USAID’s Maternal and Child Survival Program

(MCSP) - Child Health (CH)

Quarterly Progress Report

January 1 to March 31, 2018

MCSP/Ambrose Watanda

USAID/Uganda Quarterly Progress Report (Program Year 4)

Project Name: USAID’s Maternal and Child Survival Program (MCSP) Uganda Child Health (CH) Program

Reporting Period: January 1 to March 31, 2018

Obligation Funding Amount:

Project Duration: August 2016 to December 2018

Program Year (PY4): October 1, 2017 to September 30, 2018

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

Program Goal: To contribute to a reduction in child mortality in the Southwest (SW) and East Central (EC) .

Program Purpose: With USAID Uganda’s Regional Health Integration to Enhance Services (RHITES) partners, identify, implement, and test a package of low cost, high impact, evidence-based CH interventions that can be applied at different levels of the health care system and contribute to a reduction in child mortality. Program Objectives: 1. Enhance national guidelines and frameworks to support implementation of the essential CH package. 2. Strengthen technical skills, competencies and practices of the RHITES partners and MCSP-supported demonstration districts to implement the essential CH package. 3. Strengthen district level management and planning practices to support the delivery of the essential CH package using adapted REC-QI approaches. 4. Conduct a costing analysis for delivery of the essential CH package. 5. Improve availability of strategic knowledge and tools to scale-up the essential CH package.

MCSP Uganda CH PY4 Q2 Report 2 Acronym List

CHAI Clinton Health Access Initiative CDSR Child Death Surveillance Response CH Child Health CHMIS Community Health Management Information Systems COP Chief of Party CSO Civil Society Organization CSS National Child and Newborn Survival Strategy DHIS2 District Health Information System 2 DHMT District Health Management Team DHO District Health Officer DHT District Health Team DL Distance Learning DPCC Diarrhoea, Pneumonia Coordination Committee DQS&I Data Quality Self-Assessment and Improvement DT dispersible tablets EC East Central Region EID Early Infant Diagnosis EOP End of Program EPI Expanded Programme on Immunization GFTAM Global Fund Project for TB, AIDS and Malaria HC Health Centre HF Health Facility HMIS Health Management Information System HW health worker iCCM Integrated Community Case Management IMNCI Integrated Management of Neonatal and Childhood Illness IP Implementing Partner JSI John Snow, Inc. KFCP Key Family Care Practices LC Local Council MCH Maternal and Child Health MCHIP Maternal and Child Health Integrated Program MCSP USAID’s Maternal and Child Survival Program MEL Monitoring, Evaluation, and Learning MNCH Maternal, Newborn and Child Health MoH Ministry of Health – Uganda NMS National Medical Stores OPD Outpatient Department ORS Oral Rehydration Salts ORT Oral Rehydration Therapy PEPFAR U.S Presidents Emergency Plan for AIDS Relief PHC Primary Health Care PY Program Year Q2 Quarter 2 QI Quality Improvement

MCSP Uganda CH PY4 Q2 Report 3 QoC Quality of Care QRM quarterly review meetings REC-QI Reaching Every Child-Quality Improvement RHITES Regional Health Integration to Enhance Service RMNCH Reproductive, Maternal, Newborn, and Child Health RMNCAH Reproductive, Maternal, Newborn, Child and Adolescent Health SIC Short Interrupted Course SW South West Region TA technical assistance ToT Training of Trainers U5 Under Five (5) Years of Age UHSCP Uganda Health Supply Chain Program UNEPI Uganda National Expanded Programme on Immunization UNICEF United Nations Children’s Fund USAID United States Agency for International Development VHT Village Health Team WHO World Health Organization

MCSP Uganda CH PY4 Q2 Report 4 I. Introduction

The Maternal and Child Survival Program (MCSP) is a global U.S. Agency for International Development (USAID) cooperative agreement to introduce and support high-impact health interventions in 25 priority countries with the ultimate goal of preventing child and maternal deaths. MCSP is currently implementing two programs in Uganda: the Routine Immunization program (MCSP RI) which works with the Ministry of Health (MoH) and its Uganda National Expanded Programme on Immunization (UNEPI) to operationalize the Reaching Every Child/Community using Quality Improvement Approach (REC-QI) in eleven districts (2014- 2019); and the Child Health program (MCSP CH) which is an eighteen-month technical assistance (TA) program (i.e. May 2017-October 2018 for in-country implementation, and November- December 2018 for closeout) to provide tailored support in the area of Child Health (CH) to the USAID’s Regional Health Integration to Enhance Services (RHITES) projects in South West (SW) and East Central (EC) regions.

USAID’s RHITES projects are working with the Government of Uganda to support implementation of the Uganda Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) Sharpened Plan, which includes a package of low cost, high impact, evidence-based RMNCAH interventions that can be applied at different levels of the health system to reduce mortality. The RHITES projects work directly with the districts they serve to assist with national scale up of the package. The expected result of MCSP’s tailored technical assistance for CH is implementation of a standardized CH package across the RHITES projects, that determines the costs involved and gathers learning on the feasibility of implementing the package in an integrated way in four demonstration districts (Luuka, , Ntungamo and Sheema), to inform national level CH policy and program updates.

This quarterly report summarizes the progress and achievements of MCSP CH for the period of January 1 to March 31, 2018, Quarter 2 (Q2) of PY4.

II. Summary of PY4 Quarter 2 Achievements

During this quarter, MCSP continued assistance to the RHITES implementing partners (IPs) in the EC and SW region to implement a package of essential CH interventions at all levels. Roll out of the Integrated Management of Neonatal and Childhood Illness (IMNCI) at health facility level was completed in all four demonstration districts of Kaliro, Luuka, Ntungamo, and Sheema. This rollout was conducted using two alternative IMNCI training models - Distance Learning (DL) and Short Interrupted Course (SIC) - as agreed with MOH, WHO, and other partners. MCSP is analysing these experiences to derive recommendations for how the two models can be used to support IMNCI capacity strengthening of frontline health workers (HWs) across the remaining RHITES districts and eventually nationwide. MCSP in collaboration with partners through the Diarrhoea, Pneumonia Coordination Committee (DPCC), developed recommendations to address prolonged stock outs of amoxicillin dispersible tablets (DT). In addition, MCSP supported the MoH CH Division to develop recommendations for the revision of CH indicators in the national Health Management Information System (HMIS). Recommendations to include the revised WHO IMNCI classification

MCSP Uganda CH PY4 Q2 Report 5 for pneumonia, diarrhoea, malnutrition, and the sick young of infant; and an indicator to track stock outs of injectable antibiotics for management of severe disease were adopted during the first round of consultation. Indicators on appropriate treatment for pneumonia, diarrhoea and possible serious bacterial infection, remained pending requiring further discussion. District-wide roll out of the Village Health Team (VHT) package was achieved in RHITES EC demonstration districts (i.e. Kaliro and Luuka), while in the RHITES SW region it was partially completed to bring coverage to about 50% of sub-counties in both demonstration districts (i.e. Ntungamo and Sheema). Also in collaboration with partners, MCSP validated a manual for community-owned resource persons focused on Key Family Care Practices (KFCP) and used the draft manual to identify key messages for promotion of practices at the household level and integrated these messages into the VHT package being rolled out in the four demonstration districts. Finally, MCSP supported and demonstrated a district level quarterly review meeting (QRM) for RHITES EC in . District specific drafts of the CH score card were piloted during the QRMs to support evidence-based planning at health facility level. III. Description of Activities by Objective

