Uganda Voucher Plus Activity

Quarterly Report

Year 2, Quarter 2 report January 1 – March 31, 2017

Submitted: 30th April 2017 The Voucher Plus Activity produced this document for review by the United States Agency for International Development. Abt Associates prepared this document with significant input from partners.

Activity No: AID-617-LA-16-00001

Submitted to: Rhobbinah Ssempebwa, Agreement Officer’s Representative USAID Uganda

Prepared by: Abt Associates

In collaboration and partnership with:

Baylor College of Medicine Children’s Foundation Uganda (Baylor-Uganda) Communication for Development Foundation Uganda (CDFU) PricewaterhouseCoopers (pwc)

DISCLAIMER The author’s views expressed in this publication 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 ...... 2

Acronyms...... 3

Executive Summary ...... 5

1. Introduction ...... 7

1.1 Overview of the Results Framework for the Uganda Voucher Plus Activity ...... 7

1.2 Stakeholder Coordination and Collaboration ...... 8

2. Voucher Management Agency Activities ...... 10

3. Activities by Intermediate Result (IR)...... 12 3.1 IR1: Increased Utilization of High-Quality Voucher-Covered MNCH and FP Services in Designated Program Districts ...... 12 3.2 IR 2: Increased Capacity of Uganda’s Public and Private Sectors to Develop Longer Term Health Financing Options ...... 26

4. Program Management ...... 27

5. Activity Monitoring, Evaluation, and Learning ...... 27

6. Quarter 3, Year 2 Planned Activities ...... 29

Annex 1: Voucher Plus Best Practices, Lessons Learned, and Emerging Issues ...... 30

Best Practices and Lessons Learned ...... 30

Emerging issues ...... 30

Annex 2: Voucher Plus Success Stories ...... 32

Annex 3: Voucher Plus Progress Against the AMELP ...... 35

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Acronyms

ACP AIDS Control Program AIDS Acquired Immunodeficiency Syndrome AMELP Activity Monitoring Evaluation and Learning Plan ANC Antenatal Care ART Antiretroviral Therapy Baylor-Uganda Baylor College of Medicine Children’s Foundation Uganda BCC Behavior Change Communication BEmONC Basic Emergency Obstetric and Newborn Care CEmONC Comprehensive Emergency Obstetric and Newborn Care CDFU Communication for Development Foundation Uganda CHC Communication for Healthy Communities DHGS Director General of Health Services DHO District Health Office DHT District Health Teams EmONC Emergency Obstetric and Neonatal Care eMTCT Elimination of Mother to Child Transmission FP Family Planning GOU Government of Uganda HA Health Assistant HC Health Center HIV Human Immunodeficiency Virus HMIS Health Management Information System IEC Information, Education, Communication IP Implementing Partner IR Intermediate Result IVEA Independent Verification and Evaluation Agency LC Local Council M&E Monitoring and Evaluation MCH Maternal and Child Health METS Monitoring and Evaluation Technical Support Program MNCH Maternal, Neonatal and Child Health MOH Ministry of Health MOU Memorandum of Understanding PGT Poverty Grading Tool PHSP Private Health Support Program PMTCT Prevention of Mother to Child Transmission PNC Postnatal Care PNFP Private Not For Profit PPFP Postpartum Family Planning PWC PricewaterhouseCoopers QED QED Group LLC RBF Results Based Financing RH Reproductive Health

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RMNH Reproductive, Maternal, and Neonatal Health RMNCH Reproductive, Maternal, Neonatal, and Child Health SBCCO Social Behavior Change Communications Officer UGX Ugandan Shilling UHF Uganda Healthcare Federation USAID United States Agency for International Development USG United States Government UTI Urinary Tract Infection VCBD Voucher Community Based Distributor VHT Village Health Team VMA Voucher Management Agency VMIS Voucher Management Information System VSP Voucher Service Provider WB World Bank

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Executive Summary

The Uganda Voucher Plus Activity is designed to increase health services for pregnant women by promoting safe, facility-based deliveries to reduce maternal and neonatal morbidity and mortality. The Activity improves access to quality maternal and neonatal health services by recruiting private sector providers and building their technical capacity to deliver quality services to pregnant women and to process payments for services rendered.

The Uganda Voucher Plus Activity comprises the following partners:

 Abt Associates is the prime contractor, responsible for activity management and sequencing, oversight, monitoring and evaluation (M&E), and learning to inform the Government of Uganda (GOU) on health financing schemes.  With Abt Associates oversite, Baylor College of Medicine Children’s Foundation Uganda (Baylor-Uganda) is the training, quality assurance and accreditation agency for private providers.  Communication for Development Foundation Uganda (CDFU) is the community engagement agency to mobilize communities and utilize village health teams (VHTs) to distribute vouchers as Voucher Community Based Distributors (VCBDs).  PricewaterhouseCoopers (pwc) is the voucher management agency (VMA) that is managing provider claims and the reimbursement processes.  On December 7, 2016, Abt Associates submitted a request for approval of the independent verification and evaluation agency (IVEA) that will audit and ensure accountability in the voucher activity to USAID. We responded to questions from USAID in February and March 2017, and we are now waiting for the approval before we contract the IVEA.

Summary of Year 2, Quarter 2 Activities

The Activity increased voucher distribution and service delivery resulting in a cumulative sale of 45,114 vouchers since October 2016. By 31 March 2017, the Activity registered 8,321 deliveries and a 70 percent redemption rate for at least 1 service of the voucher benefits package. The Activity reimbursed UGX 713,150,670 to accredited private providers for services provided since October 2016.

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The Activity expanded to the northern region, and by 31 March 2017, 157 private providers were actively providing RMNCH services to voucher-holders in both east and norther Uganda.

Stakeholder collaboration continues to be extremely important to take advantage of all opportunities for synergy with other implementing partners, and ensure the appropriate learning agenda.

The Activity addressed quality of care deficiencies identified by the team in private providers performing RMNCH voucher-redeemable services. The team identified a number of private providers who were not actually qualified to participate in the voucher activity. This discovery prompted the Activity team to undertake a rigorous validation exercise, conduct thorough district based key stakeholder meetings, and provide intensive technical supportive supervision. By end of quarter 2, the validation exercise was completed in northern Uganda and voucher distribution in communities surrounding 12 providers were suspended to allow proprietors of the affected facilities fix the gaps identified in their facilities or risk being terminated. The validation exercise will now take place in eastern Uganda. In quarter 3, the Activity will review the field-based capacity and re-organize management of activities to ensure robust support for continuous quality improvement.

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1. Introduction

The Uganda Voucher Plus Activity is designed to increase health services for pregnant women by promoting safe, facility-based deliveries to reduce maternal and neonatal morbidity and mortality. 1.1 Overview of the Results Framework for the Uganda Voucher Plus Activity The Results Framework presented in the revised Activity Monitoring and Evaluation Plan (AMELP) of April 2017 follows in Figure 1 below. This is provisionary until USAID approves it.

