USAID’s Maternal and Child Survival Program

(MCSP) – Routine Immunization (RI)

Quarterly 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) Routine Immunization (RI) Program

Reporting Period: January 1 to March 31, 2018

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

Project Duration: July 2014 – December 2018

Program Year 4 (PY4): October 1, 2017 to September 30, 2018

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

Project Objectives:

1. Strengthen the Uganda National Expanded Programme on Immunization’s (UNEPI) institutional/technical capacity to plan, coordinate, manage, and implement immunization activities at national level.

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

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Acronym List AD auto-disable ART antiretroviral therapy CAO Chief Administrative Officers CCT Cold Chain Technician CDC Communicable Disease Control DHIS2 District Health Information System Version 2 DHMT District Health Management Team DHO District Health Officer EPI Expanded Program on Immunization HC Health Centre HF health facility HSD health sub-district IP Implementing Partners JSI John Snow Inc. LC1 Local Council 1 LMA Leadership, management and accountability MCH Maternal and Child Health MCHIP Maternal and Child Health Integrated Program MCSP Maternal and Child Survival Program MCV2 measles-containing vaccine second dose MEL Monitoring, Evaluation, and Learning MOH Ministry of Health PDSA Plan-Do-Study-Act cycles PHC primary health care PY Program Year QI Quality Improvement Q2 second quarter QRM Quarterly Review Meetings REC Reaching Every Community/Child REC-QI Reaching Every Community/Child using Quality Improvement techniques RED Reach Every District RHITES Regional Health Integration to Enhance Services in Eastern Uganda RI Routine Immunization RMNCAH Reproductive Maternal Newborn Child and Adolescent Health SAS Senior Assistant Secretary/Sub-county Chief SS supportive supervision SS4RI Stronger Systems for Routine Immunization SW South West Td tetanus diphtheria TT tetanus toxoid TWG Technical Working Group TWC Technical Working Committee UNEPI Uganda National Expanded Programme on Immunization UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States Government VHT Village Health Team WHO World Health Organization

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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’s partnership with USAID/Uganda started with the 2012 initiation of technical assistance to strengthen routine immunization (RI) through MCSP’s predecessor, the Maternal and Child Health Integrated Program (MCHIP).

With USAID’s support, MCHIP worked to strengthen UNEPI and operationalize Uganda’s national Reaching Every Community/Child (REC) strategy by adding elements of Quality Improvement (QI) to create the REC-QI approach, which introduces the Plan-Do-Study-Act (PDSA) cycles. From 2012-2014, MCHIP developed the REC-QI approach and implemented its performance improvement cycle approach in five districts. Using REC-QI, MCHIP was able to improve facility-level planning and delivery of immunization services, introduce simplified tools for using data for action, involve communities to better map and reach all who needed services, and put mechanisms into place for feedback and problem solving with health personnel and non-traditional stakeholders such as community and other leaders.

In 2014, USAID/Uganda requested MCSP to continue MCHIP’s work by expanding to 10 additional districts and maintaining technical support to UNEPI at the national level. Following the July 2017 splitting of one of the 10 districts supported by MCSP into two ( split into and Pallisa), MCSP expanded from 10 to 11 districts. In the now 11 MCSP-supported districts, MCSP is working with district health teams to improve capacity to manage RI, improve health service delivery and eventually increase vaccination coverage in a sustainable way. At national level, MCSP is supporting the Ministry of Health/Uganda National Expanded Programme on Immunisation (MOH/UNEPI) staff to enhance policies, standards and leadership toward a stronger RI system. MCSP is also being implemented alongside the “Stronger Systems for Routine Immunization” (SS4RI) project which was awarded to John Snow, Inc. (JSI) in 2014 by the Bill & Melinda Gates Foundation, and which uses the same REC-QI methodology as 26 Districts supported to MCSP/Uganda. SS4RI is introducing the REC-QI approach in an additional 10 implement REC-QI by districts, bringing the total number of districts in which REC-QI will have been the end of MCSP & introduced to 26 before MCSP and SS4RI end in 2019. SS4RI in 2019

MCSP RI’s implementation approach focuses on building the capacity of personnel in districts, health sub-districts (HSD) and health facilities to carry out REC-QI practices that strengthen the management, delivery, and utilization of routine immunization services. The key REC-QI practices include: building capacity for data analysis and use, quarterly review meetings involving political, civil and religious leaders (e.g. non-health stakeholders), integrated supportive supervision (SS) visits, mapping of health facility (HF) catchment areas, micro-planning, community engagement, Quality Work Improvement Teams, and testing changes using Plan-Do-Study-Act (PDSA) cycles. This report covers MCSP-RI’s implementation, achievements and lessons learned in the second quarter (Q2) of Program Year Four (PY4), i.e. January 1 to March 31, 2018.