Objective 1: Enhance national guidelines and frameworks to support implementation of the essential CH package

MCSP participated in the multi-sectoral workshop for KFCP held in January 2018. The meeting organised by the MoH, in collaboration with UNICEF, aimed to review, validate, and endorse a community-owned resource manual on KFCP. The manual will act as a resource for training community-based workers on promoting the KFCP at the household level, and also for developing key health education and promotion messages targeting households. MCSP has used the draft manual to identify key health messages for inclusion in the VHT package being rolled out at the community level in the four demonstration districts. UNICEF will support the initial roll out of the manual in the Karamoja region and districts of Lira, Gulu, and Arua. MCSP has supported the RHITES IPs in EC and SW to build capacity of VHTs to roll out the KFCPs in the four demonstration districts.

MCSP participated in the national iCCM technical working group meeting held in January 2018, targeting iCCM IPs. Two of the MCSP demonstration districts (Sheema and Ntungamo) are iCCM implementing districts and, as such, MCSP participated in the meeting to identify ways to collaborate on implementation of iCCM in these two demonstration districts. A review of the following was done: implementation status of action points agreed on from the previous meeting, and iCCM commodity stock status at national level and in the implementing districts. iCCM IPs shared planned activities for the upcoming quarter. Special mention was made of the low reporting rates (currently at an average of 15%) for CHMIS, which also includes reports on iCCM delivery.

Objective 2: Strengthen competencies and practices of RHITES partners and

MCSP Uganda CH PY4 Q2 Report 6 MCSP demonstration districts to implement the essential CH package

RHITES EC and SW requested MCSP to train additional teams through Training of Trainers (ToTs) to support the roll out of IMNCI within their program areas beyond the MCSP demonstration districts. In the EC region, the additional trainers were drawn from the remaining nine districts of the RHITES EC program area including Jinja, , Buyende, Busia, Kamuli, Namayingo, Namutumba, Bugiri and Mayuge with three participants drawn from each of the districts. In the SW region, the additional trainers were drawn from five districts in the RHITES SW program including Kiruhura, Mbarara, Kabale, and Rukiga, with four participants drawn from each of the four districts. The participants in both regions comprised of experienced clinicians who spend significant time and effort managing sick children in outpatient or inpatient settings from health facility level III and above. In addition to the district participants, the trainings included participants from RHITES EC and SW staff. Table 1 below summarises details of the additional participants trained during the ToTs for both RHITES EC and SW. In both regions, the participants were taken through the recently revised national IMNCI standard six-day course to equip them with the basics of the IMNCI approach. The activity was fully funded by RHITES EC and RHITES SW for their respective regions. As a next step, the participants will undergo a facilitation skills course which will equip them to facilitate the roll out of the IMNCI package at all levels in the remaining districts of the RHITES EC and SW regions.

Table 1. Participants for the IMNCI regional basic course for the RHITES by Region/ Place of Work Region/ Place of work Female Male EC district participants 15 12 SW district participants 7 11 RHITES EC participants 1 1 RHITES SW participants 3 5 TOTAL 26 29

MCSP supported RHITES EC and SW to complete the roll out of the IMNCI package at all levels of care in the four demonstration districts of Kaliro, Luuka, Sheema and Ntungamo. The roll out for the IMNCI training was conducted using two models as agreed with MoH, WHO and the RHITES EC and SW partners: the SIC which is comprised of two shortened face-to-face sessions (two and half days followed by a one and half day session) with two weeks of workplace-based self-study and practice in between; and the DL comprised of three one-day face-to-face sessions with four weeks of work-based self-study and practice in between the sessions. In both models, the work-based self-study is supported by an onsite mentorship and supportive supervision visit which is conducted by district mentors. MCSP in collaboration with the MoH and RHITES EC and SW programs implemented the two

MCSP Uganda CH PY4 Q2 Report 7 models to determine how each model addresses challenges associated with previous IMNCI implementation efforts including: disruption of service delivery; high cost; and poor translation of acquired knowledge into practice.

Figure 1. Number of health workers (HWs) trained in IMNCI by district.

400 352 350

300

250 213 200 150 151 150 132 129 95 100 71 Number of Health Workers Health of Number 56 50 31 3 6 0 Kaliro Luuka Ntungamo

# trained at baseline # trained in IMNCI by end Q2 # of HWs at facility

Figure 1 above shows a comparison of the number of HWs trained in IMNCI by district at baseline (July-September 2017) and those trained by the end of Q2 with the number of HWs health workers in each district. The number of HWs trained increased significantly from baseline to the end of Q2. In Kaliro, 68 additional health care workers were trained in Q2 (71 HWs) compared to baseline (3), representing nearly 50% of the total number of HWs in the district. In Luuka, 89 more HWs were trained in Q2 (95) than at baseline (6 HWs), representing 72% of total HWs in the district. In Ntungamo, the number of HWs trained increased from 56 at baseline to 151 HWs trained by the end of Q2, 43% of the total HWs in the district. Lastly, in Sheema, 98 more HWs were trained in Q2 (129 HWs) compared to the 31 HWs trained at baseline, representing 61% of the total HWs in the district.

From the ToTs conducted this quarter, the district trainers supported by the RHITES CH Technical Advisors have taken on a bigger role in leading and delivering the training and conducting assessments, with MCSP technical staff and national trainers taking on more of an observational role, guiding the delivery of the training and assessments as necessary.

The results from the end-of-course assessments did not show any significant differences between the average scores of participants enrolled in the DL and those enrolled in the SIC model (scores shown in Figure 2 below).

MCSP Uganda CH PY4 Q2 Report 8 Figure 2: IMNCI average scores for pre-, mid- and end-of-course assessments by district.

80 75 70 65 60 55 50 45

40 Average Scores Average 35 30 25 20 Pre test Mid assess Final Assessment Time point

Sheema Kaliro Ntungamo Luuka

The DL model was used in Kaliro (additional participants enrolled from Kamuli) with 115 (93%) out of 124 health workers enrolled completing the course, and in Sheema with 95 (86%) out of 111 health workers enrolled completing the course. The overall completion rate for the DL model was 88.9%. The SIC model was used in Luuka with 73 (96%) out of 76 health workers enrolled completing the course, and in Ntungamo with 90 (93%) out of the 97 health workers enrolled completing the course. The overall completion rate for the SIC model was 94%. The main reasons shared by participants for failing to complete the course included competing activities within or outside the district, and staff being away on annual, maternity and sick leave. The main motivation factors for completing the course included: the need to get and complete updates on child case management offered throughout the course; and the expectation of a certificate at the end of the course.

