the funds required to use the balance of bendiocarb in Kole or Nwoya Servicing of pumps Project-trained SOs and SKs serviced 2,761 pumps in Butaleja, Budaka, Bugiri, Kibuku, Otuke, Namutumba, and Tororo in preparation for the April 2016 spray round. The DSOs supervised the process. The project’s Information Technology Officer together with the Central SM updated the inventory including the Non-Expendable Property in Budaka, Tororo, Butaleja, Kibuku and Pallisa. Distribution of logistics Between March 14-18, 2016, the project received IRS equipment and supplies from Kampala for storage in the Lira central store. From March 21-25, 2016, the logistics team distributed the supplies to the district stores in the group B districts, followed by distribution to the parish stores at the end of March 2016. The SMs and DSOs supervised the distribution of supplies to the parish stores in all group B districts. The parish SKs were invited to verify and receive supplies from respective district stores and deliver them to their parish stores. Procurement To accommodate the new insecticide, the project advertised through the New Vision Newspaper for hiring additional vehicles. The project procurement committee for local procurements assessed the bids before awards were made to the successful bidders. In January 2016, the project also sent requests for quotations to prequalified suppliers for spray supplies. Based on the assessment of the local procurement team, local purchase orders were issued to the successful bidders, from February 25, 2016 onwards. In March 2016, the project delivered the respirators, gloves and aprons to the district stores. Constant flow valves, seals and nozzle tips were also received.

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C. Environmental Compliance IRS waste management and evacuation for incineration and recycling During the quarter, the project’s environmental compliance team supervised the sorting, weighing and packaging of IRS waste from all the 14 districts. The project transported 12,649 kgs of IRS waste from the October-December 2015 spray round, which included 217,124 empty sachets of bendiocarb for incineration. From January 27-28, 2016, the project also transported all the IRS plastic waste to Gentex Enterprises Ltd, a recycling company in Matugga-. A total of 2,851 kgs of plastic waste were delivered to the factory. The innovation of recycling the plastic wastes has saved the project UGX 9,123,200 (approximately 2,600 USD). A success story on this innovation is being finalized and will be shared with USAID/PMI in the next quarter. Sourcing additional storage space for the new insecticide The project team together with the DSOs searched for and identified additional space for storage of the new insecticide (pirimiphos-methyl) in Alebtong, Amolatar, Bugiri, Butaleja, Kaberamaido, Kibuku, Pallisa, and Serere. Each district, apart from Bugiri, Kaberamaido and Serere, offered additional storage facilities to the project at no cost. This helped the project to cut the cost of renting stores. The National Drug Authority (NDA) inspected all the storage facilities and certified them during the quarter. Updating the Environmental Monitoring and Mitigation Plan The project’s environmental team updated the Environmental Monitoring and Mitigation Plan (EMMP) to include precautionary and mitigation measures for the new insecticide. During the refresher training, the District Environmental Officers (DEOs) updated the previous version of the EMMP. The MoH and National Environment Management Authority representative reviewed the updated EMMP. The updated EMMP is now ready for presentation to USAID/PMI. D. Behavior Change Communication activities During the quarter, the project’s BCC focus was to equip communities with the correct knowledge about IRS and the new insecticide to prepare the ground for the upcoming spray round. The project focused on interpersonal communication (IPC) as one of the communication channels to reach the communities with integrated and gender sensitive IRS messages. The integrated messages focused on the different malaria control and prevention measures, while the gender sensitive messages encouraged both males and females to be employed as spray teams, both male and female adults to stay at home to welcome spray operators. The BCC activities also used satisfied beneficiaries from resistant population subsections, specifically organic farmers and religious sects (Kanyiriri), to act as champions for radio talk shows. Sensitization of district leaders on the new IRS insecticide The project conducted district leader sensitization in all the group B districts targeting 35 participants per district with a total of 245 participants (154 males and 91 females). Community dialogues The project together with the District Health Educators (DHEs) and the DHT members, conducted 411 community dialogues in the group B districts. Figure 4 shows a community dialogue session in progress. Special focus was given to communities who significantly resisted IRS in the previous spray round and had attained low IRS coverage. The ‘question and answer’ format at these dialogues enabled participants to ask questions about IRS, understand its benefits and Figure 4: Community dialogue meeting in allay some of their fears about the new insecticide and Agwatta sub-county, Dokolo District 9