II. Summary of PY4 Q2 Achievements

MCSP continued to strengthen UNEPI’s technical and institutional capacity to implement immunization activities at the national level and the district capacity to implement the REC-QI approach for RI system strengthening. MCSP facilitated revision of the EPI Standards, adaptation of the EPI Curriculum, and submission of these key documents to MOH for final review and endorsement. The MCSP team

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continued with REC-Q1 implementation in nine districts but began to explore modifications to the REC- QI approach to address the lack of change in reported figures for RI coverage and drop out in some of the MCSP-supported districts. Additionally, MCSP provided technical support for containment of a measles outbreak in . Finally, MCSP completed data analysis for the Kaporchwa assessment and drafted the report, which was being internally reviewed as of the end of the quarter. Round one data analysis for the REC-Q1 study was completed and sections of the report were drafted for expansion into a full draft once round two data collection and analysis are completed next quarter.

III. Description of Activities for the Quarter Objective 1: Strengthen UNEPI’s institutional/technical capacity to plan, coordinate, manage, and implement immunization activities at national level.

MCSP provided technical support to finalize and present the EPI Standards and EPI Prototype Curriculum in the Communicable Disease Control (CDC) Technical Working Group (TWG) of MOH, and provided responses to the feedback received. These two key EPI documents were made ready for presentation in the Senior Management Committee. Also through the CDC TWG and EPI Technical Working Committee (TWC) meetings, MCSP provided technical inputs into the review of the Comprehensive Multi-Year Plan for Uganda and UNEPI’s Annual Work Plan for 2018.

MCSP attended the Regional EPI Managers’ Meeting for East and Southern Africa held in Kigali, Rwanda from March 20-22, 2018. During the meeting it was emphasized that the end of funding for Polio is a reality and countries should plan to cover the gaps in funding that will be created in the 2019 country plans (particularly funding to cover the positions of surveillance officers). The elimination of Maternal Neonatal Tetanus and control of measles and rubella were discussed as well and the need for countries to switch from Tetanus Toxoid (TT) to tetanus diphtheria (Td) using a schedule recommended by the World Health Organization (WHO). In addition, the meeting provided updates and strategies for new vaccines introduction such as a second dose of measles-containing vaccine (MCV2), typhoid conjugate vaccines, and oral cholera vaccine but emphasized a need for the National Immunization Technical Advisory Group to guide selection of the new vaccines to be introduced. WHO and individual country delegations shared experiences in EPI and performance trends in the region, including the general trend of stagnation in coverage and it was agreed that there is a need ‘to do things differently’ to achieve better results. Country delegations were challenged to think of innovations that can change the trends and consider integration of maternal, child and adolescent services to increase reach, efficiency, and sustainability of services. Participation in this kind of meeting strengthened MCSP/Uganda’s ability to support UNEPI, by ensuring that global and regional perspectives are captured in MCSP’s work. This is particularly important as UNEPI prepares to take on the expanding challenges facing immunization programs, including additional vaccines and a wider target age group.

Objective 2: Improve district capacity to manage and coordinate the immunization program as guided by UNEPI leadership. Modified approach for MCSP began exploring modifications to certain aspects of the conducting QRMs REC-QI approach, particularly to address the lack of change in reported figures for coverage and drop-out in the MCSP What is new? Conduct reviews at HF/sub-county level, instead of health supported districts. The modifications primarily focused on the sub-district (HSD) headquarters and QRMs and SS visits, and were aimed at bridging the gaps identified engage additional participants in leadership, management, and accountability skills of HF In- from outside the health sector, charges, child registration and tracking by village health teams including VHTs, Parish Chiefs, Sub- County Chiefs and Senior Assistant Secretary.

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(VHTs), and mobilizing of non-health stakeholders to support and allocate funding for immunization service delivery. Additionally, the modifications aimed to minimize missed opportunities for vaccination through engagement of all HF staff to screen and refer children from all clinics for immunization.

PY2 Districts (Ntungamo, Mitooma, Kibuku and Bulambuli) Modified QRMs: MCSP provided technical assistance for the final rounds of QRMs in the four PY2 districts. Unlike previous rounds that were conducted at HSD and district levels, these modified QRMs were implemented at HF level or sub-county headquarters, and involved both health workers and community representatives (VHTs, Parish Chiefs, Sub-county Chairperson, and Senior Assistant Secretary (SAS)). The HF teams and the District Health Management Team (DHMT) reviewed the HF RI performance and planned for focused community mobilisation through ongoing child registration by VHTs. During these meetings, HF In-charges were oriented on basic leadership, management and accountability skills aimed at enhancing their capacity to plan and coordinate RI services at the HF level. In this orientation, they were reminded of their role as key players in ensuring program success, transparency and accountability when it comes to allocation of resources for EPI services.