MCSP provided TA for RHITES to conduct on-site mentorship for the IMNCI DL Achievements from mentorship visits participants in Kaliro and Sheema districts, as  Technical support to resolve challenges faced by well as IMNCI SIC participants in Ntungamo clinical trainees in translating the knowledge district. MCSP support included technical acquired from IMNCI trainings into practice input during preparation meetings for the  Support to health facility teams to apply the REC mentorship, and input into daily reflection approach (micro-mapping, health data review and meetings held by the mentors. The primary monitoring, prioritizing and targeting underserved communities in their service delivery plans) to target for MCSP’s support was RHITES improve the health facility performance in terms technical staff, and the national and district of increasing access and coverage of CH mentors for IMNCI in both regions. In the EC interventions program area, the onsite mentorship covered  Re-enforcement of District IMNCI trainers’ 20 out of the 21 health facilities in Kaliro supervisory skills district reaching 52 (M: 16, F: 36F) health

MCSP Uganda CH PY4 Q2 Report 9 workers during the first phase of the mentorship; and 49 (M: 17, F: 32) health workers during the second phase of the mentorship. In the SW program area, 102 (M: 38, F: 64) health workers were reached during the first phase of mentorship; and 73 (M: 26, F: 47) health workers were reached during the second phase of mentorship in Sheema district covering 32 out of the 35 health facilities in the district. In , 91 (M: 32, F: 59) health workers were reached during the mentorship visits, covering 41 out of the 45 health facilities in the district. Table 2 below summarises the issues observed during these mentorship visits.

Table 2: Summary of issues observed during the onsite mentorship visits to four demonstration districts.

Positives:  Progressive improvement in overall performance including case management and data capturing was noted. Participants observed to have embraced IMNCI approach better in the second mentorship compared to the first.  Functionality of the Oral Rehydration Therapy (ORT) corners greatly improved

Areas needing improvement: Gaps Steps taken to address gap  Some facilities still lack basic equipment for  In collaboration with RHITES and the District Health Officer’s IMNCI (weighing scales, height boards, wall (DHO’s) office, key equipment was redistributed from health clocks, ARI timers, thermometers, MUAC facilities which had a surplus to those facilities without tapes) that are required for provision of quality adequate equipment. The remaining gaps will be addressed by child care. the DHO and RHITES programs through future equipment procurement.  Some facilities have greatly improved in  MCSP and RHITES IPs prioritized addressing this gap in the engaging VHTs, however, utilization of data upcoming post-training mentorships; and will use VHT reports from VHTs as well as health facility data to submitted by VHTs to demonstrate how this data can be used inform planning remains a major challenge. to improve coverage of preventive CH interventions at the community.  Essential medicines stock outs, especially  MCSP in collaboration with partners through the Diarrheal, amoxicillin DT and Oral Rehydration Salts Pneumonia Coordination Committee (DPCC) developed (ORS), for an average period of two months. recommendations to address prolonged stock outs of amoxicillin DT.  Overall, Hospitals and HC IVs were still  MCSP worked with RHITES EC to ensure that the overall civil struggling with implementation of IMNCI. and political leadership was engaged to address the leadership Inadequate leadership, support, and use of challenges at higher level health facilities. Civil and political volunteers who were not trained in IMNCI to leaders have now been included as part of the health facility support Outpatient Department (OPD) care supportive supervision and mentorship teams. In addition, were cited as major reasons for weak IMNCI remedial support activities targeting HC IV and hospitals have implementation. been planned in the upcoming quarter.

Objective 3: Strengthen district level management and planning practices using adapted REC-QI approaches to support delivery of the essential CH package.

MCSP participated in the Expanded Programme on Immunization (EPI)/Early Infant Diagnosis (EID) Stakeholders meeting in January 2018 that was organised by RHITES SW. The meeting aimed to share experiences as well as expand and scale up EID services through integration into immunisation services. The MoH AIDS Control Program(ACP) has adopted integration of EID into EPI services to leverage the platforms for delivery of routine immunisation for reaching HIV exposed children not accessed during antenatal period; and also for addressing stigma associated with delivering EID services separately. The meeting targeted various stakeholders including:

MCSP Uganda CH PY4 Q2 Report 10 District Health Officers (DHOs) from the region, District EPI Focal Persons, Assistant DHOs, Maternal and Child Health (MCH) Directors, Technical Advisors, and Program Officers of RHITES SW. IMNCI and REC were appreciated as approaches that can be used to identify children being missed by EID services. A recommendation was made to revitalize integrated CH QI teams at the health facilities in the region; and for improved integration of EID into EPI to be considered as one of the key focuses for the QI teams at the health facilities.

MCSP continued with the provision of TA to RHITES for roll out of the VHT CH package in both the EC and SW regions. MCSP’s support included planning and provision of materials for orientation of District Health Teams (DHTs), Health Facility In-charges and the VHTs; and participation and technical oversight during the orientation of the VHTs at the health facility level. In the EC region, RHITES and the DHT in Kaliro were supported to provide orientation for 713 VHTs (M: 438, F: 275) covering all the 12 sub-counties in Kaliro district. In the SW region, RHITES and the DHT were supported to conduct orientation for 732 VHTs (M:146, F:586) attached to 24 health facilities in 7 sub-counties of Sheema district including Kasaana, Masheruka, Kyangenyi, Shuuku, Kagango, Sheema Central Division and Kitagata sub-counties. In both the RHITES EC and SW regions, VHTs were refreshed on their roles in promoting CH at the community level; KFCP for CH; mapping of their villages; use of the VHT registers for households with children under five (U5); using home records to identify children missing out on the CH intervention package; how to contribute to the development of health facility micro-plans; and summarising information from the VHT registers for monthly reporting. The roll out also included distribution of VHT registers to all VHTs. Furthermore, the VHTs, together with the health facilities, developed plans for quarterly supportive supervision and performance review meetings. Each of the health facilities involved also worked with the VHTs to finalise and harmonise the health facility micro-map and plans. Significantly more male VHTs were oriented by RHITES EC, raising issues of gender equity in VHT distribution and its implications for effective service provision and oversight for women community members. The majority of the local political leaders who were tasked to oversee the VHT selection exercise were male; and this biased the selection towards more male VHTs. MCSP in collaboration with RHITES EC, and the Kaliro DHT will monitor to identify and address any challenges that may arise out of having fewer females amongst the VHTs oriented by the program.

MCSP supported and demonstrated a district level QRM for RHITES EC in Luuka District. The meeting lasted two days and was attended by Health Facility In-charges and the DHT on the first day, and the civil and political leaders from the sub-county and district level on the second day. On the first day, a simple Scorecard was used to review performance of the individual health facilities against CH indicators, and best practices and change ideas for improving performance on the CH indicators were shared by the well performing health facilities for possible adoption by the rest of the health facilities in the district. On the second day, the participants were led by the DHT to share the performance of the individual health facilities, including QI performance improvement projects identified with political and technical leaders from the district and sub- county level. The technical and political leadership held the Health Facility In-charges accountable for service delivery gaps. There was also acknowledgement of specific Health Facility In-charges for good performance. The meeting was attended by 66 (M: 31, F: 35) participants on the first day and 87 (M: 49, F: 38) participants on the second day. It was noted that the size of the audience was too big on both days to be effectively engaged in fruitful discussions, and therefore, future QRMs would need to be divided up.

