USAID/ PRIVATE HEALTH SUPPORT PROGRAM YEAR 2 ANNUAL AND QUARTER 4 REPORT: OCTOBER 2014-SEPTEMBER 2015

October 30, 2015 This report is made possible by the support of the American People through the United States Agency for International Development (USAID). The contents of this report are the sole responsibility of Cardno Emerging Markets USA, Ltd. and do not necessarily reflect the views of USAID or the United States Government. USAID/UGANDA PRIVATE HEALTH SUPPORT PROGRAM YEAR 2 ANNUAL AND QUARTER 4 REPORT: OCTOBER 2014-SEPTEMBER 2015

Submitted by: Cardno Emerging Markets USA, Ltd.

Submitted to: USAID/Uganda

Contract No.: AID-617-C-13-00005

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

USAID/Uganda Private Health Support Program

Table of Contents ACRONYMS ...... V EXECUTIVE SUMMARY ...... 7 PRINCIPAL ACHIEVEMENTS ...... 7 TASK 1. EXPANDED AVAILABILITY OF HEALTH SERVICES BY PRIVATE SECTOR PROVIDERS .. 10 TASK 1.1. STRENGTHEN HIGH VOLUME SITES TO OFFER COMPREHENSIVE HEALTH SERVICES ...... 10 1.1.1. Support integration of services at PFP sites ...... 10 1.1.2. Capacity building for comprehensive service delivery through performance based grants ...... 14 1.1.3. Strengthen e-MTCT services at private sector facilities ...... 14 1.1.4. Strengthening early infant diagnosis (EID) ...... 16 1.1.5. Improve patient retention and adherence in care at PFP facilities ...... 16 1.1.6. Support routine nutrition counselling and assessment ...... 17 1.1.7. Increase private sector participation in HIV prevention through grants ...... 18 TASK 1.2. EXPAND PRIVATE SECTOR CLINICAL CAPACITY ...... 19 1.2.1. Promote team-based on site trainings, coaching and mentorship ...... 19 1.2.2. Integration of clinical and business skills ...... 20 1.2.3. Online support ...... 20 TASK 1.3. ESTABLISH LINKAGES AND FUNCTIONAL REFERRAL SYSTEMS FOR SERVICES...... 21 1.3.1. Establish linkages for referrals from low volume to high volume sites ...... 21 1.3.2. Establish linkages for referrals from high volume sites to high capacity laboratories and diagnostic centers ...... 21 1.3.3. Assessment of laboratory services ...... 21 1.3.4. Partner with National Public Health Laboratory (NPHL) for laboratory capacity building...... 22 1.3.5. Establish systems for test samples transportation ...... 22 1.3.6. Commodity supply and web-based reporting...... 22 TASK 1.4. EXPANSION OF FINANCIAL OUTREACH THROUGH DCA BANKS ...... 23 1.4.1. Expanding financial outreach through ...... 23 1.4.2. Expanding financial outreach through Ecobank ...... 26 1.4.3. Expansion of financial outreach through non DCA banks ...... 29 1.4.4. Technical Assistance to DCA, non DCA banks and borrowers ...... 29 1.4.5. Business strengthening support (Provide financial and business training and technical assistance to a network of health clinics) ...... 30 1.4.6. HaaB business counselling outputs ...... 32 Challenges in implementation of the HaaB activity ...... 33 Lessons learnt under the HaaB activity ...... 33 1.5. SUPPORT INNOVATIVE APPROACHES FOR ORPHANS AND VULNERABLE CHILDREN ...... 33 1.5.1. Performance based grants to CSOs ...... 35 1.5.2. Capacity building for grantees ...... 35 TASK 1.6. IMPROVE PRIVATE SECTOR PARTICIPATION IN DISTRICT SERVICE DELIVERY COORDINATION ...... 36 1.6.1. Strengthen district PPPH coordination ...... 36 1.6.2. Greater participation of private sector in district planning ...... 37 1.6.3. PPPH desk offices functioning ...... 37 Challenges: ...... 37 Recommendations: ...... 38 TASK 2. INCREASING AFFORDABILITY OF PRIVATE HEALTH SERVICES AND PRODUCTS ...... 39 2.1. REDUCING THE PRICES OF HEALTH PRODUCTS AND SERVICES ...... 39 2.1.1. Recommending prices for essential medicines ...... 39 2.1.2. Developing and disseminating professional fee guidelines ...... 39 2.1.3. Supporting pooled procurement for private health providers ...... 40 2.1.4. Disseminate national treatment protocols ...... 40 2.2. REDUCING FINANCIAL BARRIERS TO ACCESSING HEALTH SERVICES ...... 40 2.2.1. Promote health insurance and link it to micro and community health insurance ...... 40 2.2.2. Promote health savings schemes ...... 41 2.2.3. Increase access to and expand scope of existing franchises and voucher programs ...... 41 2.3. PROMOTING PREVENTATIVE CARE AMONGST PROVIDERS AND CLIENTS ...... 41 2.3.1. Incentivize private providers to provide more preventative care ...... 41 2.3.2. Promote early health seeking behaviors among consumers ...... 41 Challenges: ...... 41 Recommendations: ...... 41 TASK 3. IMPROVED QUALITY OF PRIVATE HEALTH SECTOR FACILITIES AND SERVICES ...... 42 3.1. DEVELOP A SELF-ASSESSMENT VOLUNTARY QUALITY IMPROVEMENT SYSTEM (VQIS) TO ENABLE PHP PROVIDERS TO DELIVER QUALITY SERVICES ...... 42 3.1.1. Benchmark the tool against international practice ...... 42 3.1.2. Pilot standards in districts outside of district...... 42 3.1.3. Develop VQIS and roll-out plan...... 42 3.1.4. Digitize and produce final standards and assessment tools ...... 43 3.1.5. Launch the VQIS at a high-level workshop ...... 43 3.2. STRENGTHEN DISTRICT HEALTH MANAGEMENT TEAMS’ (DHMTS’) CAPACITY TO ENGAGE AND PARTNER