District SS: MCSP supported Kibuku and Mitooma districts to conduct the final round of SS, where a total of 19 district supervisors (9 males, 10 female) were oriented in advance of the visits. The supervision, which involved health workers, district leadership (both civic and political), and community representatives, reached 38 health facilities (16 in Kibuku and 22 in Mitooma). For all rounds of SS conducted during this quarter, MCSP addressed the previously identified gaps in delivery and effectiveness by working with districts to implement the following changes in supervision: • Whole site approach instead of immunization team-specific: MCSP engaged all HF staff including those outside the immunization team, in utilization of the HF micro-plans. This approach promotes continuity of REC-QI implementation across all staff and helps mitigate the effects of staff transfers. This builds the capacity of health workers from other departments (e.g., outpatient, post-natal, antiretroviral therapy) to continuously identify and internally refer unimmunized children who present at those sites for vaccination before they leave the facility. • Involvement in performance review of VHTs, Parish Chiefs and Sub-County Chiefs: These non- health stakeholders contributed to discussions of RI performance, access and utilization, and challenges in ensuring reach to every village and the follow-up of children. Rationales for engagement of these stakeholders included to aid the Sub- County Chief; understand their contribution as New community linkages civil service heads; follow up and ensure process for RI accountability and value for money with primary  Each VHT registers and compiles a report of all health care (PHC) funds provided for RI; and to children under 1 year and young girls in their provide an opportunity for health workers to catchment area. leverage additional resources from local  This VHT report particularly captures number of government revenues for RI services. RI eligible infants per village, their immunisation • Focused mentorship of all HF staff on REC-QI status and parents contact details. practices: MCSP supported targeted hands-on  VHT regularly presents these reports to RI mentorship and coaching sessions at each site service delivery point (static and outreach). that led to review of current REC-QI practices,  Health worker tallies VHT list with Child Register identification of site specific gaps, and list of RI eligible infants and generates a report of corresponding remedial actions. the infants missing vaccines for VHT follow up and referral to static service delivery point or next RI • Support to VHT-led child registration within outreach activity. communities and facilitation of community linkages for RI: MCSP worked with HF leaders to conduct meetings that oriented and commissioned all VHTs in these districts to find and register all

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children under one year who needed to start the vaccination schedule and find and refer for vaccination those children who were under-vaccinated or completely unvaccinated. The meeting also strengthened HF-community linkages by having VHTs share monthly reports on the number of children registered, immunisation status, and parents’ details and contacts. VHTs are to share these reports with health workers at each service delivery point; the latter can cross-check this information with the Child Register to see whether the children referred by the VHTs have actually come for services. Similarly, the health workers were tasked to use the Child Register to generate lists of children who have missed previous vaccination appointments. This process promotes accountability for each child and a continuous cycle of infant tracking, referral and service access. In a larger sense, it is an opportunity to strengthen community linkages for other maternal, newborn, and child health services such as antenatal, expected deliveries, and post-natal services.

PY3 Districts (Mbarara, Bushenyi, Pallisa and Mayuge) Implementation of modified QRM approach: MCSP conducted modified QRMs (as described for PY2 districts above) in Mayuge, Mbarara and Bushenyi districts.

Joint technical support with RHITES South West (SW): During the QRM, MCSP worked closely with the RHITES SW team, who provided both technical and logistical support to the meeting and guided the participants to develop an improvement plan for services covering maternal and child health (MCH) in their catchment areas. This was to enable them to align with the district’s commitments and existing opportunities that could be leveraged for REQ-QI implementation. Some examples of existing opportunities include VHT monthly meetings at sub-county level, Family Health Group meetings, community dialogues, Nutrition multi-sectoral approach meetings, and on-site mentorships, as well as the RHITES SW program learning sessions where discussions are had regarding EPI service delivery bottlenecks and possible solutions.

PY4 District (Butebo) Support to QRMs: MCSP continued its support to Butebo district, which is now in the ‘Establish and strengthen’ phase of REC-QI by conducting a modified QRM at the HF or sub-county level. This brought together district leaders and other RI stakeholders to review performance and lay strategies for further strengthening of community linkages using the approach for VHT child registration and follow up described above.

Technical support to measles outbreak containment: During the reporting period, there was an outbreak of measles in Butebo district. MCSP provided technical support for outbreak containment in collaboration with RHITES Eastern, who provided logistical support specifically for distribution of vaccines to all health facilities.

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IV. Challenges, Solutions and Actions Taken Challenges faced during Actions taken to address the Results of actions taken the quarter challenges National Level Irregular TWG meetings Advocated for putting these Yet to generate consensus on the due to competing demands meetings on a Year Planner such matter on the program that the dates are predictable Bottlenecks that limit the Mapped out partners whose Yet to organize the first impact of REC-QI lie mandate covers these coordination meeting of partners outside MCSP’s mandate bottlenecks and planned for (e.g., national stock outs or coordination meetings to handle shortages of vaccines, them infrastructure) Leadership, management Modified REC-QI methodology Some positive effects were and accountability (LMA) and incorporated LMA beginning to come forth. For gaps for the District and HF component for HF In-charges. example, the CAO Mitooma In-charges hinders their District created a dedicated ability to address system- Enhanced involvement of non- budget line for vaccine wide problems, resulting in health stakeholders such as Chief distribution to address the vaccine stock outs, delays in Administrative Officers (CAOs) problem of vaccine stock outs in payment of outreach and Sub-County Chiefs to ensure health facilities after attending the allowances, and weaknesses District Health Officers (DHOs) District Leaders’ Forum Meeting in internal supervision. and HF In-charges are more in November 2017 organized by responsive and innovate to MCSP. The CAO and DHO in address the gaps identified. Mbarara instituted a policy of signing performance contracts with HF In-charges which puts responsibility on the In-charges who began innovating to improve RI outcome indicators. These measures started last quarter and the effect will be documented next quarter. In Kibuku, the Resident District Commissioner spearheaded mobilization for immunization. District Level The district Cold Chain Districts allocated budget to Effected in both districts by Technician (CCT) did not support the CCT to conduct February 2018. Results to be deliver vaccines from the monthly deliveries to health realised in the coming quarter. District Vaccine Store to facilities and reminded various the lower level health actors of the importance of facilities (e.g., in Mitooma follow up. and Bushenyi). Generally, in the districts, there was little follow-up on resolutions that had been agreed to.