MCSP Uganda CH PY4 Q2 Report 11

Objective 4: Conduct a costing analysis for delivery of the essential CH package. MCSP has continued its cost data collection among MCSP and RHITES for the costing analysis. Data has been reviewed on a regular basis to develop a consistent set of activities and coding for all activities across MCSP and RHITES programs. MCSP also began development of the facility- level costing methodology, which will look at the actual costs of delivering the essential CH package in public facilities in two districts (Sheema and Kaliro). MCSP also communicated with UNICEF regarding the iCCM costing activity that was originally included in the MCSP costing activity. UNICEF is working on its own costing activity and investment case for iCCM. Since MCSP is not directly involved in iCCM implementation and to avoid duplication of efforts, MCSP plans to use outputs from the UNICEF analysis in its calculation of the CH package delivery costs.

Objective 5: Improve availability of strategic knowledge and tools to scale-up the essential CH package.

During the reporting period, MCSP continued to refine the draft scorecard, reviewing and testing its use on various CH indicators during the QRMs. During the process, MCSP was able to identify mismatches in wording used for indicators between the primary data source and secondary tools used for compilation and reporting on DHIS2 CHMIS data. These have been compiled and shared directly for redress with the focal person for the ongoing review of CHMIS and also in meetings organised by the MoH for review of the CHMIS.

MCSP Uganda CH PY4 Q2 Report 12 Figure 4. Draft CH monitoring tool developed for Luuka District, Jan-Mar 2018.

5. Submissi Stock outs Stock outs Number on of QWIT Stock outs of Amoxicillin Measles Presence Appropri Appropri Appropri of VHT Presence team Zinc/ORS Copack dispersible tabs vaccine _ of an VHT ate RX ate RX ate RX 3. Level Villages QTRLY of QWIT addresse _ ¬Duration of _ Duration of ¬Duration of ORT QTRLY # of VHTs for for for 2. Facility name: of care served by reports team s CH stock out in days stock out in stock out in corner mtg reporting pneumo Diarrhoe Malaria Naigobya UDHA HC II 4 Yes No No 0 0 0 Yes 0 8 50 50 74 Kiyunga HC VI 28 Yes Yes Yes 40 30 0 Yes 1 4 73 29 100 Nakiswiga hcii HC II 6 Yes Yes Yes 0 0 0 Yes 1 1 67 27 100 Maundo HC III 5 Yes Yes No 0 30 0 Yes 1 1 97 33 93 Waibuga HC III 18 Yes Yes Yes 0 18 0 Yes 1 2 100 35 100 Busiiro HC II 6 Yes Yes Yes 0 0 0 Yes 1 1 75 83 100 Bukendi HC II 6 No No No 0 0 90 Yes 0 0 5 76 75 Irongo HC III 8 Yes Yes Yes 0 0 0 Yes 0 5 17 90 79 Kiwalazi HC II 8 Yes Yes Yes 0 60 90 Yes 1 5 100 100 87 Kalyowa HC II 6 No No No 0 0 0 Yes 0 7 0 100 99 Kiibinga HC II 5 No No No 90 90 90 No 0 0 0 0 125 Nawampiti HC II 12 No No No 0 30 0 Yes 1 8 33 186 141 Ikonia HC III 10 No No No 0 30 30 Yes 0 5 85 77 81 Nawanyago HC II 4 No No No 0 0 0 No 0 0 0 65 96 Naigobya Lutheran HC II 3 No Yes No 0 17 90 No 0 0 11 75 60 Bukanga HC III 42 No Yes No 0 0 0 Yes 0 4 70 80 88 Buwologoma HC II 9 No No No 30 90 90 No 0 0 0 50 100 Budhana HC II 4 No No No 5 90 30 Yes 1 0 0 91 77 Bulalu HC II 7 No No No 0 83 0 Yes 0 7 62 89 100 Ikumbya HC III 11 No Yes Yes 0 60 60 Yes 0 2 44 84 93 Ntayigirwa HC II 5 No No No 30 30 0 No 0 0 100 57 98 Nanas HC II 15 No No No 90 30 90 Yes 0 0 82 93 95 Busanda HC II 4 No Yes No 0 60 0 Yes 0 2 100 89 94 Nawanyago HC II 4 No No No 0 60 90 No 0 6 83 89 101 Nawansega HC III 12 No Yes No 14 0 0 Yes 0 0 100 75 89 Bukoova HC III 8 Yes Yes Yes 0 60 0 Yes 0 5 67 98 113 Nantamali HC II 7 No No No 0 50 0 Yes 0 0 15 97 69 Bugambo HC II 3 No No No 0 90 0 Yes 0 0 33 100 97 Innula HC II 4 No Yes No 0 21 0 Yes 2 2 67 75 94 Butogonya HC II 0 No No No 90 90 0 No 0 0 0 0 0 Lwaaki HC II 4 Yes Yes Yes 0 83 0 Yes 1 4 100 91 99 Busalamu HC II 8 Yes Yes Yes 0 0 0 Yes 1 14 103 92 100 Suubi HC II 5 No No No 90 0 0 Yes 1 0 75 100 67 Luuka Police HC II 8 No No No 0 60 90 No 0 0 39 96 99 Overall 54 76 91 Figure 4 provides a demonstration of the monitoring tool designed to trigger discussions around performance of individual health facilities on CH during the QRMs at health facility and data review meetings for community health workers.

MCSP provided TA to RHITES EC and RHITES SW to support health facilities that received mentorship and supportive supervision during this quarter on use of CH HMIS tools and data to inform planning. Reporting and documentation in OPD registers was found to be improving. VHTs oriented had used the registers to conduct community household registration, however, compilation and reporting on community data collected remained low.

During this quarter, MCSP worked with RHITES to provide mentorship on how to compile data and report data from VHT registers. MCSP provided TA for both RHITES EC and SW on the orientation and use of VHT registers. In the EC region, 713 VHTs (M: 438, F: 275) covering all12 sub-counties in Kaliro district were oriented; and in the SW region, 732 VHTs (M: 146, F: 586) covering seven sub-counties in Sheema were oriented. MCSP also supported the RHITES IPs with national household registers for all VHTs oriented.

MCSP Uganda CH PY4 Q2 Report 13 MCSP in collaboration with the MoH, USAID’s RHITES SW and EC projects and Makerere University School of Public Health MNCH Centre of Excellence held a meeting to initiate a Community of Practice on Scaling up CH Interventions at all levels of care in Uganda. The meeting, which had over 30 key stakeholders in attendance, including district front service providers from the 4 districts piloting the IMNCI approach (e.g., Kaliro, Luuka, Ntungamo, and Sheema), led to the sharing of best practices, lessons learned, and recommendations on implementing and applying the REC approach (micro-mapping and micro-planning tools) to other CH interventions. Further discussions were also held on how best to structure this Community of Practice to engage and lead to viable inputs for each of the RHITES projects to adopt.