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WITH THE PRIVATE SECTOR TO IMPROVE QUALITY ...... 43 3.2.1. Disseminate widely VQIS system, guidelines and tools to Program districts ...... 43 3.2.2. Disseminate widely treatment guidelines to Private sector facilities ...... 43 3.2.3. Orient district level staff responsible for private sector quality on VQIS ...... 43 3.3. DEVELOP TOOLS TO UNIFY AND STREAMLINE SYSTEMS SUPERVISING PRIVATE SECTOR QUALITY ...... 44 3.3.1. Update the Council Acts ...... 44 3.3.2. Advance the National Health Professions Act ...... 44 3.3.3. Assist Kampala City Directorate of Health Services to harmonize and field test a uniform application for facility licensure ...... 44 3.3.4. Assist Kampala City Directorate of Health Services and Environment to conduct a private provider census ...... 44 3.3.5. Assist Kampala City Directorate of Health services and UHF to apply VQIS ...... 44 3.4. STRENGTHEN UHF’S CAPACITY TO BUILD A COHESIVE AND CAPABLE PRIVATE SECTOR TO PROMOTE STANDARDS OF CARE TO PFP PROVIDERS...... 45 3.4.1. Strengthen UHF leadership and governance...... 45 3.4.2. Build UHF’s capacity to deliver services valued by its members ...... 45 3.4.3. Strengthen UHF’s financial sustainability ...... 45 3.4.4. Strengthen UHF’s capacity to implement VQIS ...... 46 3.5. ASSIST THE DHMTS TO IMPLEMENT PPPHS THAT STRENGTHEN PFPS’ CAPACITY TO DELIVER QUALITY SERVICES...... 46 3.5.1. Raise awareness on the PPPH Policy ...... 46 3.5.2. Support private sector associations like UHF to advocate and promote PPPHs ...... 46 3.5.3. Assist six of the most promising districts to identify and design one PPPH that will strengthen private sector quality ...... 46 Challenges: ...... 47 Recommendations: ...... 47 ANNEX 1: SUCCESS STORY—USING MOBILE MONEY TECHNOLOGY TO IMPROVE EFFICIENCIES AT PROGRAM MANAGEMENT LEVEL...... 48 ANNEX 2: SUCCESS STORY—QUALITY IMPROVEMENT STRATEGIES TO STRENGTHEN SERVICE DELIVERY AT MEHTA HOSPITAL & KINYARA HC III ...... 50

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Acronyms A2F Access to Finance ANC Antenatal Care ART Anti-Retroviral Therapy BDS Business Development Service CBO Community-Based Organization CD4 Cluster of Differentiation 4 CDCS Country Development Cooperation Strategy CME Continuous Medical Education CSR Corporate Social Responsibility DCA Development Credit Authority DHIS2 District Health Information System DHMTs District Health Management Teams DO Development Objective DOP District Operational Plan EID Early Infant Diagnosis EMTCT Elimination of Mother to Child Transmission FP Family Planning FSG Family Support Group FUE Federation of Uganda Employers GPS Global Positioning System HCT HIV Counselling and Testing HCWM Health Care Waste Management HIPS Health Initiatives for the Private Sector HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HMIS Health Management Information System HSS Health Systems Strengthening HSSIP Health Sector Strategic and Investment Plan HTC HIV Testing and Counseling IFC International Finance Corporation IHA Insight Health Advisors IDI Infectious Disease Institute IEE Initial Environment Examination IPs Implementing Partners IR Intermediate Result IRCU Inter-Religious Council of Uganda JMS Joint Medical Stores KCCA Kampala City Council Authority LMIS Logistics Management Information Systems LQAS Lot Quality Assurance MARPs Most at Risk Populations M&E Monitoring and Evaluation MEEPP Monitoring and Evaluation of the Emergency Plan Progress MCH Maternal and Child Health MFIs Micro Finance Institutions MGLSD Ministry of Gender, Labor and Social Development MOH Ministry of Health MOH HR Ministry of Health Human Resources

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MOUs Memorandum of Understanding NBL Breweries Limited NDA NHIF National Hospital Insurance Fund NHPA National Health Professionals Act NPHL National Public Health Laboratory OVC Orphans and Vulnerable Children PEPFAR President’s Emergency Plan for AIDS Relief PFP Private For Profit PHP Private Healthcare Provider PHSC Private Sector Health Advocacy Committee PMP Performance Monitoring Plan PMTCT Prevention of Mother-to-Child Transmission PNFP Private Not-For Profit PPP Public Private Partnerships PSFU Private Sector Foundation Uganda PPPH Public Private Partnerships for Health QI Quality Improvement RH Reproductive Health RLCC Regional Laboratory Coordination Committees RUTF Ready to Use Therapeutic Food SACCO Saving and Credit Cooperatives Organization SIMS Site Improvement through Monitoring Systems SDS Strengthening Decentralization for Sustainability VMMC Safe Male Circumcision STI Sexually Transmitted Infection STTA Short-Term Technical Assistance SURE Securing Uganda’s Right to Essential Medicines TB Tuberculosis UCBHFA Uganda Community Based Health Financing Association UHF Uganda Healthcare Federation UHMG Uganda Health Marketing Group UMA Uganda Manufacturers Association UMEMS Uganda Monitoring and Evaluation Management Services USAID United States Agency for International Development USG United States Government VMMC Voluntary Medical Male Circumcision VQIS Voluntary Quality Improvement System SQIS Self-Regulatory Quality improvement

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Executive Summary The USAID/Uganda Private Health Support Program is USAID’s flagship program in the private sector in Uganda. Building on the successes of USAID’s Health Initiatives for the Private Sector (HIPS) Project, the Program is designed to leverage the private sector’s strengths while addressing longstanding concerns about its capacity, quality and interests. Cardno Emerging Markets USA, Ltd. (Cardno) leads this five-year program, supported by three subcontractors: Banyan Global, the Infectious Diseases Institute (IDI) and Insight Health Advisors (IHA). The USAID/Uganda Private Health Support Program has in Year 1 issued grants to leverage and strengthen local organizations to ensure sustainability of programs. Local partners that have received these grants include private sector industry groups: Uganda Healthcare Federation (UHF), Federation of Ugandan Employers (FUE), Uganda Manufacturers Association (UMA) and Ugandan Community-Based Organizations (CBOs).