Figure 1: Results Framework for the Voucher Plus Activity

Critical Development Objective 3: Assumptions Improved health and nutritional status in focus areas and 1. Stable political population groups environment with no civil unrest, climatic shock or conflict such that demand generation Strategic Objective: and service delivery Provide measureable improvements in safe motherhood services by activities can be implemented supporting health-financing and innovative service delivery models in effectively. the private sector

2. Adequate funds available to implement of the Voucher Plus Activity. IR1: Use of comprehensive IR2: Local capacity to manage 3. MOH and obstetric care and postpartum FP and scale up results-based health- District leadership in the East and services for the poor increased financing programs strengthened North utilize the knowledge and capacity gained through the Activity to mainstream innovative RBF SIR 1.1: SIR 1.2: SIR 1.3: SIR 2.1: SIR 2.2: mechanisms in their Demand Access to Quality of Capacity of Evidence and health systems and local planning and for MNCH implementati availability of organizatio budgeting. comprehen and FP on lessons sive comprehensi services at ns and from the ve obstetric private 4. Stability in market obstetric Participati voucher Plus prices for medical care and clinics in care and ng Private Activity supplies and postpartum implementi postpartum Sector documented equipment FP services ng voucher FP services improved Facilities is schemes and increased improved. improved disseminated IR 1 focuses on increasing utilization of high-quality RMNCH services, including postpartum family planning (PPFP). Project activities support this IR through three sub-IRs and these are to:

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 Build demand for voucher-covered services in the private sector among low-income populations.  Improve access to private sector RMNCH and FP services.  Improve quality of relevant services at participating private health facilities.

IR 2 will increase the capacity of Uganda’s public and private sectors to develop health financing options that provide mechanisms targeting poor pregnant women, including adolescents, to access quality safe motherhood services. The activity establishes a safety net for at-risk populations to avoid high out-of-pocket expenditures and at times catastrophic health expenditure to attain quality RMNCH services in the private sector.

IR 2 will be achieved through two sub-IRs that concentrate on strengthening the capacity of Ugandan local organizations (including private sector facilities) to implement this fee for service output based financing mechanism, including collaborating and learning from other results based financing (RBF) and voucher activities in Uganda.

The team will generate and disseminate evidence and data to support the GOU as it considers RBF mechanisms to increase the effectiveness and efficiency of providing universal health coverage for vulnerable populations.

1.2 Stakeholder Coordination and Collaboration

Stakeholder coordination and collaboration continues to be a high priority agenda for the Activity team, and we continue to seek opportunities for learning, collaboration and sharing lessons. Table 1 gives a summary of other meetings and collaboration.

Table 1: Summary of Key Coordination and Collaboration Meetings during Quarter 2

Stakeholder Main contacts Objectives

MOH MCH cluster Dr. Dinah Nakiganda- The Activity staff attended the monthly Maternal Busiku (Acting Assistant Child Health (MCH) cluster meetings held at MOH Commissioner, during Quarter 2. Reproductive Health) Communications Ms. Nantogo Edith Partnership in orientation of VCBDs on for Health (Behavior Change interpersonal communication (IPC) in the semi- Communities Coordinator) annual VCBD meeting in Soroti. (CHC) Project MOH/ WB RHVP John Sengendo Share experiences on RBF and Voucher schemes and Project Coordinator discuss terms alignment of Uganda Voucher Plus MOH/RBF Unit Activity IR2 objectives to the MoH RBF agenda MoH John Sengendo Stakeholder information sharing meeting on the Coordinator Uganda Reproductive Health Voucher Project MOH/RBF Unit

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Stakeholder Main contacts Objectives

MOH Dr Mihayo Placcid - FP Review of Uganda country work plan to increase Focal Person Ministry of contraceptive uptake in the post-partum Health USAID PHSP Dr. Dithan Kirega, Presentation of the first ever private sector Project COP, UPHSP assessment in Uganda and launch of the PSA assessment report WB/MoH Dr Peter Okwero Global Finance facility discussion on area Health Advisor private sector potential role in increasing access to World Bank maternal and child health to urban poor women MoH/UHF Dr Timothy Musila Review of the Uganda Private Health Sector PPPH Node, MoH Strategy. The Activity has also been active in the PPPH technical working group discussions during the quarter Uganda Healthcare Grace Ssali Kiwanuka Dialogue on melding the various certification and Federation Executive Director, accreditation tools available, and how the Private UHF Health Practitioners (PHP) sub-sector can align on certification and accreditation going forward. The meeting also considered how Self-regulatory Quality Improvement System toolkit (SQIS) would relate to the planned PHP Accreditation System and set the pace for the development of a single digital tool for use by all parties. District leaders in District Health Team To seek collaboration & joint working relations in the Eastern and members and sub oversight and implementation of voucher activities. Northern regions county leaders

District stakeholders’ meeting During the quarter, the Activity conducted district meetings with key district stakeholders and private providers participating in the Uganda Voucher Plus Activity from eastern Uganda. The meetings were driven by the increasing quality of care issues, including a few referrals to the public sector that resulted in a maternal death or poor outcome, given lack of adequate EmONC supplies at referral facilities. In addition, the meetings sought to:

1. Re-introduce the Uganda Voucher Plus Activity to new district leaders who missed the district inception meetings held at the start of this Activity. 2. Introduce the private providers working in the districts to the district leadership, especially the district health team, to foster good collaborative relationships. 3. Update the district leadership on the progress of the Activity in their respective districts.

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The meetings provided the opportunity to engage the district leaders and the proprietors in addressing the quality of care challenges identified among the Activity providers. District leaders agreed to work with the Activity in support supervision of private facilities to improve the quality challenges.

2. Voucher Management Agency Activities

Contracting of Providers At inception, the Activity signed letters of intent with 160 private health facilities while awaiting approval of the clinical service contract by USAID. The contract was approved as of March 31, 2017, and a total 155 health facilities have contracted to provide voucher services. Voucher production As of March 31, 2017, the Activity has printed122,400 vouchers with pouches. The team has fully verified the correct barcoding and serialization for the printed vouchers. The table below shows the status of voucher printing, verification and distribution process. Table 2: Summary of Voucher Production to-date Description No. of vouchers Expected no. of vouchers for Year 2 122,400 Actual no. of vouchers printed to-date 122,400 No. of vouchers verified and scanned 122,400 No. of vouchers issued and distributed to CDFU 51,634

Provider reimbursements Since January, provider re-imbursements have been on the upward trend mainly attributable to the fact that voucher service private providers (VSPs) are becoming familiar with the voucher invoicing process and requirements. The tables and charts below summarize the re- imbursement trends of January-March 2017. Table 3: Summary of Payments Made in UGX to Voucher Service Providers: January- March 2017

Month, Amount Amount paid Quarantined Rejected 2017 expected amount amount January 269,951,180 146,458,775 6,418,855 711,069 February 304,055,821 193,047,510 19,563,635 955,612 March 623,586,274 373,644,385 70,994,984 13,313,191 Total 1,197,593,275 713,150,670 96,977,474 14,979,872

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During claims processing, vetters examine each claim individually to determine if it meets Activity standards of care and merits reimbursement. Amount expected refers to the amount expected by the VSP as stated in the submitted claims. Amount paid refers to the amount paid to the VSPs after vetting the claims.

The expected amount has generally been higher than the paid amount. During vetting, claim amounts often reduce after scrutiny. Depending on the vetter’s fndings, the claim may be approved in whole, approved with some deductions, quarantined or rejected. Most claims that have been quarantined or rejected are because VSPs have not fully understood how to fill in the claim form, instead requesting lump sum payments without disaggregating voucher services delivered. Table 4 summarizes common reasons why a claim may be quarantined or rejected

Table 4: Decision tree for claim review process

Decision Reason Approved in whole  Claim meets all quality standards of the Activity Approved with some  Appropriate service provided deductions  Some parts of the care package were not provided  Quoting of drug prices above the Activity set prices Quarantined  Insufficient information provided to help make the decision  No presenting complaints to justify treatment of complications  No poverty grading tool (PGT) record in the system  Not attaching lab results to confirm diagnosis of the complications.  Postnatal visits that have no previous visit of delivery  Client’s name and voucher number not matching  Not attaching voucher stickers.  Lack of clinical notes to explain management of complications Rejected  Claiming for conditions not covered under the Activity.  PGT score above 12.  PNC dates coming earlier than delivery date  Short period between ANC visits contrary to Ministry of Health guidelines.