The national HMIS is undergoing a review and update. During this quarter, MCSP supported the MoH CH Division to develop a list of indicators to be included in the national HMIS. These recommended indicators were presented by the MoH CH Division at a meeting organised by the MoH Resource Centre for the CH division and other stakeholders in March 2018. During this meeting, recommendations to include the revised WHO IMNCI classification for pneumonia, diarrhoea, malnutrition, and the sick young of infant; and an indicator to track stock outs of injectable antibiotics for management of severe disease were adopted during the first round of consultation. Indicators on appropriate treatment for pneumonia, diarrhoea and possible serious bacterial infection, remained pending requiring further discussion.

MCSP Uganda CH PY4 Q2 Report 14 IV. Challenges, Solutions and Actions Taken

Challenges faced during Actions taken to address the Results of actions the quarter challenges taken  MCSP worked with the MoH Resource Centre to lengthen the DHIS2 CHMIS 17 additional health reporting timeline. facilities with Quarter 1  MCSP with RHITES to continue ([QI], Oct-Dec 17) advocacy and communication with reporting backlog were districts to create ownership and supported to submit Lack of health facility oversight of VHT work by health their reports. ownership, and oversight for facilities including use of Primary Health VHT work; and limited and Care (PHC) funds to support VHTs. More health facilities poor coordination of have taken initiative to available resources for  RHITES EC agreed to use the U.S use some of the PHC community interventions Presidents Emergency Plan for AIDS funds to support VHT using the national VHT Relief (PEPFAR) funding in Kaliro to work. platform. This has affected support two VHT supervisors with the ability of health facilities bicycles and the community linkage Reporting in RHITES EC to hold VHT review facilitators to work with and support the region for PY4 Q2 meetings, complete CHMIS VHT reporting and supervision. improved compared to reporting, and therefore, the last quarter (see Figure  Districts to hold IP meetings on availability of community 5 above). coordination and support for VHT data on the coverage of activities; and to use mTrac* for prioritized preventive CH Yet to be ascertained- reminder messages on timely reporting interventions. progress to be shared to VHTs and health facilities. next quarter.  RHITES IPs to leverage PEPFAR funded activities at the community level such as Additional VHT tracing of HIV patients lost to follow up, orientation meetings on to facilitate engagement with the CH package held. communities through VHTs.

NMS was able to follow up with its district Medicines Management Supervisors (MMS) to MCSP in collaboration with MoH CH and Health facility level stock support districts to Pharmacy Division and National Medical outs of essential include amoxicillin DT Stores (NMS) convened DPCC meeting to commodities for during this quarter’s address root causes of consistent stock outs implementation of the procurement plan and of CH commodities. Health facilities in SW priority CH package Kit revision exercises. that have iCCM activities are borrowing continued through this Deliveries made by NMS internally from the available stocks of iCCM quarter at the end of the commodities for use in the outpatient clinic. quarter had amoxicillin DT, though the amounts delivered were not sufficient.

MCSP Uganda CH PY4 Q2 Report 15 *mTrac is a national toll free SMS-based platform used to facilitate communication between health workers and the DHO’s office in each district. V. Lessons, Best Practices and Recommendations

Increasing access to pre-referral treatment at level II health facilities in Luuka: Health workers at HC IIs are often faced with limited options for ensuring that children, including new-borns with severe disease, are able to access effective treatment in a timely manner. Often times the caregivers of children referred cannot afford the cost of transport to a higher level health facility or circumstances at home, including taking care of other children left alone at home, make accessing care very far away from home complicated. Unfortunately, the current essential medicines and supplies policy does not cater for and provide supplies for injectable “pre-referral” treatment at HC IIs, often the most feasible location for caregivers to bring their children Following training of health workers in IMNCI in Luuka District, the health workers at HC IIs brought this up as a bottle neck to implementation of IMNCI. The DHT along with the health facility In-charges during a CH implementation review meeting came up with a temporary measure to address this challenge. The measure was to twin higher level facilities (i.e. HC IIIs) which are able to access these medicines, with the HC IIs to provide a small stock of pre-referral injectable medicines for children with severe disease. To date, three HC IIs have been linked to HCIIIs and are now able to access and provide pre-referral treatment for severe disease.

Use of PHC funds to support VHT work: MCSP with RHITES have been advocating with health facility In-charges and the DHT to create ownership and oversight of VHT work by health facilities including use of PHC funds to support VHTs. This has yielded some results in Luuka district with select HFs using some of their PHC funds to facilitate VHT transport costs to attend meetings at the health facility. Reporting on CHMIS has improved and the number of health facilities conducting VHT meetings has also improved.

VI. Success Story

Please see Annex B attached. VII. Management Issues

Partnerships and collaborations: MCSP collaborated with Uganda Health Supply Chain Program (UHSCP) to support the convening of the national DPCC meeting to address the issue of persistent stock outs of essential commodities for CH, especially amoxicillin DT. The meeting brought together various stakeholders including MoH Departments of CH and Pharmacy Division; representatives from the USAID’s RHITES program (SW); USAID’s UHSCP; representatives from one of the MCSP demonstration districts (Kaliro); UNICEF; UHSCP; other IPs including the Clinton Health Access Initiative (CHAI); and representatives from the pharmaceutical manufacturing industry. During the meeting, possible factors contributing to stock outs were discussed and elaborated on with evidence shared by the stakeholders present. These factors include a perception of low demand from the users by the NMS; inadequate follow up by the users on orders made but not supplied; and cheaper cost coupled with lack of knowledge on treatment recommendations by health facilities leading to preferential ordering of co-trimoxazole over amoxicillin DT. Key outcomes from the meeting included agreement to remove co-

MCSP Uganda CH PY4 Q2 Report 16 trimoxazole 120mg from the health facilities ordering list and restrict it for ordering for management of HIV-exposed children; prioritisation of inclusion of amoxicillin DT during the district kit revision and procurement plan review meetings to be held during the quarter; and prioritisation of procurement of amoxicillin DT by NMS.

Meetings with RHITES: MCSP held one meeting with the RHITES EC team during the reporting period. The meetings engaged the Senior Advisor for RMNCH and the Senior Advisor for Community Health. The meeting focused on sharing and finding potential solutions to challenges associated with rolling out the VHT program in the two districts of Luuka and Kaliro. Key issues addressed in the meeting included parallel VHT reporting structures set up by civil society organizations (CSOs) sub-granted by the RHITES EC program; need for CSO’s to build on and complement work already started by RHITES in collaboration with MCSP; and facilitating coordination and proper alignment of various community structures set up by RHITES with the existing VHT structures.

VIII. Monitoring and Evaluation

During the reporting period, MCSP conducted collection of monitoring data for the performance period of October to December 2017. Data was analysed and results compiled into slide decks for sharing with the RHITES partners and the respective districts during QRMs with the districts. However, due to competing priorities within the RHITES programs, especially the heightened focus on activities to accelerate the identification and treatment enrolment of new HIV cases, it was only possible to share the results for Luuka District. In Luuka where the results were shared, eight sub-counties developed actions at sub-county level based on the results of the monitoring tool and results from the assessments and DHIS2. These were endorsed by sub-county political leaders. The quarterly collection of program data for the reporting period of January-March 2018 was conducted with a total of 134 health facilities assessed using four teams per district for a period of six days. Table 3 below shows the number of HFs assessed this quarter by district and level of care. All the facilities considered during this round of data collection are based on numbers agreed on with the district as fully functional health facilities, and submitting reports to DHIS2.