Goals and tasks of the USAID/Uganda Private Health Support Program The USAID/Uganda Private Health Support Program aims to strengthen, organize and mobilize the private sector to provide Ugandans with the option of obtaining high-quality health services from private for profit (PFP) providers. This supports USAID/Uganda’s 2011-2015 Country Development Cooperation Strategy (CDCS), in particular Development Objective 3 (DO3), where three of the four sub-results under Intermediate Results (IR) 3.1 (IR3.12, IR3.1.3 and IR3.1.4) align well with leveraging and expanding the existing capacity of the private sector. The goal of the Program is to improve the credibility and cohesiveness of the private sector and expand the capacity of private sector providers. The focus of its support is to provide technical expertise, enhance quality standards, improve access to capital, support accreditation and provide leadership in the private sector. In order to achieve this, the Program has three main objectives: > Expanded availability of health services by private providers; > Increased affordability of private health services and products; and > Improved quality of private health sector facilities and services.

Principal Achievements > Dissemination of National tools, standards and guidelines in the private sector: During the year, the Program in partnership with MOH and various district based health teams, supported the rollout of revised ART/EMTCT/HIV tools and guidelines at accredited private health facilities. The roll out covered 79 ART sites. A total of 1,012 health care workers were mentored on ART initiation, monitoring and follow up of patients. > Health worker capacity building: Using various innovative approaches like blended learning, onsite mentorship and online courses, the Program provided training support to a total of 1,482 health workers during the year. These included pediatric and adult HIV management, PMTCT, Early Infant Diagnosis (EID), Safe Male Circumcision (SMC), laboratory practices, HMIS and DHIS2, NACS, viral load testing and monitoring, revised integrated HIV/ART, PMTCT/EID, TB guidelines, Logistics Management Information Systems(LMIS), cervical cancer screening and quality improvement. The health worker skills were further strengthened through onsite mentorship and coaching sessions in all the above service areas. Highlights on selected trainings are below:  First online comprehensive HIV/ ART management course: The Program launched the first ever online comprehensive ART course in Uganda. 20 health workers from 17 private healthcare facilities participated in the online course. This was followed with face-to-face sessions and two 2-day practical placements at selected centers of excellence.  The Program together with the Nutrition unit of MOH conducted integrated NACS training of 29 health workers from 19 PFPs. The facilities were given tools to use in nutrition assessment including mid-upper arm circumference (MUAC) tapes, desk job aides, nutrition brochures and MOH nutrition M&E tools. The sites were further supported through on-site integrated mentorship and coaching of health workers to further strengthen the skills of health workers in integrating nutritional services into existing static health services and outreaches for quality management of services.  During Year 2, a total of 14 health workers were trained in integration of FP services into HIV care and treatment at PHP facilities. The goal of this integration is to enable PHPs to offer high quality voluntary family planning counselling and services,

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including safer pregnancy counselling and contraceptives (depending upon their fertility intentions) to all clients attending care, particularly HIV services at all care points in the facility.  In Quarter 4, the Program conducted training of 40 health workers in integrated case management of malaria. These health workers were drawn from 23 private facilities. In addition, during Quarter 4, the Program conducted training of 60 health workers in Intermittent Presumptive Treatment (IPTp) of malaria in pregnancy. This is in line with one of the objectives of the National Malaria Control Policy for the prevention of Malaria in Pregnancy (MIP). > Assessment of Tuberculosis (TB) services in the private health facilities: The Program in partnership with the National TB and Leprosy Program (NTLP) conducted an assessment of TB services in the private sector. 24 selected facilities were assessed to: (a) establish the status of TB care services (b) establish the capacity of private health facilities to offer quality TB care services (c) determine the enrollment and health outcomes of TB patients in the period September 2013 to October 2014. The detailed report will be available in Quarter 1 ofYear 3. > Assessment of laboratory services: The Program worked with the central public health laboratory (CPHL) to conduct assessment of laboratory services in the private sector. The goal of the assessment was to inform the design of the samples referrals and linkages strategy for the private sector. The report will be available in Quarter 1 of Year 3. > Hosted the Saving Mothers, Giving Life (SMGL) International team building meeting: The meeting brought together key SMGL team members and stakeholders to share updates on technical and implementation progress in the three SMGL countries (Uganda, Zambia, and Nigeria). USAID/Uganda Private Health Support Program and Macleod Russell Uganda Limited (MRUL) hosted the SMGL team at Mwenge Tea estate clinic. The Program, MRUL and Mwenge tea estate clinic demonstrated a good number of SMGL practices. > Program Year 3 Workplanning: During the reporting period, USAID/Uganda Private Health Support Program undertook a planning process for the Program Year 3. A detailed work plan has been approved by USAID. In Year 3, the Program will consolidate the achievements made in the previous year while addressing the identified concerns to improve performance using innovative approaches with specific focus on high volume sites. Special attention will be put on programming for sustainability of services in the private sector where emerging health services needs will be addressed. The Program will transition out of care and treatment support to the private sector as part of the new USAID/PEPFAR FY15 Country Operating Plan prioritization and regionalization. > Access to Finance-DCA: A total of 21 new loans valued at UGX 779,500,000 (USD 305,686) were booked under the Centenary bank DCA in Year 2, representing 10.2% utilization of the total guarantee amount. These 21 borrowers constituted 33% of the total number of borrowers (64) to date under the Centenary DCA. By the end of Year 2, utilization of the USAID/SIDA Health DCA at Centenary Bank had reached a cumulative total of UGX 4,506,500,000 (USD 1,761,254.9). This is a 58.9% utilization of total guarantee amount. Utilization was by 64 borrowers (44 rural and 20 urban).The portfolio quality of the DCA is good. Only 2 notices of default have been made so far. However, all recoveries of arrears on both loans have been made and the bank has therefore not had to resort to making a claim against the guarantee to date. 19 loans (UGX 1.4 Bn) representing 18.3% of the total guarantee amount have since been fully paid off. > Utilization of the USAID/SIDA Health DCA at Ecobank has stalled at UGX 1,290,000,000 (7.2% utilization of total guarantee amount as at end of June 2015. This is to 2 borrowers (1 rural, 1 urban). The Program has intensified TA support to Ecobank in order to ramp up the utilization of the Ecobank DCA. This has included providing financial management support to potential prospects that need it as a prerequisite to loan application. We are also working with Ecobank to ensure that identified DCA prospects complete and submit their loan applications. > Business strengthening support to private sector healthcare businesses: The Program completed the implementation of Phase 1 of the business training and mentoring program for the private healthcare sector through two business support organizations (grantees)—Private Sector Foundation Uganda (PSFU) and University College of Health Sciences. 22 business counselors were trained while 185 healthcare businesses (represented by 286 individuals) from 67 districts participated in the business counselling trainings and on-site mentorships. > Private health lending assessment: The private health lending assessment was finalized during the year and findings disseminated to key program stakeholders. The report identified