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V. Lessons, Best Practices and Recommendations National Level A multi-partner approach is needed to address the bottlenecks to RI that are beyond the scope of REC- QI. MCSP will work with UNEPI to help broker coordination with partners who have the mandate to handle such issues (particularly logistics, human resources for health, and program communication) and meet or communicate regularly with UNEPI and its partners to share field reports.

The involvement and engagement of non-health stakeholders is crucial for success of the RI program. It partly addresses issues of sustainability and self-reliance by building the capacity of districts to develop their own solutions to local problems. Districts are also innovatively generating solutions within their own budgets without necessarily asking for more external funds. Shifting review meetings from HSD to HF or sub-county levels has brought the problem closer to implementation levels and closed the gaps between HF In-charges and the Sub-County Chiefs who supervise them and are supposed to give them funds to supplement PHC funds. This has yielded positive results in some sub-counties where Sub- county or Town Councils fund some immunization activities to supplement PHC funds.

The new whole site SS approach involves all HF staff (including those from the outpatient department and antiretroviral therapy clinics) to equip them with skills to identify unvaccinated children in those clinics and send them for vaccination as a way of reducing missed opportunities. The approach also involves VHTs, Parish Chiefs and Sub-County Chiefs, thus enabling dialogue among health providers, community mobilisers, and administrators; promotes a sense of shared understanding of the bottlenecks; and ensures practicality of the proposed solutions generated during this exercise. This approach needs to be enhanced and given more time to see if it has benefits. At the end of next quarter, the whole site SS approach will have been implemented for six months and it may be possible to review its early effects (if any) on the RI system.

REC-QI principles have been adopted and adapted into RMNCAH by MOH as the key approach for implementing the RMNCAH Sharpened Plan. MCSP has provided extensive technical assistance into this process, through the RI and Child Health programs, and it is anticipated that additional technical support to the MOH from MCSP will be needed to help incorporate REC principles into RMNCAH guidelines and protocols in appropriate, effective ways. This experience offers a good opportunity to apply well- tested REC approaches from RI to other RMNCAH interventions. To ensure successful incorporation of REC into RMNCAH programs, MCSP will support UNEPI to fully embrace the approach of integration.

District Level • QRMs are a vital platform for learning: QRMs enable sharing of learning, experiences and innovations from different places and this can enhance benchmarking and adoption by other sites to address their performance gaps. For example, following Mbarara’s successful utilisation of commitment letters from HFs to work towards improving RI coverage, (which learned of the practice during a QRM), picked it up and served the first set of commitment letters to all health facilities in category 4 within the quarter. • Good HF leadership is a prerequisite for improving RI performance: MCSP has learned that HF RI performance, is dependent in large measure on the leadership capacity of the HF In-charges. Those facilities that have demonstrated good performance have In-charges who embrace good leadership principles.

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• VHT-led child registration: This approach has been received from district to community level with enthusiasm. The VHTs believe, in addition to other potential benefits, that this will assist them to conduct targeted mobilization thereby, rendering the process of mobilization and accountability for each infant and family more effective and efficient.

VI. Success Story

Please see attached Annex C.

VII. Management Issues

MCSP technical team was boosted by two new staff - Jimmy Odong, Monitoring, Evaluation, and Learning (MEL) Specialist supporting the MEL Advisor, Irene Ochola, and Bryan Tumusiime, Knowledge Management Officer who is spearheading the documentation of MCSP achievements, successes and learnings.

VIII. Monitoring and Evaluation

MCSP conducted quarterly data collection exercises at the district and HSD levels in all the MCSP- supported districts, including all 9 district offices and 18 HSDs in these districts. The data collected will further guide implementation of RI activities in these districts. MCSP also worked with the districts to plan for the semi-annual data collection at all levels (District, HSD, and HF). A team of 19 (10 Male, 9 Female) national level supervisors was trained to support the district team (DHMT and the health management information systems/records staff) during the data collection exercise planned for next quarter.

MCSP continued to conduct detailed analysis and provided REC-QI and RI performance updates to each of the supported districts. These data were shared with the district teams during planned activities, such as the QRMs, and used by the districts to plan and guide implementation of activities.

Below is a summary update on the two learning questions.