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3. Activities by Intermediate Result (IR)

3.1 IR1: Increased Utilization of High-Quality Voucher-Covered MNCH and FP Services in Designated Program Districts

Sub-IR 1.1 Demand for Maternal, Neonatal, and Child Health and FP Services in the Private Sector by the Poor Created in Designated Program Districts

Community sensitization meetings

Fifty-two community sensitization meetings were conducted in 18 districts in the Northern and Eastern regions, reaching 5,153 people with RMNCH messages. Of these 1,229 were youths (399 males & 830 females) and 3,924 adults (1,207 males & 2,717 females).

The objective for the sensitization meetings was to lobby support from the sub county stakeholders by sharing the events and issues affecting Voucher distribution in the particular areas. Sub county Chiefs, LCIII chairpersons, Community Development Officers (CDOs) based at the sub county, Health Assistants (HAs), VHT coordinators, Voucher Plus facility in charges or owners, Voucher Community Based Distributors (VCBDs) and other community members attended the meetings. Voucher Community Based Distributors (VCBD) training Four Voucher Community Based Distributors (VCBDs) training workshops were held in the Northern region in the districts of , Kitgum and Lira. One hundred and thirty-one VCBDs of which 69 were males and 62 female resulting in 314 VCBDs trained and actively distributing vouchers.

Voucher distribution

VCBDs sold 29,026 vouchers in quarter 2, against the quarterly target of 30,600, resulting in an achievement of 95%. The tables below provide voucher sales summary information through quarter 2.

Table 5: Quarter voucher sales performance analysis Quarter 1 Target Quarter 2 Achievement % achievement Voucher Sales 30,600 29,026 95%

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Table 6: Cumulative voucher sales Year 1 Year 2 Cumulative Half Year Half Year % Voucher Target Target Target Target Achievement* achievement Sales 2,400 120,000 122,400 61,200 45,114 74% * Half Year achievement represents 73.7% achievement of the cumulative target

In comparison to the year-to-date performance, the Activity has sold 45,114 vouchers since October 2016, representing 74 percent achievements against the annual sales target of 122,400. The Activity budgeted to sell 2,400 vouchers in year 1 and 120,000 in Year 2 equalling 122,400 total vouchers sold in the first two years. Figure 2: Quarterly trend analysis for voucher sales vs. targets Further analysis 70,000 Quarterly Voucher Sales vs. Targets 61,200 shows that the 60,000 Activity registered

50,000 45,114 an average

40,000 monthly sale of 30,600 30,600 7,519 vouchers 29,026 30,000 over the last six 20,000 16,088 months. Quarter 2 10,000 registered a

0 growth of 55 Quarter 1 Quarter II Half Year percent against Performance Target quarter 1 sales given the Activity’s expansion into the Northern districts in January 2017 Table 7 shows the sales performance based on region. Eastern region registered 64 percent of the total year-to-date sales compared to the Northern region at 36 percent. We attribute lower sales in the Northern districts to the fact that sales in Northern region started late January 2017, three months later than the Eastern region. In addition, of the 156 facilities accredited on the Voucher Plus Activity, the Eastern region, with 96 (66%) facilities, has a higher potential for voucher sales compared to the northern region with 60 (34%) facilities. Table 7: Cumulative YTD voucher sales by Region Region Total Percent of Sales Eastern 28,641 64% Northern 16,473 36% Total 45,114

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To improve voucher sales performance and get the Activity on track to achieve the year 2 annual targeted sales of 122,400 vouchers, media and community sensitization activities will be increased during the next two quarters. The newly acquired five motorcycles for the social behavior change communication officers (SBCCOs) will accelerate support supervision of VCBDS and ensure consistent availability of vouchers at community level.

Client follow-ups to ensure utilization of voucher supported services

A total of 675 clients were followed up at their homes to Figure 3 Voucher Redemption Status encourage them use the full benefits package as provided by the Activity and monitor voucher utilization. Among those visited 532 were still pregnant and attending ANC services, Unredeemed 80 of the clients had delivered and 50 out of those who had 40% delivered utilized PNC services. Since inception of sales in Redeemed 60% October of 2016, VCBDs have sold 45,144 vouchers. Sixty percent of the total women holding vouchers in through this Activity have utilized the voucher for at least any service (see Figure 3 right). Comparing utilization by region, more vouchers (68%) were redeemed in the Eastern region compared to the Northern region. See Table 8 below.

Table 8: Voucher redemption by region

Region Redeemed Unredeemed Total % Redemption

Eastern 18,812 9,829 28,641 65.7%

Northern 8,188 8,285 16,473 49.7%

Total 27,000 18,114 45,114 59.8%

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Demand creation for voucher covered services Figure 4 Developing IEC and promotional materials. In quarter 2, the Activity adopted and printed the revised Communications for Healthy Communities’ project (CHC) information, education and communication (IEC) materials on danger signs in pregnancy and pregnancy care planner. They will be distributed to facilities, and displayed at strategic locations within communities during quarter 3 of year 2.

A total of 500 t-shirts and 350 bags for VCBDS were also produced to increase visibility and awareness of the Voucher Plus Activity in the communities. We also produced VCBD IDs to help clients identify the VCBDs in communities, and avoid impersonation by unauthorised distributors. Distribution of all these items commenced in March and will continue into the next quarter.

Mass media campaigns.

The Activity continued to use radio media to create mass awareness of the voucher services. Radio talk shows during this period focused on two main objectives including to explain the voucher service package and where services should be accessed, and emphasize the importance of maternal health care services during pregnancies. Activity staff together with district stakeholders including district health officers (DHOs), district health educators (DHEs), and VSPs, hosted 16 radio talk shows this quarter in both Northern and Eastern districts attracting 146 callers (37 Females and 109 Males).

Community dialogues. To address negative propaganda by religious and cultural leaders against Voucher services, 33 community dialogues were conducted in the Eastern districts of Kapchorwa, Ngora, Serere, Sironko, Butaleja, Budaka and Manafwa in this quarter. The Activity actively engaged community leaders from two districts in Eastern Uganda, whereby voucher sales had ceased because of claims that the vouchers were “devilish,” to demystify the misperceptions held in communities. As a result, voucher sales resumed in these districts.

The Community dialogues conducted in seven districts reached 835 people: 121 Youths (57 M, 64 F) and 714 Adults (163 M, 551 F). The people involved in these meetings included local leaders, religious leaders, some of the voucher clients, VCBDs and VHTs, facility proprietors, in-charges and providers at the participating health facilities. The team also held three “men only” dialogues in Butaleja to promote male involvement. Male only dialogues were conducted in Bubalya, Gampe and Bingu villages in Busolwe and Nawaguffu Sub counties reaching 66 men. Uganda Voucher Plus Activity Page 15

Sub-IR 1.2 Access to comprehensive MNCH and FP services in the private sector improved By the end of the review period, 60 VSPs in Northern Uganda and 96 in Eastern Uganda were implementing the Activity. By 31 March 2017, the Activity was operational in 30 districts across the two regions.