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the constraints and opportunities of financial institutions in Uganda to serve private health sector providers (PHPs). It reported on the use of financial services (financial inclusion) by PHPs and projected financial needs in the near future. The report gives the USAID/Uganda Private Health Support Program an evidence base in its critical role and ongoing efforts of expanding financial outreach in the private health lending market. > Developing and disseminating professional fee guidelines: During the year, the Program contracted a local firm to develop professiional fee guidelines. By Quarter 4, the firm had submitted a report on the current local data and regional information on professional fees in Kenya, Tanzania, Zimbabwe and the United Kingdom. The firm will submit its 1st draft of professional fee guidelines in the first quarter of Year 3. This draft will include data collected from field visits and data analysis. > Developed the self-regulatory’ quality improvement system (SQIS): Continuing with efforts from Year 1, the Program benchmarked the SQIS tool against international practice through a visit to the Kenyan PharmAccess “SafeCare” model. The Program went ahead to conduct a two-visit pilot in 64 facilities in 8 districts and recommendations from the pilot were incorporated into the draft standards. By Quarter 4, the Program had launched the SQIS at a high level meeting in Kampala and greatly progressed towards digitizing and producing final standards and assessment tools. The demo system can be accessed following this link http://sqis.med.ug/home/#1443512959144-5470b597-8fdc.  Intergration of services and quality improvement. During Year 2, the Program supported 21 PFP facilities to integrate and offer quality Voluntary Male Medical Circumcision (VMMC) services as part of HIV prevention. The Program trained 32 health workers in VMMC. PFPs were further supported to conduct integrated VMMC outreaches, attend VMMC QI learning sessions as well as on site mentorship and coaching to strengthen their practical skills in VMMC including counselling, circumcision and integration with other services. All (100%) of the SMC targets were exceeded. > See the below example of a VMMC dashboard from one of the PHPs that demonstrates improvement in VMMC services delivery in the private sector under Chart 1. > During Year 2, the Program continued to support innovative approaches for orphans and other vulnerable children through 10 performance based grants to 10 CBOs. These 10 grantees reached 4,705 OVC with services through the private sector engagement model of matching Program funds with the private sector funds and resources to deliver services to the OVC. By engaging private companies, the CBOs enhanced the support they provided and further ensured the sustainability of OVC services. Beyond monetary contributions, the companies supported OVCs in the following ways:  Eco-Agric Company Limited and Elgonia Coffee provided seedlings to the apprentices and guided them on setting up nursery beds. Many of the OVC households that engaged in agricultural activities such as growing orange fleshed sweet potatoes, maize, beans and vegetables had realized two seasons of harvest by the end of the year.  Traidlinks Hoima worked with Eco-Agric to market its produce and create more value addition to their crops.  Nexus Uganda Limited (a local construction firm) leads efforts for apprenticeship trainings for OVCs supported by KIFAD. This included skills trainings for the OVCs is in the fields of construction, carpentry and joinery as well as brick laying.  Kakira Sugar Limited offered internship placement for OVCs for a period of one year to get skills in plumbing and metal fabrication (among others) at the sugar factory.  Barclays bank Masindi facilitated entrepreneurial trainings for the caregivers of the OVCs supported by Family Spirit Children’s Centre. The bank supported the VSLA groups to grow their savings through offering them skills in investment and management of loans. > To improve private sector reporting, USAID/Uganda Private Health Support Program continued to strengthen data collection and reporting within the private sector and worked to ensure that private sector outputs are reflected in the National DHIS2. The Program provided updated HMIS tools, HMIS on-site mentorship, in-class trainings in HMIS and DHIS2, support supervision visits and partner performance review meetings. As a result, private sector reporting through the DHIS2 has improved from 27% at baseline, 62% and end of Year 1 to 80% by the end Year 2

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Task 1. Expanded Availability of Health Services by Private Sector Providers

Task 1.1. Strengthen high volume sites to offer comprehensive health services

1.1.1. Support integration of services at PFP sites During Year 2, the Program continued to support integration of services at 109 PFP facilities to minimize missed opportunities towards provision of quality care by using unique and specific interventions (depending on current services capacity and comprehensiveness) for partner PFPs with emphasis on integration of HIV counseling and testing (HCT), Family Planning (FP), TB, VMMC, malaria prevention and management into existing Maternal, Newborn and Child Health (MNCH), HIV, Out Patient Department (OPD)/In-Patient Department (IPD) services and community outreaches among others. This has been done through skills building (Continuing Medical Education--CMEs, training, learning sessions, mentorships and coaching sessions), logistical support with supplies (for VMMC, FP), data tools and integrated outreaches with the facilities to deliver integrated services to the target populations.