IRS in general. For instance in Butaleja, some community members were fearful that the new insecticide creates impotence and infertility among men and women respectively. During the community dialogue meetings, the community members had a chance to ask questions, clear their doubts about the safety of the insecticide, and in the end agreed to have their houses sprayed. Community members reached with BCC messages Through community dialogues, door-to-door sensitization, and radio talk shows, the project reached 23,709 community members (10,586 males and 13,123 females). Sensitization of sub-county task force and LCIs The project staff and DHT members sensitized the sub-county taskforces which included key political and technical leaders, and LCI chairpersons from all the group B districts, at their respective sub- counties. The participants were sensitized about their roles and responsibilities as key mobilizers, and were taught mobilization strategies needed to create awareness among the communities about IRS and the new insecticide. They were informed about the key features of the new insecticide, including the fact that it would be used for spraying once a year, and has a strong odor which disappears with time. They were also informed about the fact that the new insecticide leaves a white residue on the sprayed surface. Emphasis was given to integrated malaria messaging and ensuring that the LCIs and the sub- county taskforce members are able to communicate these integrated messages to the community members accurately and timely. The participants were able to share previous experiences, challenges and successes openly through formal discussions and this enriched their participation and involvement. The participants were informed that spraying will be conducted once a year because the new insecticide lasts longer on the walls than bendiocarb. A total of 3,026 LCIs (91females, 2,935 males) attended these sensitization meetings. Radio broadcasts During this quarter, the project conducted five radio talk shows and ran 70 spot messages across radio stations in the seven group B districts. This was done to create more awareness about the upcoming spray round and inform the listeners about the new insecticide and its benefits, such as longer duration which requires just one spray per year. They also informed the listeners about the smell and the white residue left on the walls after spraying with the new insecticide-Actellic. Emphasis was also placed on ensuring safety of human and animal life during the radio spot and interactive talk shows. Distribution of BCC materials During the quarter, the LCIs and sub-county leaders distributed IEC materials including posters and leaflets with Frequently Asked Questions. A total 10,887 IEC materials were printed for the 14 districts. Of these, 6,762 posters were distributed to the seven group B districts. These materials contained information about the new insecticide, and were used for IPC and door-to-door mobilization of communities. Visit by BCC Specialist During the quarter Ms. Gael O’Sullivan from Abt home office provided short-term technical assistance (STTA) on BCC to the project. This STTA, working together with CDFU, focused on the communication strategy, which emphasized the new insecticide, use of IPC as the primary medium, integrated malaria and gender sensitive BCC messaging. This communication strategy is in line with the broader communication strategy developed by the NMCP. Ms. O’Sullivan also attended community dialogues to understand community perceptions regarding IRS and the new insecticide, and to understand the challenges, achievements, testimonies and success stories from the previous spray rounds. She held meetings with other implementing partners/projects working on BCC, such as Communication for Healthy Communities and at the end of her visit, debriefed the Contracting Officer’s Representative (COR), Joel Kisubi.

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2.2 Result 2: Capacity building and innovative approaches in IRS implemented

Table 4: Summary of output indicators for quarter two, January 1- March 31, 2016

January-March 2016 Performance Indicator Title Target Actual Dashboard charts populated with district data 14 14

National and district staff receiving in-service training 99 1311*

IRS policy stakeholder meeting held 1 1

* 33 DEOs, 14 DHEs, 14DIOs, 14 district biostatisticians, 25 VCOs, and 31 MoH staff were trained A. Capacity dashboard In February 2016, the project’s Capacity Building Manager and Operations Manager disseminated the district capacity dashboard results for the October–December 2015 spray period to the district SMT and the DHT members. The results showed that among the six project areas tracked by the dashboard (entomological competence, environmental compliance, BCC, logistics management, spray operations and monitoring and evaluation), the biggest growth in district capacity was in entomological competence, across all the districts (Figures 5-6). The dashboard results are being used by the district leadership in decision making. For example, in , based on dashboard data, the CAO identified another staff in the environment department to replace the current DEO who was unable to do his job in a timely manner. The capacity building team also developed goals for key district technical staff for the upcoming spray round. These newly-set goals will help guide and motivate the district employees including DEO, DHEs, Vector Control Officer (VCO)/IRS focal person, DSOs and District Biostatistician, to increase their ownership and participation in IRS. These goals, which were signed off by the technical staff in the presence of the CAO and senior district leadership, will also assist the CAOs in evaluating the performance of their district staff in IRS activities.