Deliveries in participating facilities paid for by the Voucher Plus Activity for the period January – March 2017

Increasing the proportion of women who deliver in a health facility is an important means of reducing maternal mortality and morbidity amongst participating districts. The Activity aims to reduce maternal and infant mortality through increased utilization of facility delivery services.

Table 9: Number of deliveries achieved against the quarterly target Quarter 2 Quarter 2 Achievement % achievement Deliveries in Target Voucher facilities 21,420 6,205 29.0%

During the quarter, VSPs registered 6,205 deliveries across the voucher implementing facilities. The statistics represent twenty-nine percent achievement of the quarterly target, and an increase of 34 percent over quarter 1 that registered 2116. The increase in deliveries in quarter 2 against quarter 1 indicates growth in demand for vouchers and the fact that women buy vouchers at different gestation periods. A number of women who bought vouchers in quarter 1 were still pregnant by 31 December 2016.

Cumulatively, providers registered 8,321 deliveries since the beginning of Activity year 2, representing 9.7 percent achievement of year 2 targets as detailed in the table 10 below.

Table 10: Cumulative deliveries against YTD target Year 2 Half Year Half Year % half year % cumulative Deliveries in Target Target Achievement achievement achievement voucher facilities 85,680 42,840 8,321 19.4% 9.7%

The proportion of women 18 years or less who delivered on the voucher Activity is 10.8 percent, while the cumulative figure (since October 2016) is 10 percent.

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Figure 5: Trend of deliveries in participating facilities Figure 5 highlights the Trend of deliveries in participating facilities monthly trend in 4,000 3,476 deliveries from the 3,500 first delivery 3,000 2,723 registered on 18 2,500 1,993 2,000 October 2016. Since 1,500 1,217 the commencement of 1,000 787 service delivery, there

500 112 has been an upward - trend in the number of Oct.16 Nov.16 Dec.16 Jan.17 Feb.17 Mar.17 deliveries registered. Delivery

Figure 6: Quarterly trend analysis of deliveries The Activity registered approximately 10 percent of quarter I target and an improvement of 30 percent against the quarter 2 target. Cumulatively, 8,321 of the target 85,680 deliveries have been registered. This performance is attributed to late start in service delivery, and delayed completion of critical voucher management start-up activities.

Disaggregation of deliveries by type

Data collected on disaggregation by delivery type has shown that over eighty percent of the deliveries are usually normal, only a few (approximately 6%) end up into caesarean sections, all of which fall within the expected normal ranges. The proportion of assisted deliveries take up approximately 10 percent of the total deliveries as highlighted in the table below.

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Table 11: Disaggregation of deliveries by type Quarter 2 Cumulative Delivery Type

Number Percent Number Percent Normal 5,178 83.4% 6,981 83.9% Assisted 648 10.4% 831 10.0% Caesarian Section 379 6.2% 509 6.1% Total 6,205 8,321

Antenatal, Postnatal and Family Planning Service utilization

ANC 1 and two had the highest redeemed vouchers during the quarter. The total number of ANC I vouchers redeemed represent 53 percent achievement of the quarter’s targets while ANC 2 vouchers redeemed represent approximately fifty six percent redemption of the quarter’s target.

Table12: Summary of ANC, PNC and PPFP the quarterly performance against targets Indicator Quarter 2 Target Quarter 2 % achievement Achievement

ANC 1 28,764 15,236 53.0%

ANC 2 15,300 8,488 55.5%

ANC 3 15,300 4,438 29.3%

ANC 4 14,382 1,963 13.6%

PNC 10,710 3,637 34.1%

Postpartum FP 6,426 1,318 20.5%

Cumulatively, 24,104 ANC I visit clients have registered, this represents 20.9% achievement of the annual target. Achievement of Year II targets is lowest for ANC 4th visits (3.8%), postpartum family planning (6.7%) and postnatal care (10.7%) as detailed in the table below.

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Table 13: Summary of cumulative performance against targets Year 2 Half Year Half Year % half year % cumulative Indicator Target Target Achievement achievement achievement

ANC 1 115,056 57,528 24,104 41.9% 20.9%

ANC 2 61,200 30,600 11,417 37.3% 18.7%

ANC 3 61,200 30,600 5,160 16.9% 8.4%

ANC 4 57,528 28,764 2,192 7.6% 3.8%

PNC 42,840 21,420 4,564 21.3% 10.7%

PPFP 25,704 12,852 1,721 13.4% 6.7%

Postpartum Family Planning Service utilization

Postpartum family planning provides an opportunity to meet the needs of women who want to prevent unintended pregnancies or who want to delay having more children especially in the first 12 months following childbirth. At least seven in every ten mothers who delivered from a voucher facility were counselled for family planning. The proportion of mothers counselled for family planning increased gradually from 71.4 percent in quarter I to 87.6 percent in quarter 2 as highlighted in the table below.

Table 14: Number of clients counselled for PPFP Indicator Quarter I Quarter II Cumulative # % # % # %

Counselled for PPFP 1,510 71.4% 5,438 87.6% 6,948 83.5% Not Counselled for PPFP 606 28.6% 767 12.4% 1,373 16.5%

Total 2,116 6,205 8,321

The Activity finds 16.5% “not counselled” high given our strong emphasis on comprehensive counselling for all clients at all facilities. However, this situation can be attributed to two main reasons: 1. Providers forgetting to complete the claim form well even when they have counselled. 2. Some providers claim that FP counselling is tedious if done on individual client basis as opposed to a group sessions since many of their voucher clients walk in for ANC any day.

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Disaggregation of Postpartum Family Planning users by Method

Utilization of postpartum family planning services has gradually increased. Utilization of short- term FP methods more than tripled from quarter I to quarter 2. The most preferred short term family planning methods are Lactational Amenorrhea Method, injectable and male condoms as detailed in the table below.

Table 15: Summary of PPFP by short-term acting FP methods Quarter I Quarter II Cumulative Method Achievement Achievement Achievement Contraceptive pills 6 5 11 Male condoms 90 160 250 Female condoms 13 18 31 Injectable 98 340 438 Lactational Amenorrhea Method 91 460 551 Rhythm/ Moon beads 17 92 109 Other (Withdraw) 4 6 10 Total 319 1,081 1,400

Long-term and permanent FP methods

Utilization of long term and permanent methods increased during the quarter, with implants emerging as the most preferred method. The activity has cumulatively registered a total of 97 female sterilizations and 88 IUCDs as detailed in the table below.

Table 16: Summary of PPFP by long-term FP methods Quarter I Quarter II Cumulative Method Achievement Achievement Achievement

21 115 136 Implants 31 57 88 IUCDs 32 65 97 BTLs 84 237 321 Total

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Challenges noted in up-take of PPFP services

 Facilities affiliated to Uganda Catholic Medical Bureau (UCMB) facilities do not offer modern FP.  UCMB facilities do not counsel on modern FP services. UCMB focus their FP counselling on traditional methods.  Poor linkage to care for PPFP from UCMB and other non-FP facilities to FP facilities.  Lack of knowledge and skills in comprehensive FP by providers.  Many facilities at district level lack consistent supply chain, and do not have a stable supply of FP commodities, with frequent stock outs.  Many facilities do not have the equipment and infrastructure necessary to offer long acting reversible methods of FP.  Low demand for FP services due to wide spread community myths about FP.  Low male involvement in FP services.