Table 3: Number of health facilities assessed this quarter by district and level of care (Jan- Mar 2018).

Hospital HC IV HC III HC II TOTAL Luuka 0 1 7 13 21 Kaliro 0 1 8 25 34 Ntungamo 1 4 12 25 42 Sheema 0 1 7 13 21 TOTAL 1 7 33 91 134

MCSP followed up and engaged RHITES to identify ways to improve on CHMIS reporting. As part of the follow up, MCSP together with the respective biostatisticians of Luuka and Kaliro, conducted site visits to 11 health facilities in Kaliro and Luuka to establish challenges faced by

MCSP Uganda CH PY4 Q2 Report 17 health facilities with CHMIS reporting. Several challenges for poor CHMIS reporting were identified and solutions to address the challenges identified.

Overall reporting for the quarter 2 has improved in the EC region from baseline. The improvement in the EC region is more marked for Luuka district than Kaliro district. From the data it can be observed, that the districts that have existing external financial support for VHT work did not make progress on CHMIS reporting. Ntungamo received external financial support for community activities including iCCM from UNICEF up till end June 2017; Sheema received financial support for community activities from the Global Fund Project for TB, AIDS and Malaria (GFTAM) through PACE (a local CSO) up till end December 2017. The ending of the 14th implementation phase of GFTAM funding in December 2017 and the re-organization of UNICEF and other partner support for iCCM activities has affected funding support of VHT activities in the two districts for the last two quarters. This has negatively impacted on reporting rates in both districts. The expectation of renewal and continuation of this external funding breeds reluctance amongst the district and health facility leadership to pursue other options to support VHT work. The same kind of challenge has been realized in Kaliro, where the district awaits the funding from RHITES to come through, before it follows up with quarterly VHT meetings and reporting. MCSP in collaboration with RHITES have initiated advocacy and communication efforts to create local district and health facility ownership and to identify more sustainable means of supporting VHT work.

Findings from the health facility assessments: Selected findings on appropriate treatment received for some common childhood illnesses collected through the health facility assessments conducted as part of the program’s routine monitoring system are presented below. The results presented here include assessment findings from July-September 2017 (baseline), October-December 2017 (round 1), and January-March 2018 (round 2).

Almost all children under five (U5) with fever received diagnostic testing with RDT and/or microscopy (over 94%) and nearly all confirmed cases of malaria received ACTs (over 90%) (see Figure 5 below). Both EC and SW regions show a substantial improvement in appropriate treatment for U5 pneumonia cases with amoxicillin DT (see Figure 6), with the increase in Sheema and Luuka districts especially significant. Figure 8 shows trend in diarrhea treatment with oral rehydration salts (ORS) and zinc in the demonstration districts. Kaliro shows highest improvement where proportion receiving appropriate treatment increased from 58% in baseline (July-September 2017) to 82% in this quarter (January-March 2018). In Ntungamo, the proportion of diarrhea cases receiving appropriate treatment increased from 84% to 97%. In Sheema, an improvement in this quarter is observed after a dip in last quarter. The proportion is Luuka dropped to 76% this quarter from 96% in last quarter. Luuka’s case may need further exploration to understand whether this finding is due to issues with data quality and/or other programmatic aspects.

MCSP Uganda CH PY4 Q2 Report 18 Figure 5: Number and proportion of U5 children among RDT positive cases who received appropriate treatment with ACT by district (January-March 2018).

Sheema 97%

Ntungamo 98%

Kaliro 91%

Luuka 94%

0 2000 4000 6000 8000 10000

Cases of fever RDT/microscopy done RDT positive Received ACT

Figure 6: Proportion of U5 pneumonia cases appropriately treated with amoxicillin DT by district (July 2017-March 2018).

100 90 80 70 60 Luuka 50 Kaliro 40 Ntungamo 30 Sheema

20 Proportion of U5 pnemonia cases pnemonia U5 of Proportion 10 0 Jul-Sep'17 (baseline) Oct-Dec'17 Jan-Mar'18 Quarter

MCSP Uganda CH PY4 Q2 Report 19 Figure 7: Proportion of U5 diarrhoea cases appropriately treated with ORS and Zinc by district (July 2017-March 2018).

100

90

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50

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10

0 Jul-Sep'17 (baseline) Oct-Dec'17 Jan-Mar'18

Luuka Kaliro Ntungamo Sheema

MCSP, in collaboration with RHITES, has continuously empowered health workers to address challenges of data quality. During the reporting period, a trend analysis revealed an improvement in the proportion of health facilities that conducted a Data Quality Self- Assessment (DQSA) (see Figure 8 below). During this quarter (January-March 2018), more than half of HFs in SW conducted their DQSAs. In Sheema, though the proportion of HFs conducting DQSA has increased from baseline in this quarter, it is however, lower than the last quarter. In EC, the proportion of HFs conducting their DQSAs have increased from the baseline (July-September 2017), however, it is still low compared to SW.

MCSP Uganda CH PY4 Q2 Report 20 Figure 8: Proportion of health facilities with evidence (in the form of documentation) of DQSA conducted by district (July 2017-March 2018).

100

90

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0 Jul-Sep'17 (baseline) Oct-Dec'17 Jan-Mar'18

Luuka Kaliro Ntungamo Sheema

Disparities still exist between data in the health facility registers and that reported in the DHIS2 using the HMIS reporting forms.

IX. Summary of Quarterly Results

The following table shows the compiled MCSP performance indicators for data available from the four demonstration districts in SW and EC regions where MCSP implemented activities in PY4 Quarter 2.

MCSP Uganda CH PY4 Q2 Report 21

Quarterly Quarterly Quarterly End of Program Result achievement (Jul-Sept Indicator Districts achievement (Oct- achievement (EOP) Target Comments Area 2017) Dec 2017) (Jan –March 2018) value (Baseline) Objective 1: Enhance national guidelines and frameworks for implementation of the essential CH package 1. # of national level guidelines, tools and manuals, report, briefs IR1,IR2, developed or revised for 0 6* 0 5 IR3 CH with MSCP support (CSS, QoC, CDSR, IMNCI) disaggregated by topics and type of products Quarterly Quarterly Quarterly End of Program Result Indicator Districts achievement (Jul-Sept achievement achievement (EOP) Target Comments Area 2017) (Baseline) (Oct-Dec 2017) (Jan –March 2018) value Objective 2: Strengthen competencies and practices of RHITES partners and MCSP demonstration districts to implement the essential CH package Health workers= Kaliro 117 F=78 M=39 Health workers= 73 Luuka Health worker= 31 Health worker = 12 F= 53 M= 20 1. Number of health RHITES partners= 2 Health workers= 90 Health workers and RHITES staff Ntungamo This quarter all the trainings have F= 60 M= 30 worker= 39 IR1,IR2, trained as trainers for been completed and the numbers Health workers= 95 IR3,IR4 IMNCI using updated Sheema reflected in the table are those F= 57 M= 38 RHITES guidelines, job aides and who completed. National ToT on IMNCI partners= 6 tools National M= 13 F= 9 Regional ToT on Regional ToT on IMNCI IMNCI participants Regional participants (SW) (EC) M= 4 F= 7 M= 4 F= 8 Luuka 2.78% 48.4% (33/34) 97.1%