The capacity dashboard results have enabled project staff to better understand key areas where capacity growth is needed. The results will be shared with MoH and NMCP to help management better understand the current capabilities of the districts and existing gaps which must be addressed for future government-implemented IRS programs.

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Figure 5: Capacity transfer of group A districts from round five to seven

Note: Round 5,6 and 7 represent spray rounds 1,2 and 3 in group A districts

Figure 6: Capacity transfer of group B districts from round six to seven

Note: Round 6 and 7 represent spray rounds 1 and 2 in group B districts

B. IRS exit strategy and malaria control sustainability plan From February 9-11, 2016 the project held meetings with the CAO, DHO, IRS focal persons and DHEs from all the 14 districts to discuss the IRS exit strategy and malaria control sustainability plans. The objective of these meetings was to discuss key strategies for sustaining and increasing integrated malaria prevention (insecticide treated nets, intermittent preventive treatment of malaria in pregnancy, BCC) and care (test and treat) in order to avoid upsurges and maintain low prevalence. Following these meetings, the districts will prepare their own plans, and share them with different donors for funding, including working with district officials to commit funds for these activities. All these preparations are aimed at preventing the malaria upsurges such as those which occurred after the discontinuation of IRS in the previous northern IRS districts. The Program Manager of the NMCP and the Senior Health Educator from the MoH also attended these meetings. During the meetings, held in Mbale and Lira, the DHTs from every district made presentations on their draft exit strategies and sustainability plans which highlighted the interventions that the districts could themselves implement, rather than those that require support from the central Ministry and the donor community. While all

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districts advocated for rolling out integrated community case management (ICCM), they also recognized the challenge of limited and inconsistent drug supplies from National Medical Store to support ICCM. C. National and district in-service training After the dissemination of dashboard results to district senior management and MoH SMT, in preparation for the new insecticide, the project conducted several technical trainings for national and district-based staff. The content was based on the weaknesses/gaps identified during dashboard data collection in the six key project areas covered. The capacity dashboard data was instrumental in helping tailor these trainings to address the gaps that had been identified. A total of 33 DEOs were oriented in environmental compliance, 25 VCOs in entomological monitoring, 14 DHEs and 14 District Information Officers in social mobilization and 14 district biostatisticians focused on review of the revised M&E tools and IRS data management. These comprehensive orientation trainings helped to build local district capacity and provided district staff ample opportunities to learn through experience sharing with project staff who were facilitators. Table 5 below provides details regarding the district orientation trainings that were conducted in quarter two.

Table 5: Number of in-service trainings conducted by category Training Training schedule Attendance Scores category Male Female Total Average Average Average pretest post test growth DEOs March 14 -15, 31 2 33 61% 73% 19.9% 2016 VCOs March 14 -15, 24 1 25 64% 81% 20.9% 2016 DHEs/DIOs March 16 -17, 23 5 28 72% 85% 17.2% 2016 Biostatisticians March 16 -17, 10 4 14 72% 87% 20.9% 2016

On March 7, 2016, the project oriented 31 MoH personnel involved in IRS supervision and ensured that they have up-to-date information about the new insecticide. On March 30, 2016, the project together with Arysta Life Science Ltd, the company that supplied and distributed the new insecticide to the IRS districts, organized a one-day orientation training for 24 MoH staff on the different aspects of IRS including spray techniques, spray equipment, environmental compliance, transportation, storage and the adverse side-effects of the new insecticide. This two-day national MoH orientation training was officially opened by the new program Manager of NMCP, Dr. Jimmy Opigo at Vector Control Division (VCD) Kampala. Development of the private sector capacity to engage and conduct IRS activities In an effort to develop capacity of the private sector to engage in and conduct quality IRS activities, the Uganda IRS Project was instrumental in the formation of the Uganda Pest Control Association (UPCA) in 2011 and trained its members. UPCA is a broad-based organization that handles and uses different pesticides including insecticides for public health, and is regulated by the Uganda Allied Health Professionals’ Council (UAHPC), a professional body under the MoH. The Vector Control Officers Association (VCOA) falls under the UPCA. The IRS project in collaboration with the VCOA, VCD, NMCP and UPCA held a series of meetings during the quarter to develop and finalize draft guidelines which will regulate activities of UPCA while handling and using insecticides for public health use. The guidelines were sent to the VCOA for forwarding on to the public health board, which is part of the UAHPC. The project is finalizing the draft guidelines and will share a copy with USAID/PMI.