Addressing the PPF Challenges The Activity has identified various opportunities below for improvements in FP service provision to ensure that every woman who needs FP services has access to comprehensive information and a FP method of her choice:  Use the VCBDs to integrate FP messaging into the maternal health community sensitization activities to improve demand and target men.  Use the planned comprehensive FP training by Uganda Voucher Plus Activity for providers to address provider knowledge and skill gaps in FP.  Collaborate with UCMB to encourage the UCMB-affiliated facilities to counsel women on comprehensive FP and refer for modern methods.  Collaboration with existing FP implementing partners to create linkages and referral for clients from catholic based facilities who want to access modern FP.  Collaborate with MOH and UHMG through the alternate RH commodity security supply chain to link all voucher facilities to access free FP commodities.  Start on-site mentorships after classroom FP trainings to ensure providers are able to transfer the learned skills into practice at their work stations

HIV/AIDS Service utilization Globally, approximately 90 percent of children get HIV from their mothers during pregnancy, delivery, and breastfeeding. In Uganda, vertical HIV transmission historically ranked second to sexual transmission as the predominant mode of HIV infection in the country, accounting for about 20 percent of new infections. However, after implementing Option B+ for the past three

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years, there has been a dramatic reduction in new vertical infections from 25,000 in 2000 to about 3,486 in 2015 (spectrum estimates 2015). Under the guidance of the current national policy of “Test & Treat”, the Uganda Voucher Plus Activity is supporting private providers to ensure all voucher clients access HIV testing during ANC and those who are confirmed positive access ART as well as their exposed babies.

The total number of HIV tests conducted more than doubled in quarter 2 against quarter 1. The positivity rate also rose by 0.6 percent from 1.5 percent last quarter to 2.1 percent in quarter2.

Table 17: Summary of HIV/AIDS tests conducted by the Voucher Activity Period/ Status Negative Positive Total Positivity Rate Quarter I 14,648 219 14,867 1.5% Quarter II 35,593 756 36,349 2.1% Total 50,241 975 51,216 1.9%

Initiation on HIV positive mothers on EMTCT

Elimination of HIV transmission from mother to child (eMTCT) reduces infant mortality and is a first line of defense against the spread of the epidemic. During the quarter, a decline in the number of clients initiated on eMTCT was registered, dropping from 52.5 percent in quarter 1 to 38.9 percent in the current. The HIV positive voucher clients who are not initiated under eMTCT within the voucher facilities are usually referred out to nearby ART accredited facilities that may not be on the voucher and hence we do not capture their statistics. The main reason HIV positive mothers are not initiated on eMTCT within voucher facilities is that some voucher facilities are currently not accredited by MOH to offer ARVs and hence have no ARVs to initiate HIV positive clients under eMTCT.

Addressing the eMTCT challenge At the start of the Activity, the team noted that 94 of the 160 approved private facilities were not accredited to provide ART services. During quarter1, the Activity team engaged the MOH– AIDS Control Programme (ACP) team who worked with the District HIV focal persons at the District Health Offices (DHOs) in both the Eastern and Northern region to assess the 94 facilities for possible accreditation to offer Antiretroviral Therapy (ART) under the eMTCT service component. The results of this exercise indicated the following:  Eleven sites meet all the requirements and were forwarded to the Director General of Health Service (DGHS) for approval;

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 44 sites need training on ART provision course of a second staff before accreditation is done;  31sites need improvements in infrastructure, counselling room, functional laboratory, and storage facilities;  41 sites need to start HIV testing services as entry point to ART; and  Six sites need to recruit qualified staff.

The following strategies will be implemented in quarter 3 to ensure access to HIV testing and enrollment onto ART treatment for every HIV positive mother:  Work with MoH/ACP to expedite the letters of ART accreditation for the 11 sites that meet requirements from DGHS/MoH;  Collaborate with DHOs to foster effective eMTCT linkages with public sector facilities for facilities that didn’t meet accreditation standards;  Collaborate with MoH/ACP, DHO & district HIV focal persons to conduct trainings for 44 facilities whose only problem is missing a second staff trained in ART before a repeat accreditation exercise is conducted;  Work with 31 facilities that need support in other capacity such as infrastructure improvements, counselling space, lab strengthening, and good storage facilities. The Activity will work with the proprietors to ensure the required capacity needs are in place before a repeat accreditation exercise is conducted; and  Collaborate with other implementing partners such as STAR-E and ASSIST to support the efforts in enhancing eMTCT capability in voucher facilities.

Sub-IR 1.3 Quality of MNCH and FP services at participating private sector facilities improved During this quarter, the Voucher Plus Activity continued working on standardizing and improving the quality of care offered at the supported facilities.

Provider trainings

During this quarter, the Activity extended the provider training program that we began at end of quarter 4 of year 1 to cover basic emergency obstetric and neonatal care (BEmONC). The Activity used the MOH EmONC curricular, other approved reference materials and MOH to implement the training. This was the second phase of BEmONC trainings and five training workshops were conducted in both regions to cover the second midwife from each VSP to beef up the first midwives trained last quarter in phase 1. The table below summarizes the RMNCH training courses so far held and number of providers reached.

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Table 18: Summary of Provider trainings Conducted during the Quarter # Type of Training # of training #providers Cumulative # of workshops held trained providers trained this quarter to-date 1 Option B plus - 93 154 (eMTCT) 2 BEmONC 5 132 289

Mentorship and technical support supervision

During this quarter, 77 health facilities in Eastern region were visited by the Activity team to conduct on-site mentorships to deepen the providers understanding of the Voucher Activity and using service claim forms. The team also assessed the facility’s current capacity and existing gaps in offering EmONC services using the MOH mentorship tool for comprehensive maternal child health services. Action plans were developed to address the gaps at the respective facilities. In quarter 3, the team will plan an extensive EmONC skills mentorship plan based on the provider skill gaps identified this quarter. Key among the emerging challenges identified at some of the VSPs during these visits included:

 Inability to offer emergency obstetric care services at some facilities;  Frequent stock-outs of key essential RMNCH drugs and medical supplies;  Demotivated, poorly remunerated providers leading to high attrition of voucher trained qualified providers who have been replaced by un qualified staff in some facilities;  Poor facility leadership/management leading to human resource issues;  Inadequate facility infrastructure to offer emergency obstetric care services; and  Knowledge and skills gaps in obstetric care among available staff at most facilities.

During the quarter, the Activity also provided supportive supervision to facilities to do the following:

 Check/assess facilities’ adherence to quality standards , identify gaps, discuss/support providers to fill them at agreed upon timelines (make action plans); and  Assess linkages for missing services (ARVs for eMTCT, vaccines, HMIS reporting) at the facility level for discussion with DHOs for collaboration on identified facility linkage challenges.

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Participants and a facilitator discussing diagnosis of obstructed labor using a partograph at a BEMONC training course in Gulu town

Below is summary of the lessons learned and actionable issues that the Activity has started to address in quarter 3:  CEmONC sites require more time than BEmONC sites for adequate and meaningful support supervision and mentorship to be done.  Good leadership and management at the VSPs is important for staff to be able to translate learning into practice, and importantly to plan for the increased income realized under the Voucher program and utilize it well for the purpose of improving quality of care  The districts’ role and other regulatory bodies in supervising private health facilities needs to be utilized to improve service provision, performance and accountability  The referral mechanism for Voucher clients remains a challenge especially to public referral facilities due to frequent stock outs of drugs and medical supplies.  Many facilities have lost Voucher Activity trained providers and there is need for on-site capacity building efforts to improve the skills of the new staff.