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

Data analysis and report writing progressed for the first round of data which was collected from all six selected districts at the end of PY3. Plans for the second round of data collection were developed and will be conducted next quarter. The findings of the assessment will be shared with USAID, and key EPI stakeholders in country and at the global level to inform REC-QI implementation.

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

Dr. Xavier Nsabagasani, the local Principal Investigator for this learning question, analyzed the findings from the largely qualitative assessment exploring the factors that impacted uptake of REC-QI practices among health facilities in Kapchorwa District that did and did not implement the key processes in REC- QI. The findings, together with those from the first learning question above, will be shared with USAID and key EPI stakeholders and will be used to inform REC-QI implementation.

MCSP Uganda RI PY4 Q2 Report 10 IX. Summary of Quarterly Results

The following table shows the compiled MCSP Uganda RI performance indicators for data available for PY4 Q2 from the 11 supported districts. Commented [KO1]: Is it possible to include a column to show the results from the previous quarter? This will give us a No Indicators Districts Quarterly PY4 Q1 PY4 Q2 Achievement sense of the progress made from quarter to quarter, as well as Target Achievement Numerator Denominator Percentage Comments a snapshot for each quarter. (Percentage) (%) (%) Irene: Column has been included with previous quarter 1 Number of deaths in Reported every 5 years. The last achievement the under five Uganda Demographic Health children per 1000 Survey was released in 2016. live births (context) 2 DTP 3 coverage Reported annually nationwide 3 DPT 3 coverage by Reported annually district PY1 districts Reporting rates are 97.5% and 4 Kanungu 90% 81.8% 2,715 3,051 89.0% 100% for Kanungu and Butaleja Butaleja 90% 86.1% 2,347 2,954 79.8% respectively. Total 90% Data downloaded from MOH 83.9% 5,062 6,005 84.3% District Health Information System Version 2 (DHIS2) 16th April, 2018 4.45pm Number of children PY2 districts Completeness of reporting rates who at 12 months Ntungam 90% is 99.4%, 97.6%, 97.9%, and have received three 75.6% 4,592 5,855 78.4% o 100% for Ntungamo, Mitooma, doses of DPT/Penta Mitooma 90% 65.6% 1,532 2,220 69.0% Kibuku and Bulambuli vaccination from a respectively. United States Kibuku 90% 80.7% 2,094 2,444 85.7% Bulambuli 90% 66.9% 1,506 2,112 71.3% Government (USG)- Data downloaded from MOH 90% supported Total 73.4% 9,724 12,630 77.0% DHIS2 16th April, 2018 4.45pm immunization PY3 districts Reporting rates are 100%, 100%, program. (Standard Mbarara 90% 74.8% 4,015 5,719 70.2% 100%, and 91% for Mbarara, 3.1.6 – 61) Bushenyi 90% 71.6% 2,320 2,837 81.8% Bushenyi, Pallisa and Mayuge Pallisa 90% 141.2% 1,987 2,671 74.4% respectively. Mayuge 90% 69.0% 4,132 5,726 72.2% Data downloaded from MOH 90% Total 78.5% 12,454 16,952 73.5% DHIS2 16th April, 2018 4.45pm PY4 district Reporting rates for Butebo are Butebo 90% 103.3% 1,017 1,706 59.6% 89.7%. Total 90% 103.3% 1,017 1,706 59.6%

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No Indicators Districts Quarterly PY4 Q1 PY4 Q2 Achievement Target Achievement Numerator Denominator Percentage Comments (Percentage) (%) (%) Butebo is a newly created district still in the process of setting up infrastructural and administrative structures; gaps exist in coordination of RI activities such as vaccine distribution affecting RI coverage. Butebo harmonised their population figure in this quarter. When it split from Pallisa, there were bordering parishes that were left out which were subsequently included in the district population, and therefore the denominator changed this quarter. All other districts remain the same.

Data downloaded from MOH DHIS2 16th April, 2018 4.45pm 5 Kanungu 91% - - - - MCSP exited the PY1 districts in Butaleja 91% - - - - Feb 2017. PY1 districts Total 91% - - - -

Ntungam 91% Cold chain breakdown, vaccine o - 1,731 1,779 97.3% % of planned RI stock outs and the rainy seasons Mitooma 91% - 910 993 91.6% affected implementation of sessions that were conducted in the Kibuku 91% - 849 2,099 40.4% planned RI sessions in Kibuku year (IP custom) PY2 districts Bulambuli 91% - 1,858 3,291 56.5% and Bulambuli. Total 91% - 5,348 8,162 65.0% Pallisa reported lack of funds for Mbarara 91% - 2,642 2,850 92.7% allowances and transport for Bushenyi 91% - 1,560 1,587 98.3% outreaches, and vaccine stock Pallisa 91% - 1,320 2,027 65.1% outs as reasons for not PY3 districts Mayuge 91% - 1,709 1,874 91.2% conducting planned RI sessions.