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These guidelines are critical since the pest control industry, which is regulated by MoH, is growing at a high speed, with many companies not yet registered with UPCA and UAHPC. As a result there are several unqualified service providers implementing IRS, using chemicals not recommended by World Health Organization.

To help regulate the private pest controllers, the Capacity Building Manager also met with NDA. The NDA is responsible for registering all insecticides for public health use in Uganda. During this meeting, NDA reiterated that they are the only body in Uganda which registers insecticide products for public health use after recommendation from MoH. They don’t import insecticides for the public to buy and advised that they should be advised of any cases of misuse or unauthorized use of insecticides. 2.3 Result 3: Comprehensive monitoring and evaluation of the IRS program performed Table 6: Result 3: Summary of output indicators for quarter two January 1- March 31, 2016 January – March , 2016 INDICATOR Target Actual PMP developed and submitted 0 0

Updated PMP submitted quarterly to USAID/PMI 1 1

Annual work plan developed and approved 1 1

Number of district-level IRS digital maps prepared 0 0

Number of parish level IRS digital maps prepared 0 0

Number of sub-county level IRS digital maps prepared 36 41

Number of progress reports prepared and submitted 4 4

IRS entomological monitoring plans developed and implemented 0 0

Number of spray teams inspected by supervisors per spray round 0 0

Percentage of IRS operational units (washing bays and soak pits) inspected according to IEE/SEA guidance 0 0

IEE and/or SEA completed as required 0 0

Number of independent environmental compliance inspections conducted 0 0

Number of national insecticide susceptibility tests conducted 0 0

Number of CDC bottle bioassays conducted 0 0

Number of wall bioassay tests conducted according to WHO standards 90 90

Number of PSCs carried out in the previous IRS districts 216 216

84 84 Number of pre- and post-PSCs carried out in the 7 group B

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January – March , 2016 INDICATOR Target Actual current IRS districts

Number of bionomic studies conducted 12 12

A. Monitoring and Evaluation Progress reports During the quarter the project compiled and submitted monthly reports for January and February 2016, one end of spray report, and one quarterly report for October-December, 2015 to the USAID Contracting Officer’s Representative (COR) as detailed in the reporting section under business management. Entomological monitoring activities Bionomics studies conducted During this reporting period, the project conducted bionomics studies in the districts of Lira and Tororo (current IRS districts), Apac (former IRS district) and Soroti (a non-IRS district). The study involved pyrethrum spray catches (PSCs) in 12 houses per sentinel district, light trap catches in three houses per sentinel district for one night, human baited-net collections (HBNCs) indoors and outdoors in three houses per sentinel district for three nights, and larval sampling in the sub-county where the sentinel site is located.

There has been a slight increase in the vectors collected in the non-IRS districts during this period compared to October-December 2015 period. Of the total of 5,528 female vectors collected (148 An. gambiae s.l. and 5,380 An. funestsus), most (98.5 percent) were caught in Soroti and Apac, compared to only 1.5 percent collected in the IRS districts. The non-IRS districts of Soroti and Apac accounted for 59.5 percent and 39.0 percent of the total female malaria vectors collected respectively, indicating the effectiveness of IRS. A summary of the results is shown in Table 7 below. An. gambiae s.l. predominated the adult vector catches in the IRS districts of Lira and Tororo while An. funestus predominated the adult vector catches in Soroti and Apac. Most the mosquitoes were collected using PSCs (2,614 or 47.3 percent) and HBNC indoors (1,752 or 31.7 percent) out of the total 5,528 female vectors collected (Table 7). Indoor HBNCs showed that most vectors (74.8 percent), both An. gambiae s.l. (53.42 percent) and An. funestus (75.6 percent) were biting after midnight (Figure 7 & Table 8). IRS and long lasting insecticidal nets (LLINs) can therefore be effective for the control of the vectors in all these districts. On average the ownership of LLINs is at 80.6 percent and the lowest being in Lira at 63.9 percent. Most common and major larval mosquito breeding sites included: brick pits, rice paddies, road side puddles, murrum pits, sand pits and swamp edges.