Integration of HTC services During the reporting period, the Program supported 109 partner facilities to integrate HTC into outreach and routine static services. Healthworkers were trained, mentored and coached. At the facilities, HTC was performed at several points that included: MNCH clinic, and IPD. PFP health workers were encouraged to use the Provider Initiated Testing and Counselling (PITC) approach as opposed to Voluntary Counselling and Testing (VCT). Some of the key results from this integration were increased number of mothers (Antenatal care -ANC, labor and delivery and post- natal care) received HTC with same day results.

Graph 1: Individuals Counselled and Tested for HIV

40,000

35,000

30,000

25,000

20,000

15,000

Numberindividuals of 10,000

5,000

- Qtr1 Qtr2 Qtr3 Qtr4 Number of individuals counselled 32,863 33,775 31,856 33,015 and tested for HIV Number found HIV positive 1,469 1,448 1,448 1,004

Integration of Family planning into HIV/AIDS services The Program worked with the APC project of FHI360 to strengthen integration of FP services into HIV care and treatment at PHP facilities. The goal of this integration is to enable PHP’s to offer high quality voluntary family planning counselling and services, including safer pregnancy counselling and contraceptives (depending upon their fertility intentions) to all clients attending care, particularly HIV services at all care points in the facility. In Quarter 4, A total of 14 health workers from six private health facilities1 were trained and mentored on FP integration into other services including but not limited to HIV/ART clinics,

1 Mwenge Estate clinic, Hope Again Medical centre, Mabale estate clinic, Hima cement Clinic, Santa Maria Medical centre and D&D Mwesigwa Medical centre

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MNCH clinics (ANC, Post-natal care –PNC and Young Child Clinics-YCC), OPD and community outreaches. During onsite mentorship, health workers carried out insertion of Intra uterine devices (IUDs) and implants under supervision and guidance of the mentors thus strengthening their skills in long term FP. Other facilities were supported to integrate family planning through mentorship and supervision visits.

Graph 2: Family Planning services uptake

New acceptors to FP 50,000 45,000 43,360 40,000 38,532 35,000 30,000 27,407 25,000 20,000 15,000 12,528 10,000 5,000 0 Qtr1 Qtr2 Qtr3 Qtr4

Quarter Cumulative Cumulative number new of acceptors

Integration of TB services In Quarter 4, the Program trained 30 PHP health workers in TB/HIV management. The goal of the training was to: equip the health workers with knowledge and skills to conduct clinical assessment and diagnosis of TB; screen for HIV in TB patient; appropriately manage TB/HIV co- infection; correctly document TB/HIV variables in the respective MOH data tools; develop Quality Improvement (QI) strategies and implement TB prevention and effective infection control practices. In Year 2, the Program worked with the National Tuberculosis and Leprosy Program (NTLP) to carry out an assessment of TB services in the private sector. Preliminary results show that there are gaps in management of pediatric TB cases, limited knowledge on Most Drug Resistant TB (MDR TB), limited access to Genexpert. Furthermore, PFPs have challenges in implementing Isoniazid Preventive Therapy (IPT) and only 54% of the PFPs are diagnosing TB using microscopy. Results also showed that only 27.1% (83/306) of all the smear positive clients completed treatment and were cured; 83% (540/652) of the patients diagnosed with tuberculosis were tested for HIV co-infection of whom 38% (203/540) were HIV positive. At the 24 health facilities a total of 2081 HIV+ clients were identified and recorded between September 2013 – October 2014. However, only 58.2% (1212/2081) were screened at least once for tuberculosis infection. 10.5% (127/1212) of those screened were found to be infected with tuberculosis and none of the clients were availed with IPT. The findings from this report have critically informed Program intervention for strengthening of TB services in the private sector. During the year, 779 (65% of the target) patients were initiated on TB treament . Out of these 655 were tested for HIV and 265 patients were found to be co-infected with HIV.

