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USAID/Uganda's District-Based Technical Assistance (DBTA)

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ANNEX A. STATEMENT OF WORK STATEMENT OF WORK FOR EVALUATION OF USAID/UGANDA’S DISTRICT-BASED TECHNICAL ASSISTANCE (DBTA) PROJECTS, STRENGTHENING TUBERCULOSIS AND HIV/AIDS RESPONSES (STAR) PROJECTS IN EAST, EAST-CENTRAL, AND SOUTH-WEST UGANDA INTRODUCTION The STAR projects in East, East-Central, and South-West Uganda were the first in USAID/Uganda’s District Based Technical Assistance (DBTA) model featuring regional focus on improving accessibility, quality, and availability of integrated health service delivery as well as health financing and management. The STAR program is implemented by Management Sciences for Health (MSH) in East Uganda, by John Snow International (JSI) in East-Central Uganda, and by Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) in South-West Uganda, covering thirty- four districts in total. Working closely with the Ministry of Health and through district health management teams (DHMTs), district councils, health facilities, and communities, the projects’ goal is to increase access to, coverage of, and utilization of quality comprehensive HIV/AIDS and TB prevention, care, and treatment services within district health facilities and their respective communities. This will be achieved through the following objectives: (a) strengthening decentralized HIV/AIDS and TB service delivery systems; (b) improving the quality and efficiency of HIV/AIDS and TB service delivery within health facilities; (c) strengthening networks and referrals systems to improve access to, coverage of, and use of HIV/AIDS and TB services; and (d) increasing demand for comprehensive HIV/AIDS and TB prevention, care, and treatment services. All three STAR projects are designed to strengthen systems at the decentralized level to facilitate improved delivery and uptake of HIV/AIDS and TB services, including district-led performance reviews to help identify coverage and service gaps. Systems include, but are not limited to, leadership, management, health management information systems (HMIS), and human resources for health, supply chain management, SI, infrastructure, and laboratories. An efficient and transparent grant mechanism for funding and providing technical support to civil society organizations (CSOs) to facilitate behavior change and increase uptake of comprehensive services is also a critical component of these projects. This approach is closely linked to or complemented by USAID’s Strengthening Decentralization for Sustainability (SDS) project, which was designed to improve systems and coordination at the decentralized level. SDS enhances primary health care (PHC) support through quarterly coordination meetings, district-integrated supervision to health centers, transportation of lab samples, HIV/AIDS care and treatment, and monthly follow up of community-based (CB) directly observed therapy short courses (DOTSs). Some of these activities were initially covered under the STAR portfolio (i.e., the healthcare management support led by districts) until a decision was made to transition the activities to SDS as part of Grant A activities. While the SDS project itself will not be part of this evaluation, it will be valuable to understand how it was implemented and how it collaborated with the STARs to affect the anticipated project outcomes. USAID/UGANDA’S DBTA MODEL AS APPLIED UNDER STAR PROJECTS IN EAST, EAST-CENTRAL, AND SOUTH-WEST UGANDA 41 STAR-E and STAR-EC began in 2010 and STAR-SW started in 2011, all were scheduled to end together in March 2015. This document outlines a statement of work for a program evaluation of the three STAR projects as one comprehensive program across three geographical regions. EVALUATION Purpose of the Evaluation The purpose of the evaluation is to establish the extent of efficiency and effectiveness of the USAID/Uganda’s District Based Technical Assistance (DBTA) project model that features comprehensive and integrated service delivery towards improving access, quality and availability of integrated health service delivery as well as health financing and management tailored for specific regions. Integrated regional based health service delivery approaches are a key feature of the current USAID Uganda’s Development Objective 3 targeted at improving health and nutrition in targeted populations. This evaluation will therefore provide key lessons on the implementation process and value of the approach. Note that the focus is not so much on what targets have been achieved as this is already largely known from the ongoing performance monitoring processes, but more on understanding how this model and approach applied across the different regions affected the project outcomes. Audience The primary user of the evaluation findings is USAID /Uganda Mission staff, other United States government agencies; USAID funded implementing partners (IPs), Ministry of Health, and other national and international stakeholders with interest in decentralized HIV/AIDS programing and SI systems. Evaluation Questions Specific questions to be addressed by the evaluation will be divided into: (1) improved capacity and sustainability, (2) service delivery, and (3) cost efficiency. Improved Capacity and Sustainability The DBTAs were designed to strengthen decentralized service delivery systems for improved uptake of quality HIV/AIDS and TB services, including the institutionalization of evidence-based program management. Improved district capacity is defined/manifested as the district’s ability to: Deliver quality health services that meet national and/or international standards Provide leadership, management, functional health management information systems (HMIS), human resources for health, supply chain management, financial management systems, SI, physical infrastructure including laboratories for the delivery of quality health services CSOs’ increased advocacy for efficient and effective service delivery within the health sector Sustainability is important for the results achieved through these investments to continue making a difference into the future. The deliberate focus on working with the district local governments as the key provider of health services was to ensure that structures, processes and resources are strengthened, functional and in place to continue providing services even after the end of USAID’s support. This evaluation will attempt to inform the USAID Uganda Mission on the likelihood that results of the DBTA program can be sustained after USAID support. The evaluation will answer the following questions in this regard: 42 USAID/UGANDA’S DBTA MODEL AS APPLIED UNDER STAR PROJECTS IN EAST, EAST-CENTRAL, AND SOUTH-WEST UGANDA 1. Approaches utilized by the STARs to strengthen districts and local governments to deliver health services, have differed and evolved over time. What are: a) the most successful and b) least successful approaches applied by STAR-E, STAR-EC and STAR- SW respectively towards strengthening the institutional, management, and human capacity of CSOs and local governments to deliver health services? What are the facilitators and barriers of these approaches to achieving results? Are the approaches used and results achieved for old/established and relatively new/naive districts significantly different? 2. What was the effect of transition of direct implementation of district led health care management activities from the STARs projects to district grants through SDS? 3. To what extent has the STARS program developed, established and/or strengthened management and technical structures at the local government and health facility levels that will sustainably improve quality, availability and accessibility of HIV/AIDS and TB services? 4. What technical capacity in strategic information have the STARs developed, built and/or strengthened? Where has this capacity been developed, built and or strengthened? How is it manifested/demonstrated? How sustainable is this capacity after the STARs’ exit? Service delivery 5. How has the support by the STARs contributed to improved health service delivery? What are the Service delivery outcomes attributed to the DBTAs (USAID is not asking for a rigorous impact evaluation here; the team may use comparisons it deems appropriate)? 6. What was the effect of integration of HIV/TB, HIV/Family Planning, HIV/AIDS and health on overall health outcomes? Cost Efficiency Efficiency refers to the transformation of inputs into results. It is the extent to which the STARS program has converted its resources economically into results in order to achieve the maximum possible outputs, outcomes, and impacts with the minimum possible inputs. This analysis will include desk analysis of data and documents on each of the three projects. The primary question to be answered by the evaluation is: 7. To what extent can the DBTA design be considered cost efficient in strengthening capacity of districts and CSOs to improve health service delivery? Evaluation team is encouraged to make use of the recent PEPFAR expenditure analysis. METHODOLOGY The evaluation will apply cross-sectional design using mixed method approach i.e. using both quantitative and qualitative methods. The evaluation team will in build before and after methods to understand changes that could be linked to the program. The evaluation team is expected to propose and use sound sampling techniques to determine districts, CSOs and facilities to be visited and from which data will be collected. Suggested data collection methods include: USAID/UGANDA’S DBTA MODEL AS APPLIED UNDER STAR PROJECTS IN EAST, EAST-CENTRAL,
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