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Table 7: Summary of Bionomics study results: Female malaria vectors collected using various sampling techniques by sentinel district during Bionomics studies in January - March 2016. Sampling District Grand Total Total technique Apac Lira Soroti Tororo An. An. An. An. An. An. An. An. An. An. No. % gambi funestus gambia funestus gambia funestus gambia funestus gambia funestus ae s.l. e s.l. e s.l. e s.l. e s.l. PSC 4 683 7 0 23 1885 11 1 45 2569 2614 47.3 CDC-LTC 10 973 3 0 3 64 18 0 34 1037 1071 19.4 Indoor 17 461 3 0 9 1231 29 2 58 1694 1752 HBNC 31.7 Outdoor 2 7 3 0 0 73 6 0 11 80 91 HLC 1.6 Total 33 2124 16 0 35 3253 64 3 148 5380 5,528 100.0

Figure 7: Percentage of malaria vectors biting before and after midnight by district in 4 sentinel districts: Apac (former IRS district), Lira and Tororo (current IRS district) and Soroti (a non- IRS district), March 2016.

6-00p.m-12.00a.m 12.00a.m.-6.00a.m.

120 100

100 81 77.8 74 80 69 53 60 47 50 50 40 31 22.2 26

%of Vectors Biting 19 20 0 - - - An. An. An. An. An. An. An. An. gambiae funestus gambiae funestus gambiae funestus gambiae funestus s.l. s.l. s.l. s.l. Apac Lira Soroti Tororo SENTINEL DISTRICT

Table 8: No of female anopheline mosquito species collected during outdoor HBNC by hour, January- March 2016 Time Apac Lira Soroti Tororo An. An. Other An. An. Other An. An. Other An. An. Other gambi funest Anophel gambi funest Anophel gambia funest Anophel gambi funest Anophel ae s.l. us es spp ae s.l. us es spp e s.l. us es spp ae s.l. us es spp 6–7 p.m. 0 1 0 0 0 1 0 0 1 2 0 3 7-8 p.m. 0 2 1 1 0 0 0 6 1 2 0 6 8-9 p.m. 0 1 5 1 0 0 0 18 1 1 0 2 9-10 p.m. 2 3 5 1 0 1 0 49 1 3 0 2 TOTAL 2 7 11 3 0 2 0 73 4 8 0 13

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Post-IRS wall bio-assays In this quarter, the project conducted 108 cone tests in the four monitoring sentinel sites in the four districts of Lira, Kaberamaido, Pallisa and Tororo to assess the residual efficacy of bendiocarb sprayed on different wall surfaces. All the An. gambiae s.s. mosquitoes exposed to plastered painted wall surfaces were knocked down within 50 minutes post-exposure in all the sentinel districts by March 2016. However, An. gambiae s.s. mosquitoes exposed to plain brick and mud and wattle wall surfaces were knocked down after 60 minutes post-exposure in all the sentinel districts except for plain brick wall surfaces in that were knocked down by the 60th minute post-exposure. However, 100 percent mortality after the 24 hour holding period was achieved in all the 4 districts. These knockdown rates indicates that the residual efficacy on plain brick and mud and wattle wall surfaces has waned by March 2016, but 100 percent mortality after the 24-hour holding period indicated that the insecticide was still effectively killing malaria vectors resting on the sprayed wall surfaces in all the study districts.

Pre-IRS pyrethrum collections in group B IRS districts In March 2016, the project conducted 84 pre-IRS PSCs in the seven sentinel sites in the seven districts of Butaleja, Dokolo, Kaberamaido, Kibuku, Namutumba, Otuke and Pallisa to assess the current indoor resting malaria vector densities. A total of 267 female vectors (175 An. gambiae s.l. and 92 An. funestus) were collected as follows: Butaleja - 128, Kaberamaido - 74, Namutumba – 37, Kibuku – 15, Pallisa – 12, Dokolo – 1 and Otuke - 0). A total of 42 and 1 unfed female Anopheles gambiae s.l. and An. funestus respectively were collected and dissected. 12 or 28.6 percent, and 0 or 0 percent Anopheles gambiae s.l. and An. funestus respectively were parous, i.e. taken a blood meal at least once and could have transmitted malaria. This indicates on-going malaria transmission in these districts ( Figure 8).