Graph 3: TB services

900 800 700 600 500 400 300 200

100 Cumulative Cumulative numberindividuals of 0 Qtr1 Qtr2 Qtr3 Qtr4

Cumulative number of TB patients TB/HIV co-infected patients

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Integration of VMMC services In Quarter 4, the Program supported 5 PFP facilities (Family Health Resource Centre, Mehta hospital, Buzirasagama, Community Health Plan and Charis Health Centre) to conduct integrated VMMC outreaches. During the outreaches, 3,324 persons were tested for HIV and received same day results, including 38% (1269/3324) of whom were testing for the first time in 12 months. 2.6% of the persons tested were HIV+ and were linked to care. In this exercise, 1,809 males were circumcised, of whom 44% were followed up with in 48 hours after circumcision. Of those followed up with, 1.2% were identified with adverse events and were managed appropriately at the facilities. A total of 33,498 condoms including 50 female condoms were distributed in the outreaches while 81 women received FP methods of their choice of whom 17 received long term FP methods. 88 children were assessed for growth and nutrition as well as receiving age appropriate vaccination. 83 pregnant and lactating women received long-lasting insecticide treated mosquito nets. Still in Quarter 4, the Program conducted baseline assessment for VMMC services at Wagagai Health Center IV, Safe guard Nursing Home, Ankole Tea Estate Clinic, Hope Again Medical Centre and Hima Cement Clinic to determine the capacity of the two sites to provide quality VMMC services, identify gaps and make recommendations for quality VMMC service delivery. The facilities have good physical facilities appropriate for VMMC service provision to conduct static VMMC services. Hope Again Medical Center is conducting Static VMMC services while Ankole conducts VMMC outreaches. However, there were challenges of incomplete documentation, especially in the follow-up and vitals sections. Hope Again Medical Centre did not have a functional quality improvement team at the time of the assessment. Hima had suspended circumcisions citing lack of funds to provide quality VMMC services and inadequate staffing. These challenges/gaps were discussed with the facility managers and staff. To address this challenges in Year 3, and basing on PEPFAR COP 15, the Program will support 13 PFP facilities in the focus districts of Kampala, Wakiso, and to provide more static VMMC services and use outreaches to continue to target underserved populations. VMMC services will include a minimum package of clinical services, prevention services including promotion of risk reduction strategies especially focusing on ages 15-29 years. VMMC being a vehicle for engaging boys and men to know their HIV status, the Program will support sites to offer HTC to all males who turn up for VMMC and if HIV positive, offered comprehensive post-test counselling and be linked to care and treatment services. The Program will continue to support facilities in handling of emergencies through trainings & mentorship. Post-operative follow up of clients will continue to be supported through skills strengthening of health workers to provide adequate counselling of clients, use of appointment systems and tracking of clients to improve post VMMC return rates. To ensure safety, quality and compliance with standards of care for VMMC, continuous quality improvement self-assessments will be routinely conducted at all circumcising sites. The program recognizes the ongoing safety review of VMMC services by PEPFAR teams and MOH regarding adverse events in particular tetanus. The final guidance and shifts will be implemented as and when the communication is shared. During Year 2, the Program supported 21 PFP facilities2 to integrate and offer quality VMMC services as part of HIV prevention. These facilities received training in VMMC as well as supplies that included circumcision kits, HIV test kits, emergency kits, Bupivacaine, Lidocaine, Iodine, Ethanol, gloves, sutures, sodium chloride 0.9%, Jik, medicine envelopes, determination kits, paracetamol and male condoms. The Program trained 32 health workers in VMMC. PFPs were further supported to conduct integrated VMMC outreaches, attend VMMC QI learning sessions as well as on site mentorship and coaching to strengthen their practical skills in VMMC including counselling, circumcision and integration with other services. Below is an example of an VMMC dashboard from one of the PFPs. It demonstrates improvement in VMMC services delivery in the private sector.

2Lambu medical centre, Kyotera medical centre, Family Health resource centre, Ankole Tea estate, Hima cement clinic, Mabale tea estate clinic, Buzirasagama, Peoples Medical centre, St. Ambrose Charity, Emesco, Charis HC, Kinyara Sugar clinic, Kakira hospital, Mehta hospital, Community health Plan, Chandaria, Mwenge estate clinic, Ggwatiro Hospital, Galilee Hospital, Span Medicare and Old )

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 12 USAID/Uganda Private Health Support Program

Chart 1: VMMC Dash Board Baseline Feb-May 2013 Feb-15 Sep-15

Health Unit Supplies, Supplies, Supplies, Registratio Individual Male Registratio Individual Male Registratio Individual Male IP equipment Monitoring equipment Monitoring equipment Monitoring Manageme n group counseling circumcisi Infection Manageme n group counseling circumcisi Infection Manageme n group counseling circumcisi Infection Supportin & & & & & & nt systems education & HIV on surgical prevention nt systems education & HIV on surgical prevention nt systems education & HIV on surgical prevention g Site environme evaluation environme evaluation environme evaluation and IEC testing procedure and IEC testing procedure and IEC testing procedure District nt nt nt

Kinyara HCII, 30 50 0 33 80 100 85 100 60 83 70 87 80 57 100 Masindi Mehta, 40 83 0 14 84.6 80 100 83 80 90 78 92 80 100 100 100 88 86 100

Key >80% Meets/exceeds expectation 50-<80% Needs improvement <50% Needs Immediate action Area not assessed because there were not clients at time of visit

As a result of the above interventions, the capacity of PFP facilities was strengthened to provide integrated VMMC services, thus enabling the Program to achieve 133% (13,573/10200) of the VMMC target for Year 2, distribute 688,710 condoms, and test and provide same-day HIV results to 14,982 persons (as part of the VMMC activities). During integrated VMMC outreaches other services provided include health education, HTC, ANC, FP, cervical cancer screening, condom distribution, STI screening and treatment, linkage and referral. Graph 4 below summarises these achievements.

Graph 4: VMMC Achievements

12,000 11,208 10,000 8,828 8,000

6,000 5,509 4,000 2,936 2,000

- Cumulative Cumulative males circumcised Qtr1 Qtr2 Qtr3 Qtr4 Quarter

Integration of management of malaria In Quarter 4, the Program conducted training of 40 health workers in integrated case management of malaria. These health workers were drawn from Family Health Resource Centre, Span, Hope Again Medical centre, Santa Maria, Chandaria, Bugambe, Lambu, Kyotera Medical Centre, Touch , Hima, Engari, Kinyara, Charis, Ayira, Lira Medical Centre, Galilea, St. Catherine, Paragon, Wagagai, St. Ambrose, Emesco, Mukwaya and Case Hospital. In addition, during Quarter 4, the Program conducted training of 60 health workers in IPTp. This is in line with one of the objectives of the National Malaria Control Policy for the prevention of MIP. The health workers were drawn from 34 health facilities3. Going forward, the trained health

3Mwenge, Chandaria, Santa Maria, Double Cure, Touch Namuwongo, Emesco, Hope Again, Living water, St. Ambrose Charity, Peoples Medical Centre, Span, Galilea, Community Health Plan, Engari, Kyotera, Kitante, Bugambe, kadic, kiko, St Apollo, HIA, Charis, Mehta, Tooro Kahuna, Case Hospital, Royal Van Zanteen, Mukisa Nursing Home, St Apollo, Living water, Ikan, Kakira hospital, Rwenzori commodities-Buzirasagama, Mirembe, Busabala Nursing Home