2. Proportion of Health Kaliro 0% 77.3% (20/21) 95.2% Facilities with job aides for Total EC 1.79% 62.7% 96.2% IR1,IR3, case management of 60% IR4 Ntungamo 11.1% 48.7% (42/42)100% childhood illnesses in MCSP Sheema 13.5% 25% (33/37) 89.2% demonstration districts Total SW 12.1% 36.9% 94.6%

IR1,IR2, 3. Proportion of cases of Luuka 84.4% 97.6% (8497/8952) 94.9% 85% IR3,IR4 children under 5 years of Kaliro 87.4% 83.4% (4764/4922) 96.8%

MCSP Uganda CH PY4 Q2 Report 22 Quarterly Quarterly Quarterly End of Program Result achievement (Jul-Sept Indicator Districts achievement (Oct- achievement (EOP) Target Comments Area 2017) Dec 2017) (Jan –March 2018) value (Baseline) age with fever seeking care Total EC 85.9% 90.5% 95.9% at HFs who received RDT Ntungamo 99.5% 86.4% (4835/4908) 98.5% and/or microscopy testing Sheema 94.3% 90.1% (1718/1831) 93.8% for malaria during the last quarter Total SW SW = 96.5% 88.3% 96.2% Luuka 99.2% 98.3% (5508/5864) 93.4% 4. Proportion of cases of children under 5 years of Kaliro 88.1% 88.6 % (2511/2762) 90.9% age diagnosed with malaria Total EC 93% 93.5 % 92.2% IR1,IR2, through RDT and/or 85% IR3,IR4 Ntungamo 97.6% 101% (1045/1062) 98.4% microscopy testing who received ACT treatment Sheema 100% 116% (320/331) 96.7% during the last quarter1 Total SW 98% 108% 97.6% 5. Proportion of cases of Luuka 31.4% 20.6% (455/721) 63.1% children under 5 years of Kaliro 26.5% 38.9% (529/1258) 42.1% age with pneumonia IR1, IR2, Total EC 29.0% 29.7% 52.6% seeking care at HFs who 85% IR3,IR4 Ntungamo 76.9% 96.3% (1160/1205) 96.3% received appropriate treatment with antibiotic Sheema 37.8% 92.6% (759/834) 91.0% during the last quarter Total SW 57.4% 94.4% 93.7% 6. Proportion of cases of Luuka 72.9% 96.0% (1129/1478) 76.4% children under 5 years of Kaliro 58.2% 64.7% (928/1131) 82.1% IR1,IR2, age with diarrhoea seeking Total EC 65.6% 80.3% 79.3% 85% IR3,IR4 care at HFs who received Ntungamo 84.4% 93.5% (859/888) 96.7 % ORS and Zinc (ZN) in the Sheema 94.6% 67.5% (531/556) 95.5% last quarter Total SW 85.9% 80.5% 96.1% Objective 3: Strengthen district level management and planning practices using the adapted REC-QI to support delivery of essential CH package

Quarterly Quarterly Quarterly End of Program Result Indicator District achievement achievement achievement (EOP) Target Comments Area (Jul-Sept2017) (Oct-Dec 2017) (Jan – Mar 2018) value

1. Number of health 0 Health Luuka IRI,IR2, workers and RHITES IP workers= 0 EC: EC: Health Health workers were oriented on IR3, IR4 staff trained on adapted Kaliro Health workers=72* Health workers=51 workers =173 the use of the scorecard and REC-QI approach Total EC RHITES RHITES Partner=2 VHTs=10 mapping to reach every child

1 Data from register shows that some RDT negative children aged 5 years were given ACTs for treatment of fever contrary to the treatment guidelines. The South Western region 8% of the cases that received ACTs had a negative RDT/ Microscopy result from the laboratory MCSP Uganda CH PY4 Q2 Report 23 Quarterly Quarterly Quarterly End of Program Result achievement (Jul-Sept Indicator Districts achievement (Oct- achievement (EOP) Target Comments Area 2017) Dec 2017) (Jan –March 2018) value (Baseline) Ntungamo partner= 0 SW: RHITES Sheema Health workers=72 Non-health partner = 22 Total SW RHITES Partner=2 stakeholders=28 Luuka 30 2. Number of health Kaliro 0 20/21 facilities supported2 by IR1,IR2, MCSP to conduct micro- Total EC 30 20/35 These facilities were supported 0 137 IR3, IR4 mapping and planning to Ntungamo 22 41/42 during the mentorship visits improve coverage of CH interventions Sheema 0 32/35 Total SW 22 3. Proportion of health Luuka 25% 31.8% 18/34(52.9%) facilities with catchment Kaliro 50% 64.5% 10/21 (47.6%) IR1,IR2, area micro-map available Total EC 37.5% 48.2% 50.3% 80% IR3, IR4 and displayed showing Ntungamo 46.3% 78.4% 31/42(73.8%) health provider assigned Sheema 56.8% 57.5% 27/37(73%) for every village Total SW 51.6% 68.0% 73.4% Luuka 332 275 340 4. Number of cases of Kaliro 126 258 202 30% increase IR1,IR2, children under 5 years of Total EC from baseline to IR3, IR4 age referred to HFs for care Ntungamo 10 56 234 EOP by VHTs Sheema 370 59 28 Total SW

Quarterly Quarterly Quarterly Result End of Program Indicator District achievement achievement achievement Comments Area Target value (Jul-Sept2017) (Oct-Dec 2017) (Jan – Mar 2018)

Objective 5: Improve availability of strategic knowledge and tools to scale-up the essential CH package 1. Number of health Luuka 8(22.2%) 9/31=29% 12/34 (35.3%) 37 IR1,IR2, facilities with updated Kaliro 9 (45%) 11/21=50% 6/21 (28.6%) 21 IR4,IR5, monitoring chart or REC Total EC 31.9% 100% of Health Facilities IR6 tool showing coverage of Ntungamo 33 (61.1%) 23/37=62.2% 30/42 (71.4%) 44 CH indicators Sheema 23 (62.2%) 19/40=47.5% (26/37) 70.3% 35

2 MCSP has been conducting integrated training at health facility level to empower VHTs and health workers to use data for planning which also part of the micro planning. Mentorship activities have also been tailored to support the development of micro plans to improve child health indicators and targets.