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No Indicators Districts Quarterly PY4 Q1 PY4 Q2 Achievement Target Achievement Numerator Denominator Percentage Comments (Percentage) (%) (%) Total 91% - 7,231 8,338 86.0% Few staff allocated for RI Butebo 91% - 485 992 48.9% sessions, cold chain breakdown, and vaccine stock out were reasons for not conducting PY4 district Total 91% - 485 992 48.9% planned RI sessions in Butebo. 6 # of national level - - - - No national level documents guidelines, manuals, were planned for the quarter. and tools in which REC-QI concepts are incorporated (IP custom) - 7

Kanungu - - - - - MCSP exited the PY1 districts in

Butaleja - - - - - Feb 2017.

- - PY1 districts Total - - -

Ntungam - - - o - - Mitooma - - - - - Number of people No trainings were conducted Kibuku - - - - trained in child - during the quarter in the PY2 health and nutrition PY2 districts Bulambuli - - - - - districts. through USG- Total - - - - - supported programs (IP custom) Mbarara - - - - - Bushenyi - - - - - No trainings were conducted PY3 districts Pallisa - - - - - during the quarter in the PY3 Mayuge - - - - - districts. Total - - - - -

No trainings were conducted in PY4 district Butebo - - - - - Butebo district. Total - - - - -

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No Indicators Districts Quarterly PY4 Q1 PY4 Q2 Achievement Target Achievement Numerator Denominator Percentage Comments (Percentage) (%) (%) 8 % MoH / UNEPI TWG coordination meetings held where Routine 3 50% 2 3 66.7% Immunization was discussed in a year (IP custom) 9 MCSP exited the PY1 districts in Kanungu - - - - - Feb 2017. Butaleja - - - - -

- - PY1 districts Total - - -

Ntungam 0% 100% o 100% 1 1 Bulambuli did not conduct the % of planned Mitooma 100% 0% 1 1 100% QRM due to limited PHC funds. quarterly review/coordination Kibuku 100% 0% 1 1 100% meetings held Bulambuli 100% 100% 0 1 0% where routine immunization was PY2 districts 25% 75% discussed in a Total 100% 3 4 district per year (IP custom) Mbarara 100% 100% 1 1 100% Limited PHC funds was the Bushenyi 100% 100% 1 1 100% reason given for not conducting Pallisa 100% 100% 1 1 100% the QRM in Mayuge. Mayuge 100% 100% 0 1 0% PY3 districts Total 100% 100% 3 4 75%

PY4 district Butebo 100% 0% 1 1 100% Total 100% 0% 1 1 100% 10 % of planned Kanungu - - - - - integrated SS visits Butaleja - - - - - conducted in a PY1 districts Total - - - - - district in a year (IP

custom) PY2 districts Ntungam 100% 100% 1 1 100%

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No Indicators Districts Quarterly PY4 Q1 PY4 Q2 Achievement Target Achievement Numerator Denominator Percentage Comments (Percentage) (%) (%) o Mitooma 100% 100% 1 1 100% Kibuku 100% 100% 1 1 100% Bulambuli 100% 0% 1 1 100% Total 100% 75% 4 4 100% Limited PHC funds to support all Mbarara 100% 100% 1 1 100% planned activities was the Bushenyi 100% 100% 1 1 100% reason given for not conducting Pallisa 100% 100% 0 1 0% SS visits in Pallisa. Mayuge 100% 100% 1 1 100% PY3 districts Total 100% 100% 3 4 75% Limited PHC funding was the Butebo 100% 0% 0 1 0% reason given for not conducting PY4 district Total 100% 0% 0 1 0% the QRM in Butebo. 11 Kanungu 44% - - - - Butaleja 44% - - - - PY1 districts Total 44% - - - -

Ntungam o 44% - 34 42 81.0% Mitooma 44% - 21 24 87.5% Kibuku 44% - 12 16 75.0% % of health facilities PY2 districts Bulambuli 44% - 17 21 81.0% with complete REC Total 44% - 84 103 81.0% micro-plans (IP custom) The two main reasons for the lack of completed micro-plans in Mbarara 44% - 51 63 81.0% Pallisa and Mayuge were – 1) Bushenyi 44% - 35 36 97.2% staff transfers, where people Pallisa 44% - 10 21 47.6% trained in micro-planning were Mayuge 44% - 27 48 56.3% transferred before completing the micro-planning process, and 2) limited staff at health facilities who are overwhelmed by multiple tasks. This is coupled PY3 districts Total 44% - 123 168 73.0% with limited follow up by the

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No Indicators Districts Quarterly PY4 Q1 PY4 Q2 Achievement Target Achievement Numerator Denominator Percentage Comments (Percentage) (%) (%) DHO with lower level staff to complete the micro-plans.

Butebo harmonised catchment Butebo 44% - 4 13 30.8% populations during the quarter, so most of the health facilities were found to be in the process PY4 district Total 44% - 4 13 30.8% of completing their micro-plans.