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 13 USAID/Uganda Private Health Support Program workers will be followed up with at their places of work for post training mentorship and coaching to strengthen their skills. This training leads to a total of 80 health workers trained in IPT in Year 2. During the reporting period, the Program supported PFP facilities to provide quality IPT in pregnancy and case management of malaria in pregnant women and children under 5 as part of MNCH and general services. The support included trainings IPT and case management that were followed with onsite mentorship and coaching during which health workers received skills support from mentors. As a result of the above interventions 10,307 women received IPT1 while 6,853 women received IPT2 constituting 48% (6,853/14200) of the annual target for IPT2. A total of 109,162 cases of malaria were managed according to the recommended guidelines as part of the comprehensive services.

Strengthening integration of pediatric HIV In Quarter 4, the Program trained 9 medical doctors in pediatric HIV/ Early Infant Diagnosis (EID). The goal of the training was to strengthen management of children with HIV. These were drawn from Charis, Kakira, Case Medical Centre, Life Link Hospital, St. Ambrose, Hima, Case Hospital and . They will further be supported through onsite mentorship and coaching. Continued online support through AIDS Treatment Information Centre (ATIC) will be availed to all healthworkers managing HIV in children.

Health worker capacity building A total of 1,482 health workers received various trainings during the year. A total of 473 received classroom (blended with practicum) while the rest received on-site trainings (through CMEs, mentorships and practicum). Areas of training included: pediatric and adult HIV management, Elimination of Mother to Child Transmission (EMTCT), EID, VMMC, Laboratory practices, HMIS and DHIS2, NACS, viral load testing and monitoring, revised integrated HIV/ART, EMTCT/EID, TB guidelines, LMIS, cervical cancer screening and quality improvement. The health worker skills were further strengthened through onsite mentorship and coaching sessions in all the above service areas. The graph below summarizes healthworker capacity building (through training) to strengthen integration of services.

1.1.2. Capacity building for comprehensive service delivery through performance based grants In Year 2, the Program had proposed (subject to financial capacity and risk assessments of potential grantees) to use performance based grants for the high volume sites. Unfortunately, the Program has cancelled this grant as a result of COP 15 guidance for Program engagement with HIV care and treatment services in the private sector and the need to transition clinical sites.

1.1.3. Strengthen e-MTCT services at private sector facilities During Year 2, a total of 50 health workers from 36 PFPs were trained in EMTCT. This training focussed on the revised HIV/ART/EMTCT guidelines. Apart from the technical skills, the training also included training in stock, supplies, and logistics management as well as data management, reporting and improved M&E systems. The health workers were further mentored and coached onsite. The Program provided MCH data management tools to the PFPs. The facilities were supported to access HIV supplies and ARVs for EMTCT from Joint Medical Store (JMS) . a. During the fourth quarter, analysis of reports in the Monitoring and Evaluation Technical Assistance project (META) dash boards revealed that private sector reporting rates were poor and fluctuating. The Program embarked on a fact finding for why PFPs were continuing to report poorly despite the targeted efforts throughout the year. Findings from the facilities were: - Reports from Toro Kahuna, Kiko and Mukwaya general hospital were being sent but they were not being reflected in the system - The phone numbers used at Toro Kahuna, St Apollo and Kitante MC were assigned to either more than one facility or more than one implementing partner - Buzirasagama doesn’t offer ANC, Delivery and PNC due to infrastructural challenges - Royal Van Zanteen had stopped offering EMTCT due to absence of a midwife - System specific challenges for example the case of Ikan Health Centre where messages from lines were rejected by the META system

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 14 USAID/Uganda Private Health Support Program

- St. Apollo was using a number registered for the weekly surveillance reports. These were rejected by the system even when they sent reports. To address the above, the Program communicated findings to META for the system challenges to be addressed immediately. In addition, the Program with IDI ATIC center designed a short message service platform that is used to send weekly reminders to facilities to submit weekly Option B+ reports in time. Further support will be given through onsite mentorship and coaching of facilities.

Graph 5: EMTCT reporting trends by week in Q4

88% 86% 86% 84% 83% 82% 80% 81% 78% 76% 75% 74% 72% 70%

Percent Percent sites of reporting 68% WK1 Wk2 Wk3 Wk4 Weeks

 The Program supported integrated EMTCT outreaches at Kinyara HCIII Clinic in Masindi district and Hima HC III in Kasese district. During these outreaches, 2519 (1711 females and 808 males) were counselled and tested, 2502 received results, 22 tested HIV positive and were all linked to care. 34 couples tested together (couple testing) while 851 women were screened for cervical cancer and those found with suspicious lesions were referred for further management. At the same outreaches, 100 pregnant women received ANC services while 69 women received FP methods, of whom 20 received long term methods. A total of 322 HIV negative males were circumcised while 2030 condoms were distributed. The Program participated in the EMTCT campaigns for South Western Uganda. The outreaches above were part of the Program campaigns participation. The EMTCT campaigns ended with a launch by the First Lady of the Republic of Uganda Hon. Janet Kataha Museveni in Hoima district. The theme of the launch were: Stand Out…..Participate……..Protect. Using this event and the exhibition, the Program distributed EMTCT Information Education and Communication (IEC) materials to the community. > In Quarter 4, the Program trained 24 health workers in EMTCT/EID. These were drawn from Bamu, Community Health Plan, Double Cure, Emesco, Engari, Health Initiative Association, Kadic, Kiiko, Living Water, Mwenge, Peoples Medical Center, Rwenzori commodities, St Ambrose and St. Apollo HC III. These health workers will get further support through onsite mentorship and coaching