Figure 8: Number of malaria vectors collected during pre-IRS PSCs in group B IRS districts in Northern and Eastern Uganda in March 2016

An. gambiae s.l. An. funestus

140 128

120

100

80 74

60

40 33 No.of Female Vectors 20 9 6 5 7 0 0 1 0 4 0 0 0 Butaleja Dokolo Kaberamaido Kibuku Namutumba Otuke Pallisa SENTINEL DISTRICT

Results of monthly monitoring PSCs in six old IRS districts From January to March 2016, the project conducted monthly monitoring PSCs in the six old IRS districts of Amuru, Apac, Gulu, Kitgum, Oyam and Pader. A total of 1110 indoor resting female vectors (400 female Anopheles gambiae s.l. and 710 female An. funestus) were caught with the following distribution: Apac (693), Kitgum (286), Amuru (41), Pader (40), Gulu (38) and Oyam (12), and a total of 926 and 0 female Culex and Mansonia mosquito species respectively were caught in the

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six districts. The results indicate that there has been a slight decrease in malaria vectors in most of these districts. However, close monitoring of malaria cases in all of these districts using slide/RDT positivity rates and taking appropriate action and also encouraging communities to use LLINs correctly and consistently every night is still required. This indicates on-going malaria transmission in these districts. Not all houses sampled in old IRS districts during PSCs had LLINs, varying between 33.3percent and 75.0percent.

A total of 13 and 70 unfed female Anopheles gambiae s.l. and An. funestus respectively were collected and dissected. Two (2) or 15.4percent and 25 or 35.7percent Anopheles gambiae s.l. and An. funestus respectively were parous, i.e. taken a blood meal at least once and could have transmitted malaria. This indicates on-going malaria transmission in these districts. Of the houses sampled for the PSCs in the previous IRS districts on average about 61 percent had LLINs. Insectary support During this quarter, the project continued to support the Gulu University and VCD insectaries with staff (Insectary Technicians) and supplies. The insectaries have continued to supply susceptible mosquitoes for the project’s entomological monitoring activities. The project also had to terminate the contract of the vendor who was responsible for renovating the insectary building at Tororo Hospital, due to sub-standard quality of work. A revised scope of work to complete the insectary has been developed and selection, contracting and construction will take place during quarter three. 3. Business Management Project personnel During the quarter, two new staff reported to the project, including Finance Manager, Norah Kushaba who started on January 4, 2016, and M&E Manager Asaph Muhanguzi, who started on March 14, 2016. On-boarding, orientation and training was arranged for both of these staff to facilitate their transition. Reporting During the quarter, the project developed and submitted four reports to the project’s COR: monthly reports for January and February, the end of spray report (October – December 2015), and one quarterly report (October – December 2015). Property control In January 2016, the project reported the loss of one laptop, which was stolen from James Mugenyi a SM in Lira. The project submitted a loss report to USAID. Annual staff retreat During this quarter, the project held its annual retreat for all project staff from January 11-13, 2016 at Mbale Resort Hotel. The retreat was also attended by the COR. The retreat focused on discussing the challenges and lessons learned in project year three, the main priorities for transitioning to the new insecticide in year four, and agreeing on the way forward for the April-July 2016 spray period. Staff trainings From January 30 - February 06, 2016, the International Accounting Manager, Sita Magua was funded by Abt Associates Inc., to conduct finance training for the new Finance Manager and other project staff. The new M&E Manager and the COP attended the USAID M&E training from March 15- 18, 2016. The objective of the meeting was CLA orientation.

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4. Successful Interventions  The project successfully coordinated remotely with the Operations Director of the Africa Indoor Residual Spraying Project. This helped with information sharing about operations and planning, which enriched the project’s preparation for the upcoming spray exercise using OP.  The project was successful in negotiating with Arystra, the supplier of the new insecticide to provide 7000 free special, custom-made haversacks for the SOs to carry the Actellic CS bottles.  Several districts provided additional storage facilities to the project, free of charge thereby saving rental costs.  The project spearheaded the development of draft policy guidelines for the private pest control sector, which will strengthen provision of professional and high quality IRS private services, and work to eliminate unqualified service providers.  After dissemination of the dashboard results, the Assistant Commissioner in charge of vector control in MoH appreciated the progress and commented that the dashboard was an evidence- based tool that was instrumental in identifying the strengths and weaknesses in staffing at the district level.  The regional workshops on IRS exit strategies and malaria control sustainability plans conducted by the project in all the 14 districts, set in motion discussions and created awareness among the district leadership regarding the importance of interventions needed to prevent malaria upsurges once IRS programming is withdrawn from their district.