Provider validation exercise

Given growing concerns about quality of care at some VSPs and the suspicion that some providers may have deceived the initial facility assessors during the VSP assessments exercise conducted last year, the Voucher Activity team decided to institute a facility validation exercise

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for all VSPs. During quarter 2, the Activity completed the validation exercise for 60 voucher facilities in Northern Uganda. The findings indicated that 12 of the 60 facilities did not meet all the basic requirements to offer BEmONC. The Activity team suspended VSPs temporarily from receiving new voucher clients to give VSPs time to address the gaps identified or risk Activity termination. The team is carrying out this exercise in Eastern region as well.

Hotline

The Activity continues to use the hotline as a source for voucher clients to receive referrals, counseling on pre-service and aftercare queries, complications, and provide other information to stakeholders and couples seeking voucher services. The hotline received 705 calls (427 from males and 278 females) during quarter 2. The hotline provides information, counselling and referral. It also acts as a feedback mechanism for callers who have issues with service delivery. The hotline provided 685 callers with counselling, education and guidance on voucher services in quarter 2.

3.2 IR 2: Increased Capacity of Uganda’s Public and Private Sectors to Develop Longer Term Health Financing Options

Sub-IR 2.1 Local organizations with the capacity to implement output-based financing activities strengthened HMIS on-site orientation and Support Supervision:

Due to the importance of quality data, and following the HMIS trainings from quarter 1, the Activity conducted on-site mentoring and supportive supervision to private providers to ensure they were properly reporting into the HMIS. The team focused on addressing facility specific HMIS challenges identified, and that private service providers fully understood how to complete the HMIS tools provided and report in a timely manner to the districts and health sub-districts. During the support supervision, HMIS Registers were distributed. The team provided an orientation with private providers on how to use the tools. District Biostatisticians/HMIS Focal Persons participated in these on-site visits to over 150 facilities. We provided orientation and demonstration of the following tools: OPD Registers, Integrated ANC registers, Integrated Maternity Registers, Integrated PNC Register, Integrated Family Planning Register, HMIS 105, 108 and 106 among others. The team used an adapted MOH supportive supervision tool for these visits. In addition, the team conducted the visits to build the capacity of private providers to conduct internal data quality assessments, data audits, and data validation exercises to ensure data integrity, while ensuring private providers report into DHIS2.

Bolstering collaboration with stakeholders During the HMIS orientation and support supervision, the Activity team worked closely with stakeholders from the Ministry of Health, Districts and the Monitoring and Evaluation Technical Support Program (METS). Ministry of Health Resource center supported and coordinated

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inclusion of private providers implementing the Activity into DHIS2. The Ministry also provided DHIS2 access rights to Uganda Voucher Plus to monitor private providers reporting and submission of their outputs into the national system. To strengthen relationships between the districts and private providers, Districts Biostatisticians were also part of the supervision team. Among the resolutions made, Biostatisticians resolved to include private providers implementing the Activity in their quarterly schedules for supportive supervision. METS was very instrumental in providing some of the HMIS tools distributed to the service providers.

4. Program Management

The Activity is waiting for feedback on the, Independent Verification and Evaluation Agency and approval to start engaging private public sector wings to improve the referral mechanism.

Abt Associates continued to hold partner coordination meetings aimed at ensuring strong and effective partner management, reviewing the Voucher Plus Activity critical path and performance, addressing any challenges in a timely manner and fostering a spirt of teamwork.

5. Activity Monitoring, Evaluation, and Learning

Revising the AMELP The Activity worked closely with USAID Monitoring and Learning Contract Agency, QED, to review, update and re-align the Activity AMELP to the donor requirements and standards. In adherence to donor reporting requirements, additional indicators such as Family Health and PEPFAR were incorporated into the plan in line with the mission’s requirements to report on the implementation of the CDCS.

Revising the claims forms During the reporting, the claims forms were reviewed and revised to better address the data needs and demands for the Activity. These included the Antenatal, Delivery and PNC forms. The revisions were made in line with data needs for the Family Health and PEPFAR indicators, which are reporting requirements for USAID implementing partners. The revisions were also made to ensure that the Activity collects all the required data needed to meaningfully evaluate the Activity interventions and to ensure that data collection tools avoid collection of unnecessary data.

Orientation of partners and service providers on the revised claim forms Through the Quality Assurance department, partners and service providers were oriented on the revised claims. Partners were oriented mainly, so they in turn could do cascade training and orientation for the service providers. During the reporting period, the quality assurance department conducted a validation exercise for all service providers, and among the objectives of this exercise was to orient VSPs on the revised voucher claim forms.

Ensuring quality and integrity of data for effective decision making and evidenced-based planning Uganda Voucher Plus Activity Page 27

The Activity commenced provision of safe motherhood services in October 2016 while claims processing commenced in December 2016. Private providers complete claim forms at the facility to reflect the services provided by the health providers, and then these forms are reviewed and inputted into the VMIS. The claim form therefore doubles as an activity reporting/M&E tool and as a provider invoice against which health providers are reimbursed for services provided based on agreed standards. Thus, the Activity recognizes the importance of ensuring quality of data at all levels (i.e. provider, data entry and analysis). In quarter 2, the Activity engaged the services of an external consultant to support data entrants to ensure quality data is captured in the VMIS. The consultant directly supervised the data entry team to ensure timely, accurate, reliable and correct data was entered into the VMIS, conducting random spot check data audits and validation on a regular basis to ensure data integrity. The consultant was tasked to engage in rigorous data cleaning and to ensure security of the data. The key deliverables of the exercise included a clean dataset for use in quarter 2 reporting.

Activity Learning:

Building a model for supporting private providers to report using national HMIS and DHIS2 systems

Private providers not reporting using national tools – HMIS and DHIS2 is one of challenges faced in the health sector. The Activity in collaboration with the Ministry of Health Resource developed a model to support private providers to report using national systems HMIS and DHIS2. Through this model, Uganda Voucher Plus Activity identified private providers (PNFPs and PFPs) to implement the voucher activity. In the previous quarter, training was organized for the providers on use of HMIS tools for reporting. The Activity printed and distributed HMIS registers to all the private providers and conducted on-site mentorships and support supervision to ensure they are comfortable using the tools for reporting in 157 facilities participating in the program. Together with the Ministry of Health, the Activity supported inclusion of these providers’ data into DHIS2. Of the 157 private providers implementing the Voucher Plus Activity, 145 have been included in DHIS2. All providers are now submitting monthly returns to the districts who are in turn reporting the data into the national system. There reporting rates are being monitored by the Voucher Plus Activity and respective districts, targeting to have all providers with 100% reporting rates and timelines by end of year 2.

Improving the quality of Voucher private service providers

We are compiling lessons in improving the quality of VSP service provision through this active validation exercise. We will be applying these lessons to improving facilities and for future contracting requirements with facilities. We will share more in quarter 3 on these lessons.