MCSP Uganda RI PY4 Q2 Report 16 X. PY4 Quarter 3 Planned Activities

The following are the activities planned for next quarter, April to June 2018:

National Level Activities • Attend CDC and MCH Cluster TWG and EPI TWC • Work with MCSP-Child Health to fully adopt REC-QI into RMNCAH guidelines and protocols • Support the planning for introduction of rotavirus vaccine into the national program • Support UNEPI to process the EPI standards and the adapted EPI curricula through MOH structures (e.g., approval) • Provide technical assistance to MOH in training tutors in the adapted EPI curricula and Immunization in Practice Manual

District Level Activities PY1 Districts (Kanungu and Butaleja) • Potentially provide technical assistance, if requested by the district, to strengthen sustainability.

PY2 Districts (Mitooma, Bulambuli, Kibuku and Ntungamo) • Conduct sustainability fora for the four PY2 districts.

PY3 Districts (Mbarara, Bushenyi, Pallisa and Mayuge) • Conduct QRMs and SS visits in all four PY3 districts

PY4 District (Butebo) • Conduct QRMs and SS visits

Monitoring, Evaluation and Learning • Collect data from district, HSD and HF levels in all the 9 districts • Compile data and draft the PY4 Quarter 3 progress report • Operationalize a web-enabled database to track REC-QI performance • Roll out the customised Reaching Every District (RED) Categorisation Tool in the MOH DHIS2 to MCSP-supported districts • Finalise the assessment report for the Kapchorwa study • Finalise analysis for phase one of the REC-QI study and conduct second phase of data collection in the PY2 districts.

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

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Annex A: EMMR Quarterly Update

List each Mitigation List of any Measure from outstanding issues Column 3 in the Status of Mitigation Measure Remarks relating to required EMMP Mitigation conditions Plan Utilization of auto- Vaccinators were trained in vaccine MCSP only gives disable syringes and and immunization logistics technical assistance needles for all management, including ordering to management of immunization from the health sub-district vaccine auto- disable (AD) activities. store/district vaccine store that syringes, does not includes bundling of auto-disable procure nor

(AD) syringes with vaccines to distribute them to ensure available stock of vaccines districts and health doses at the HF at any time have facilities (this is equal number of AD syringes, stock responsibility of the management and the use of only AD National Medical syringes for immunization. Store.

Training of vaccinators MCSP Uganda contributed to efforts to avoid recapping of aimed at avoidance of recapping needles after syringes by promoting proper use of vaccination and use of the AD syringes (provided through safety boxes following MOH/UNEPI) through project guidelines, with the trainings, quality improvement motto “no safety box, activities, and SS visits. no vaccination.”

Reduction in waste generation and segregation of wastes Through the trainings, quality during vaccination. improvement activities, and SS visits Sharps to be that it supports, MCSP Uganda separated from other promotes segregation of waste by wastes. Sharps proper use of safety boxes for containers which sharps disposal during vaccination puncture-proof, sessions. impermeable and tamperproof with fitted covers should be used.

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List each Mitigation List of any Measure from outstanding issues Column 3 in the Status of Mitigation Measure Remarks relating to required EMMP Mitigation conditions Plan Put in place a system MCSP Uganda builds local capacity Overall, MCSP to identify expired to ensure systems are in place to Uganda aims to vaccines and identify expired vaccines and discuss consumables, remove remove them from the cold storage environmental them from shelves, (EPI fridges) at health facilities and impact place them in well drugs for district retrieval and as part of technical labelled boxes, and disposal, locked storage place for assistance, training forward them to filled safety boxes exist are and other incineration / disposal communicated and monitored in materials. points. project trainings, quality improvement activities, and SS visits

conducted. Identification of expired drugs and their removal from drug stores for disposal.

Before final disposal of filled safety boxes, they should be stored in a secure place that is inaccessible to people and animals.

Construction of Training, quality improvement incinerators to be activities, and SS are geared towards used for burning of building local capacity to properly safety boxes and use incinerators, where they exist, other wastes. and the ‘burn and bury’ method recommended by MOH/UNEPI is known and practiced at health Fencing of the disposal facilities where incinerators do not sites. exist. Where incinerators are unavailable, use burn and bury methods in areas with limited access that is adequately protected from ground contamination.

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List each Mitigation List of any Measure from outstanding issues Column 3 in the Status of Mitigation Measure Remarks relating to required EMMP Mitigation conditions Plan Mercury MCSP Uganda works to ensure that MOH/UNEPI now thermometers will be mercury thermometers are uses alcohol disposed of in a safe destroyed and fridge tags are thermometers for place where the disposed of according to WHO its EPI fridges and mercury will not protocols. other cold storage contaminate the equipment as ground water. They clarified by UNEPI. should not be burned in open spaces where the fumes will destroy the environment.

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

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

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Annex B: Photo Gallery

MCSP/Kate Holt

Health workers having their PDSA-fishbone assessed at a joint MCSP and district supportive supervision visit.

MCSP/Kate Holt Naula Christine, a VHT-Kasozi Health Center II, is shown her catchment area as a guide for RI follow up.

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MCSP/Kate Holt

A VHT attached to Kakoba HCIII- Mbarara, checks the immunisation status of an infant in her catchment area

MCSP/Kate Holt The Sub-County Chief, Kadama Sub-County in facilitating a supportive supervision session, Mar 2018.