MCSP Uganda CH PY4 Q2 Report 24 Quarterly Quarterly Quarterly End of Program Result achievement (Jul-Sept Indicator Districts achievement (Oct- achievement (EOP) Target Comments Area 2017) Dec 2017) (Jan –March 2018) value (Baseline) Total SW 70.9% VHTs: 487 F= 26 M= 227 VHTs in Kaliro= 713 HWs: 72 EC 0 F= 36 M= 36 F= 275 During the period, Kaliro and 2. Number of health RHITES Partner: 2 M= 438 Sheema were conducted this IR1,IR2, workers and RHITES IPs quarter after being postponed IR4,IR5, trained and mentored on M= 1 F= 1 350 from the quarter Oct-Dec when IR6 the proper use of CH HMIS VHTs=595 VHTs in Luuka and Ntungamo VHTs were tools F= 365 M= 230 Sheema=732 trained HWs=72 SW 0 F= 32 M= 40 M=146 RHITES Partner=2 F=586 M=2 3. Number of technical and policy briefs on the IR1,IR2, essential CH package Presentation to MCH Cluster on IR4,IR5, 0 1 0 2 developed by program to IMNCI Training delivery models IR6 inform the national scale up 4. Proportion of health Luuka 1 (2.8%) 0 (0%) 15/35 (42.9%) facilities with timely and Kaliro 7 (35%) 0 (0%) 9/21(42.9%) complete reports on IR1,IR2, Total EC EC= 8 (19%) 0 (0%) 24/56(42%) community level CH IR4,IR5, 85% indicators from VHT Ntungamo 17 (31.5%) 0 (0%) 2/44 (4.5%) IR6 registers and CH registers Sheema 14 (37.8%) 19(47.5%) 12/36(33.3%) entered in DHIS2 for the previous quarter Total SW 31 (34.6%) 20.9% 17.5% Luuka 5 (13.9%) 5/31=16% 8/34=23.5% 5. Proportion of Health Kaliro 3 (15%) 9/22=41% 8/21=38.1% IR1,IR2, facilities that conduct Data Total EC 8 (14.3%) 14 (26.4 %) 16/55 (30 %) IR4,IR5, quality self-assessment 100% Ntungamo 21 (38.9%) (37.8%) 22/42 (52.4%) IR6 (DQSA) and reporting to validate CH indicators Sheema 12 (32.4%) 29 (72.9%) 20/37 (54.1%) Total SW 33 (36.3%) 43 (55.8%) 42/ 79 (53.3%) Malaria Diagnosis= Malaria Diagnosis = Malaria Diagnosis IR1,IR2,I 6. Proportion of HFs with a 22.4% 20.6% =30.6% R4,IR5,IR deviation between <10% Pneumonia diagnosis Pneumonia diagnosis Pneumonia 6 recorded data in registers =21.8% = 4.3% diagnosis

MCSP Uganda CH PY4 Q2 Report 25 Quarterly Quarterly Quarterly End of Program Result achievement (Jul-Sept Indicator Districts achievement (Oct- achievement (EOP) Target Comments Area 2017) Dec 2017) (Jan –March 2018) value (Baseline) and reported data in DHIS 2 =32.1 for selected CH indicators Diarrhoea diagnosis Diarrhoea Diarrhoea =38.8% diagnosis =3.6% diagnosis =27.6%

MCSP Uganda CH PY4 Q2 Report 26

X. PY4 Quarter 3 Planned Activities

The following are the activities planned for PY4 for the period April to June 2018:

Objective 1: Enhance national guidelines and frameworks to support implementation of the essential CH package.

1) Participate and support MoH in national consultative meeting to develop guidelines for Catchment Area Population Planning and Action for RMNCAH; 2) Participate and support MoH in consultative meeting to determine the scope of an updated referral care package for CH; 3) Participate and support MoH in the adoption and adaptation of the WHO Paediatric Quality of Care (QoC) standards; 4) Follow up on a potential collaboration with RHITES, UNICEF, and PACE to strengthen reporting in the districts of Sheema and Ntungamo.

Objective 2: Strengthen competencies and practices of RHITES partners and MCSP demonstration districts to implement the essential CH package.

1) Participate and support RHITES EC and SW to conduct IMNCI facilitation skills course for an additional team of ToTs enrolled during this last quarter; 2) Provide TA to RHITES IPs for post IMNCI training mentorship and supportive supervision; 3) Follow up on collaboration with UHSCP and RHITES to ensure availability of essential commodities for CH at health facility; 4) Review, compile, and document experiences on conducting IMNCI training in the MCSP demonstration districts using the two models agreed on with MoH, WHO and RHITES IPs. A joint external review led by WHO to derive recommendations for how the two models can be used to support IMNCI capacity strengthening of frontline health workers across the remaining RHITES districts and eventually nationwide, will also be conducted.

Objective 3: Strengthen district level management and planning practices using adapted REC-QI approaches to support delivery of the essential CH package.

1) Depending on availability of funds from RHITES, continue TA to RHITES IP and district health management teams (DHMT) during VHT orientation and health facility micro- mapping; 2) Provide TA to RHITES IPs to strengthen CHMIS reporting and using health facility and community data to improve targeting of service delivery interventions; 3) Follow up on potential collaboration with RHITES and UNICEF to strengthen CHMIS reporting in Sheema and Ntungamo; 4) Conduct demonstration QRMs in Kaliro, Sheema and Ntungamo; 2 day non-residential meetings targeting Health Facility In-charges, DHT, and civic and political leaders in both Sheema and Ntungamo; and monitoring of progress made on actions derived from QRMs will be done in collaboration with RHITES teams;

MCSP Uganda CH PY4 Q2 Report 27 5) Document promising practices on supporting VHT work by health facilities.

Objective 4: Complete a costing analysis for delivery of the essential CH package.

1) Continue to collect MCSP and RHITES cost data. Based on the current activity plans, MCSP will likely stop data collection of MCSP and RHITES data at the end of Q3 to allow for sufficient analysis time; 2) Begin data analysis for already collected MCSP and RHITES activities; 3) Finalize the facility-level costing methodology and data collection tools. Based on consultation with MCSP and RHITES to determine when the package is being implemented at a sufficient level of quality and accuracy, MCSP will conduct the facility-level data collection in late Q3 or early Q4.

Objective 5: Improve availability of strategic knowledge and tools to scale-up the essential CH package.

1) Participate in the review and planning processes, based on the baseline and periodic data collected; 2) Review DHIS2 report submission dashboards before submission deadline and support district/facilities that have not yet submitted reports; 3) Follow up with the selected health facilities to ensure availability of HMIS tools; 4) Provide ongoing support through mentorship during supportive supervision/on-site training to RHITES and MCSP districts to use and conduct Data Quality Self-Assessment & Improvement (DQS&I) for CH data; 5) Provide support to integrate review of the CH indicators within already planned RHITES district and regional program review meetings; 6) Provide support to document program implementation briefs to the National MNCH Technical Cluster; 7) Support and convene a Community of Practice meeting on applying REC to other CH interventions.

Monitoring and evaluation activities

1) Automation of the monitoring tool; 2) Share data for action during QRMs; 3) Train and mentor RHITES IPs and demonstration districts on proper use of the CH HMIS tools and utilization of data to inform planning; 4) Support quarterly data reviews at community level to improve availability of strategic information.

MCSP Uganda CH PY4 Q2 Report 28 Annex A: Photo Gallery

An Oral Rehydration Corner at a health facility in Western Uganda.

A VHT attached to Rushooka HCII- Ntungamo district, assessing a home for child health indicators using a household register.

MCSP Uganda CH PY4 Q2 Report 29

IMNCI DL training participants from Kaliro district, during a clinical exposure visit at Iganga General Hospital.

DL participants from Kaliro district are mentored during an IMNCI face-to-face session.

MCSP Uganda CH PY4 Q2 Report 30