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6. Quarter 3, Year 2 Planned Activities

1. Contract and onboard the IVEA 2. Recruitment of additional Activity staff, including replacing key personnel, the Financial Management/Administration (FMA) Specialist, and the clinical team 3. Sign MOUs with all Activity districts 4. Continue to engage and collaborate with districts 5. Identify and contract regional sub offices for field staff 6. Manage provider contracts and reimbursements 7. Roll out provider trainings in RMNCH/FP and CEMONC in both regions 8. Carry out on-site mentorships for supported facilities 9. Extend the facility validation exercise to the Eastern region 10. Collaborate with Uganda National Health Laboratory Services to undertake an assessment of laboratory capacity in selected participating facilities to identify specific areas for capacity improvement 11. Collaborate with ASSIST in laboratory services capacity improvement for selected facilities in the North 12. Distribute communication materials 13. Continue community mobilization and sensitization meetings for different target groups 14. Continue mass media activities including radio talk shows to promote the voucher services

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Annex 1: Voucher Plus Best Practices, Lessons Learned, and Emerging Issues

Best Practices and Lessons Learned

. Collaboration with district enhances synergies to increase access to comprehensive RMNCH services.

Quality of care

. Training and re-training on quality (through CQI mentorships) is essential in ensuring that all private health providers understand how quality is measured and sustain quality standards.

. Quality of care depends on proprietors’ buy-in. Facility owners should be fully engaged in the quality of care as much as they care for running their facilities as businesses.

. Human resource is a major constraint to provision of quality services in the health system. Availability of qualified staff is challenge. Private sector borrows pubic sector staff to work at their facilities, resulting in absenteeism in public facilities and private part-time availability in private sector

. Staff motivation is critical in improving quality of care standards. Participating providers are encouraged to consider staff motivation as one of the action plans for staff retention.

Community

. Involvement of community leaders continues to be a critical component for mobilization & ownership at local level. Community dialogues provide a good platform for feedback, and they foster a collaborative relationship with the local leaders.

Emerging issues

During this reporting period, below are the key emerging issues: . Managing district expectations – payment for supervision, poor attendance of stakeholder meetings due to the new per-diem policy . Broken health system- use of unqualified staff, high staff turnover; use of part time qualified staff; poor compliance to standards; poor supply chain management, inability to offer comprehensive RMNCH package; poor data capture and use; poor linkages and referral practice for CEMONC and other services such as FP, EMTCT and immunization; non licensed health service providers . Lack of drugs and supplies at public facilities resulting in exorbitant unofficial fees charged to clients referred for comprehensive management and therefore making referrals for emergency care a huge challenge

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. Very low capacity in ART services in private sector . Lack of linkage to care for EMTCT, PPFP and immunization in remote rural facilities where poor women are unable to travel for referred services. Fifty-three percent of voucher facilities are PNFPs who don’t provide FP services . Poor distribution of private sector facilities in remote rural areas, and therefore unable to reach many of the poorest of the poor . Long distances of referral facilities for poor mothers which complicates transport back home after delivery from a referral facility . Community myths about the voucher- linked to “illuminati”, “too good to be true” perception

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Annex 2: Voucher Plus Success Stories

A Young Couple Celebrates its first Twins in , Eastern Uganda:

21-year-old Lunyoro Jackline lives in Nalugugu Parish in Sironko district. Jackline heard about the Voucher from Open Gate Radio during a radio talk show. She shared: “I heard from the radio that if a poor pregnant woman buys that card at 4,000= Uganda shillings, she could use it to access 4 ANCs, delivery at health facility; and that in case of any complications, she would be treated free of charge at the health facility.” Jackline then looked for the voucher distributor in her area, and found Nandudu Lidia, a Voucher Community Based Distributor (VCBD) who later visited her at her home, assessed her for eligibility, counselled her on RMNCH, and sold her the voucher.

By the time she bought the voucher in her third trimester, she had not accessed maternal health services: “I was seven months pregnant when I bought the voucher. I had never gone to any health center because I trusted that my mother in-law would deliver me from home. The VCBD advised me to go to Shared Blessing Health Centre with my voucher to start accessing services. When I went to Shared Blessings Health Center for antenatal care, I was examined by the midwife, and she informed me that I had a very big baby that I would not manage to deliver normally.”

For Jackline, accessing the voucher was timely: “At the time of delivery, I went back to Shared Blessings Health Centre and the midwives tried to help me deliver. But later they realized that I could not deliver normally because the baby was too big. I was then referred to Kolonyi Hospital accompanied by the midwife and my relative in a vehicle. Upon reaching Kolonyi hospital, I was examined again and informed that I had twins who were so big that I would not be able to push normally. I was then taken to the theater for operation, which was successful.”

Jackline and her husband, Delison, with their twin babies (Esther & Juliet) During follow up visit by the SBCC Officer, Wafula Delison, Jackline’s husband had this to say: “I did not pay any extra money at Shared Blessings health Centre neither at Kolonyi Hospital. This voucher really helped me to meet all the related costs that I would not have managed to raise on my own. As a young couple, we feel very grateful to Voucher Plus Activity, my family now is very healthy.”

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Jackline and her husband recommend other eligible pregnant women to buy and use the voucher cards because the voucher enables them access good quality health services without paying additional money.

Alungo Jessica’s Story

32-year-old Alungo Jessica is a mother of eight children. She lives with her husband Osire Jonathan in Okapel village in .

Upon buying the voucher, Jessica accessed ANC services at Atiira Medical Centre. Jessica’s labor pain started before the expected due date as communicated to her by the midwife during ANC visit. She went via motorbike accompanied by her mother in-law to the facility. As Jessica approached Atiira Medical Centre, she began to bleed and had severe pain. Upon reaching the health facility, she was quickly received by the health workers who examined her and then initiated her on drip.

Because of the continuous bleeding coupled with severe pain, Jessica was referred to Bethesda Hospital in Soroti where she gave birth through caesarean section. She was amazed that the card she bought from the VCBD at 4,000 UGX allowed her to access all the critical services without having to pay extra money.

She is happy because she did not have to sell land in order to pay for services: “During the delivery of my seventh child, I also gave birth through caesarean section. At that time, my husband sold a piece of land, which was the only option to pay the bill.”

Jessica is grateful for her life: “The health workers counseled me and advised that my husband and I consider taking up family planning services since this was the second time I have been operated. After the counseling session, my husband and I discussed about the range of modern family planning methods and agreed that I use injectable, which I am using now.

I would have probably lost my life through this risky pregnancy and delivery if it were not for the voucher program. I pledge to share my experience about the benefits I have received from the voucher with other mothers in the community; and how the voucher has saved my life” – says Jessica.

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Voucher Supports a Neglected Teenager Deliver a Healthy Baby

15-year-old Adong Damerla lives with her grandmother in Barmogo village in Omoro district bordering . This was Darmela’s first pregnancy. Unfortunately, she was impregnated by a man who denied responsibility. Due to the stigma attached to teen pregnancy among unmarried girls, Damerla was chased by her father from home, saying she was a disgrace.

At the time of assessment for eligibility, Damerla was living with her grandmother who assisted her with money to buy the voucher. She had no plan to go for ANC or to deliver at a health facility due to shame, lack of money to buy the mama kit, and long distance to the nearest government health facility. As a result, Damerla had planned to deliver from home with the help of her grandmother.

She bought the voucher from the VCBD at 4,000 UGX, and three days later, she went into labor. Damerla’s grandmother brought her to Apostolic Medical Centre where a midwife examined her and helped her deliver her baby.

“I am so happy with the Voucher program. Although my father chased me from home, and the man responsible for my pregnancy abandoned me, the voucher has enabled me to access all the services that I needed without extra payment. If it wasn’t for the support of a skilled midwife, I would have probably died since I am still young. Besides that, I would have been required to buy a mama kit if I went to government health facility, which my grandmother and I could not afford” –says Damerla.