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Annex C: Success Story SUCCESS STORY UGANDA Strong management and commitment by facility and community leaders for routine immunization at Nabuli Health Centre in Kibuku district, Uganda As the newly-appointed officer in charge of Nabuli Health Centre in Kibuku district, Esther Nairuba faced the dual challenges of harmonizing a new team assembled from different health facilities and addressing community disdain and low patient turnout due to the previous poor services at the clinic. During an immunization quarterly review meeting supported by USAID’s Maternal and Child Survival Program (MCSP), she realised she had an even harder task ahead of her as her facility was reported to have the lowest coverage for routine immunization in the entire district. A health education session for mothers with infants awaiting Routine Only half of the children under one year of age received their first Immunisation at a USAID MCSP supported health facility. and third doses of pentavalent vaccine – far below the national MCSP/Kate Holt target of 90%.

NAME MCSP, which has supported routine immunization system Esther Nairuba strengthening in Uganda since 2014, and the district health office invited Esther and the in-charges from other health facilities to participate in a strategy meeting. Guided by input from MCSP and ROLE the local leader (the subcounty chief), Esther mapped out the Health Officer, Nabuli Health Centre health facility’s entire target population for vaccination of children under one year of age in each of four villages. MCSP also provided LOCATION her with user-friendly tools to identify barriers to service access and Kibuku District, Uganda establish effective links between each child and the clinic or outreach site where they are to get immunization services. MCSP has adapted these methods from the field of quality improvement SUMMARY and applied them to the standard WHO/UNICEF management approach for immunization to create a revised version called USAID’s Maternal and Child Survival Program Reaching Every Child using Routine Immunization (REC-QI). (MCSP) in Uganda supports facility and With support from USAID, MCSP has introduced REC-QI in over community leaders to strengthen the routine 350 health facilities across eleven . immunization (RI) system. During an MCSP- supported immunization quarterly review Back at her own health facility, Esther applied her new skills by meeting, Esther Nairuba, a newly appointed convening a meeting of her staff and members of the local Village Health Officer for Nabuli Health Centre in Health Team (VHT) to identify barriers to immunization and Kibuku District, was introduced to key quality brainstorm on solutions. Problems included: offering improvement and management tools immunization only one day per week at the clinic; low interest in developed by MCSP. Utilizing these tools, routine immunization among health workers who often delegated Esther supported her health centre to this role to poorly-trained staff; and insufficient funds (about US$ increase coverage for pentavalent first and 48 per quarter) for community outreaches. This amount covered third dose vaccination from 50% to 90% in all the costs of only a single outreach session per quarter, meaning that each of the four villages in the facility’s catchment was visited only of the villages that it serves. once a year. Nor was there budget to cover the costs incurred by VHTs to mobilize communities for immunisation.

Esther and her team introduced changes the next “We realised that the mothers didn’t want to come quarter. They started offering immunization twice to outreaches to sit and wait through long queues per week; assigned qualified staff, including herself, to vaccinate children and women; and more than for their children to be immunised. Instead as they doubled the funding allocated for immunization to waited, we provided information and family $104 per quarter which additional funds she planning products of their choice which made them deliberately topped up from her regular quartely primary health care budget as provided by the feel like they had benefited on two fronts. They district . This covered transport and meal costs so were more excited to come for routine that more than one health worker could conduct immunization outreaches.” outreach visits which increased to reach at least three out of the four villages each quarter. They also - Esther Nairuba, Health Officer allocated funds to four VHT members to mobilize

Nabuli Health Centre staff convened a follow-up performance review meeting with VHTs and local community

leaders and found that, despite the expansion of outreach services, utilization was still low. They brainstormed the causes and arranged for the civil leaders of the villages (Local Council 1 [LC1] chairpersons) to lead community dialogue meetings to educate families on the lifesaving value of immunization. They also ensured that community mobilizers specifically met with the LC1 chairperson from the lowest-performing village to ask him to promote use of services and address anti-vaccination rumors in his village.

Nabuli Health Centre also identified one additional village that had not received services for over three years due to a swamp that cut it off from services. The staff arranged for outreach services for both immunization and family planning. This greatly incentivized mothers to come with their infants. As Esther narrates:

“We realised that the mothers didn’t want to come to outreaches to sit and wait through long queues for their children to be immunised. Instead as they waited, we provided information and family planning products of their choice which made them feel like they had benefited on two fronts. They were more excited to come for routine immunization outreaches.”

Within six months, Nabuli Health Centre reported that coverage for the first and third doses of pentavalent vaccine increased from 50% to 90% in all of the villages that it serves. Esther attributes these improvements to her commitment as a leader, engaging and facilitating relevant community resource persons for mobilisation and demand creation, listening to and addressing community needs for integrated services, and actively using her facility’s own data to determine which actions would bring services closer to every child and family. These are measures that she recommends be used in other health facilities that, like Nabuli Health Centre, face the challenge of limited resources.

By: Bryan Tumusiime