 The project is co-opting individuals from resistant communities like the organic farmers in Dokolo, Lira and Kaberamaido, and religious sects like Kanyiriri in Pallisa, Budaka and Kibuku to testify as satisfied users of IRS during radio talk shows and community dialogues. 5. Project surveillance Visit by Contracting Officer’s Representative The project’s COR visited the Tororo Insectary that is still under renovation to ascertain progress. Subsequently he provided a report to the Chief of Party (COP), detailing his observations about the quality of the work, and specifying the remaining work needed to complete the renovation process. The COP and management team in Tororo worked to conclude the existing renovation subcontract satisfactorily and are seeking to identify and engage a capable contractor to carry out the additional work, under close technical supervision. Monthly meetings with the Contracting Officer’s Representative During this quarter, the project held regular monthly meetings with the COR. These monthly meetings provide an opportunity for the COR to check-in with the project SMT regarding key issues, provide guidance on project activities, and brainstorm ideas for areas that need attention. Visit by Portfolio Manager, Technical Project Officer During this quarter, Abt Associates home office staff including Ms. Melinda Ojermark, the Portfolio Manager, and Ms. Ananya Price, the Technical Project Officer visited the project. The goal of Ms. Ojermark’s trip, which took place January 11-21, 2016 was to provide a resource to project management through participation in: 1) the annual staff retreat and 2) in the annual award fee meeting. Ms. Price’s trip was focused on coordinating and facilitating the annual staff retreat held in Mbale from January 11-13, 2016.

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6. Cost considerations During the quarter, the project ensured that all cost considerations were met in a timely and effective manner. The project ensured that all quarterly expenditures were on track, quarterly accrual reports were completed and submitted on time, and that there were no unallowable expenditures. 7. Challenges .  Rains and strong winds affected outdoor human baited net collection during the bionomic studies in all the four study districts especially in March 2016. Mosquitoes do not come outside their hiding places when there are strong winds resulting in no or minimal mosquito collection. Outdoor HBNCs are conducted in the open in the compounds and if it is raining, such activity has to be stopped. This is likely to be the case throughout the rainy season.  Until now, availability of appropriate storage in Butaleja continues to be a problem, and there is no extra storage space in Butaleja District.  The district authorities reported staffing problems in areas of recruitment, transfer and redeployment/designation of duties, which adversely impacted the capacity building of the districts. Several competing activities such as the Neglected Tropical Disease program and polio immunization campaigns led to non-availability of some district staff for IRS activities.  The activities of the electoral commission in Uganda during the campaigns and voting for presidential, parliamentary and district leaders’ positions, disrupted the plans and programs for the early commencement of community dialogues, radio talk shows and spot messages. 8. Lessons learned/recommendations  Joint sensitization of the LCIs and sub county leaders enriches the discussion and enables these officials to share their views with each other. The joint meeting saves project resources and makes maximum use of the limited technical human resources. The joint meeting also helps vet the spray team members for credibility and honesty.  It is important to train the spray team on mobilization and ensuring that they emphasize an integrated approach to malaria prevention and control. The project prolonged the training of the spray team to accommodate the training on integrated messages. The integrated message enables the community to utilize multiple preventive measures rather than solely relying on IRS for malaria control and prevention.  The project learnt important lessons when conducting training for the new insecticide. For instance the strainer if not washed properly and soaked in a bucket of water over night, clogs and distorts the spray pattern. Both the strainer and the constant flow valve, need to be soaked in a bucket of water to improve the efficiency and quality of spray.

9. Plans for next reporting period In the next quarter, the project will complete the preparations for spraying, and spray the 14 districts. During the upcoming spray period, the project will transition to a new insecticide-Actellic, and will ensure that all operational, logistical and environmental arrangements are in place for successful spraying and high coverage.

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