District

Damerla’s grandmother was equally happy since her granddaughter had delivered normally under skilled personnel. “I was worried that Damerla would not push the baby normally since she is young. I had no extra money to buy mama kit and meet other related costs”- says Damerla’s grandmother.

“Before I gave birth, I had told three people whom I met at the well about the benefits of the voucher.

Now that I have experienced the good and quality services at Apostolic Medical Centre, I encourage all the pregnant mothers to give birth at the facility under skilled attendance” – says Damerla.

After discharge from the health facility, the VCBD followed up Damerla at her home and found both the mother and the baby healthy. The mother had gone back to the health facility for PNC once at the time of the visit and hoped to complete the visits.

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Annex 3: Voucher Plus Progress Against the AMELP

Objective Performance Indicator Annual Performance Target Current Cumulative Narrative on Performance Year II Quarter for Year II Strategic Objective: Provide measurable improvements in safe motherhood services by supporting health financing and innovative service delivery models in the private sector IR1: Use of comprehensive obstetric care and postpartum FP services for the poor increased Number of deliveries in participating facilities The Voucher Plus Activity supported VSPs to reach that are paid for by the Voucher Plus Activity 85,680 8,192 10,308 8,192 mothers with delivery services during the quarter. The Activity plans to increase deliveries through increased voucher sales and redemption and sensitizing communities more about the Activity Percentage of women participating in the The Activity will increase sensitization of mothers and voucher program who attend all four ANC 47% 10.3% 11.1% further support VSPs to ensure mothers attend all the visits four antenatal visits

Percentage of infants born to voucher covered Some facilities not being accredited and stock-out of women living with HIV receiving ARVs as ARV are the main reasons for not initiating infants on prophylaxis for elimination of mother-to-child 50% 38.6% 44.0% ARVs. The Activity with work with VSPs to strengthen transmission (EMTCT) linkages to accredited facilities.

Percentage of voucher covered pregnant Over 70% of mothers not initiated on EMTC were women living with HIV who received already on ART. The Activity plans to support VSP to antiretroviral drugs to reduce the risk of 80% 38.9% 41.9% improve linkage of mothers to ensure all positive clients mother-to-child transmission (MTCT) are initiated on ART

Cesarean Section Rates Approximately 6% of the Activity deliveries end into 15% 6.2% 6.1% Cesarean sections. Activity to work with VSPs to strengthen the referral system. Facility still birth rate per 1000 live births 1.8 1.8 15 The Activity reports only deliveries from VSPs and these are attended by a skilled provider. The Activity built the Percent of deliveries attended by skilled health 100% capacity of these providers to provide quality MCH personnel 100% 100% services through the provider trainings conducted in Year I.

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Objective Performance Indicator Annual Performance Target Current Cumulative Narrative on Performance Year II Quarter for Year II Percentage of births delivered at a health facility 100% 100% 100%

Percentage of Mothers receiving PNC checks Providers encourage mothers to return for PNC within within 6 days the first 6 days of delivery, challenges lay in lack of 50% 47.3% 43.2% transport for mothers to return for the checks

Number of individuals attending community Performance attributed to the routine home visits, SIR1.1 Demand for mobilization events conducted to increase 93,236 26,341 46,969 community dialogue, sub-county and community comprehensive uptake of maternal health vouchers sensitization sessions held by CDFU and the obstetric care and communities. postpartum FP services increased Number of USG-assisted community health Activity affected by some VCBDs/ CHWs that are not workers (CHWs) providing Family Planning (FP) 160 331 331 active and a few that have pulled out of the Activity information, referrals, and/or services during the year  Distribution of vouchers partly affected by delays in starting implementation in Northern region. In the Number of vouchers distributed 122,400 29,026 45,115 region, distribution started mid-January. CDFU will expedite the distribution process and sensitize communities about the Activity.  Activity is strengthening sensitization efforts to address myths and misconceptions held in some communities. “Some communities say this is too good to be true – accessing all these services for a voucher purchased at UGX. 4000”

Percentage of vouchers ANC1 94% 64.4% 61.1% The Activity is supporting CDFU and VCBDs to redeemed ANC2 50% 37.6% 30.7% continuous sensitize and encourage mothers to redeem ANC3 50% 20.6% 14.9% their vouchers through accessing the comprehensive ANC4 47% 9.5% 6.6% health care package (i.e. ANC, Delivery, PNC and PPFP) Delivery 70% 28.2% 22.8% provided by the Activity. Postnatal care 50% 16.2% 12.4%

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Objective Performance Indicator Annual Performance Target Current Cumulative Narrative on Performance Year II Quarter for Year II Postpartum FP 30% 4.4% 3.8% SIR 1.2: Access to and Percentage of voucher covered pregnant Mentorships conducted to VSPs have focused on availability of women tested for HIV during any ANC visit ensuring that providers implement and adhere to MoH comprehensive and received results 100% 100% 100% policies and guidelines including ensuring that all obstetric care and pregnant mothers are tested for HIV during ANC visits. post-partum FP services increased Number of voucher covered clients treated for Activities by other IP have distributed free ITNs to malaria using the IPTp 15,000 2,700 3,183 pregnant women to reduce incidence of malaria in pregnancy.

Percentage of voucher covered pregnant Through facility mentorships, VSPs are encouraged to women who received all the three doses of 80.4% 77.3% ensure that all pregnant mothers receive all the 3 doses 60% intermittent preventive treatment (IPT) for of IPT for prophylaxis of Malaria malaria Percentage of USG-assisted service delivery  Catholic/ UCMB facilities do not offer modern family sites providing family planning (FP) counseling planning services because of their faith. and/or services  Poor linkage to care for PPFP from UCMB and other 100% 55.4% 70.7% non-FP facilities to FP facilities  Some providers claiming that FP counselling is tedious if done on individual client basis as opposed to a group session Number of USG supported service delivery  Lack of knowledge and skills in comprehensive FP by points offering any modern contraceptive 56 87 111 providers method among postpartum women  Lack of access to an assured source of FP commodities and supplies at district level Percentage of women who received  Lack of equipment & infrastructure necessary to offer 100% 87.8% 83.6% postpartum counselling for FP long acting reversible methods of FP.  Low demand for FP services due to wide spread Number of clients provided with FP services 42,840 1,318 1,721 community myths about FP

SIR 1.3: Quality of Number of private health facilities accredited to Demand for MNCH services high in the intervention comprehensive participate in the voucher program 120 157 157 districts, Activity increased the number of providers to obstetric care and address the demand. post-partum FP Number of providers trained in MNCH and 200 More numbers trained than planned. Some providers left

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Objective Performance Indicator Annual Performance Target Current Cumulative Narrative on Performance Year II Quarter for Year II services improved family 0 382 their facilities as soon as the training had been finalized. planning The Activity had to re-train more providers.

IR 2: Local capacity to manage and scale up result based financing programs strengthened SIR 2.2: Evidence and Only 12 of the 157 accredited providers are not in implementation lessons Number of private facilities that report data on 120 145 145 DHIS2. Activity has access rights to the system and is from the Voucher Plus health indicators into the DHIS2 monitoring reporting into DHIS2. The Activity is also Activity documented working closely with MoH resource center and district and disseminated biostatisticians to ensure that the 12 facilities missing in DHIS2 are included.

Number of routine monitoring reports produced to 4 1 2 Monitoring reports for quarter I and II have been disseminate Voucher Plus Activity results compiled and disseminated to share progress results for the Activity.

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