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Graph 6: Prevention of Mother-to-Child Transmission

1.1.4. Strengthening early infant diagnosis (EID) During the reporting period, the Program rolled out the revised integrated HIV/ART/EMTCT guidelines that incorporated components of early infant diagnosis of HIV among exposed infants. A total of 657 health workers from all the EMTCT implementing facilities were trained in the above guidelines. In addition, the EMTCT and pediatric HIV care trainings were integrated with EID training thus the 70 health workers that attended these trainings also acquired more knowledge and skills in EID. These were followed with onsite mentorship and coaching as well as CMEs to further strengthen the skills of the health workers. In the mentorship and coaching sessions, health workers were supported to deepen their skills in exposed infant identification, drawing and drying of Blood Spot (DBS) samples, packaging and dispatch as well as the related documentation and follow up for results and infants. The facilities were also supported with job aids, DBS test kits, EID data tools like exposed infant register, Appointment books, DBS dispatch forms and referral forms. The Program also supported PFPs to establish and strengthen functionality of mother baby care points (MBC) where both the mother and exposed baby receive all services at a one stop centre. The health facilities were linked with the District Health Teams (DHT) and accessed services of the hub riders in the districts who pick DBS samples and deliver results to the PFP facilities. As a result of all the above interventions, in Year 2, 102% (660 out of the targeted 650) of exposed infants below 18 months of age were tested for HIV. Of those tested, 94% tested HIV negative while 6% (40/660) were HIV+. About 60% (24/40) of those positive were linked and enrolled into care, treatment (ART) and support.

Graph 7: Number of Infants Diagnosed for HIV

200 180 160 140 120 100 80 60 40

20 Numberexposed of infants tested 0 Qtr1 Qtr2 Qtr3 Qtr4 Number of infants 160 176 157 167 Infants tested HIV+ 5 11 9 15

1.1.5. Improve patient retention and adherence in care at PFP facilities Improving client retention and adherence to care is an ongoing activity that is integrated into several strategies. In Year 2, the Program supported integrated, regular onsite, team based coaching and mentorship using experienced external mentors and Program staff. The Program worked with the PFPs to set QI projects on retention, adherence and follow up. Use of linkage facilitators;

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 16 USAID/Uganda Private Health Support Program tracking tools (appointment books, triplicate referral forms) as well as existing community structures alongside improved client counselling has been emphasized during site coaching and mentorship. To strengthen this further, the Program worked with USAID/ASSIST to train high volume partner sites in QI strategies as well as supporting formation of functional QI teams. The health facilities were also supported to attend QI learning sessions that facilitated sharing of; progress on old projects, good practices, new lessons learnt, challenges and identifying new QI projects. 50 health workers received training in the 5S strategy4 of quality improvement while 48 health workers were supported to attend the HIV continuum of response learning sessions. A total of 140 health workers benefited from these trainings/learning sessions. PFPs were supported to come up with feasible interventions to sustain the good practices as well as addressing the existing concerns. The Program/ASSIST partnership led to implementation of quality improvement interventions such as establishment of QI teams and QI projects. As a result of the interventions above 3,395 clients were enrolled into chronic HIV care, treatment and support constituting 130% (3,395/2,604) of the annual program target during the reporting period. During year2, 78.4% (1,961/2,500) of the targeted new and eligible HIV+ enrolled clients initiated on ART in line with the revised integrated national HIV/ART/PMTCT/EID guidelines. Out of the 2,952 HIV+ clients enrolled in the cohort of October 2013- September 2014, only 2,728 were still in care by the end of October 2015 constituting a retention rate of 92% against the target of 70%.

1.1.6. Support routine nutrition counselling and assessment > The Program together with the Nutrition unit of MOH conducted integrated NACS training of 29 health workers from 19 PFPs5. The facilities were given tools to use in nutrition assessment including mid-upper arm circumference (MUAC) tapes, desk job aides, nutrition brochures and MOH nutrition M&E tools. The sites were further supported through on-site integrated mentorship and coaching of the health workers to further strengthen the skills of health workers in integrating nutritional services into existing static health services and outreaches for quality management of services. > During the reporting period, a reminder was sent to USAID on the Ready to Use Therapeutic Foods (RUTF) activation process for Health Initiative Association and Mwenge Tea estate clinics and feedback is awaited. This followed a rapid Healthworkers training in NACS assessment for ready to use RUTF activation at the two private sector sites (Mwenge Estate Clinic, and Health Initiative Association Uganda, ) to determine how best to increase access to nutrition through the Production for Improved Nutrition (PIN) project distribution system supported by USAID. > The Program is a member of the National Nutrition Technical Working Group and during Year 2, we participated in the revision and development of national nutrition standards and review of the Nutrition Facility Assessment tools. The Program also held a meeting with the MOH team to plan for post training support to private facilities.

4 5S is the name of a workplace organization method that uses a list of five Japanese words: seiri, seiton, seiso, seiketsu, and shitsuke. Transliterated into English, they all start with the letter "S". The list describes how to organize a work space for efficiency and effectiveness by identifying and storing the items used, maintaining the area and items, and sustaining the new order. 5 Kyotera Medical Centre, Community Health Plan, Hope Again Medical Center, EMESCO, Family Health resource center, Charis HC, St. Ambrose Charity, Kitante Medical Centre, Mukwaya general hospital, Health Initiatives Association, Galilee General hospital, Mwenge estate clinic, Kakira Hospital, Engari, Gwatiro Hospital, Buzirasagama, Touch Namuwongo, Bugambe HC III, Kinyara Sugar works clinic and Mehta Hospital Lugazi

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 17 USAID/Uganda Private Health Support Program

1.1.7. Increase private sector participation in HIV prevention through grants During Year 2, the Program provided two performance based grants to the Federation of Uganda Employers (FUE) and the Uganda Manufacturers Association (UMA) to increase private sector participation in HIV prevention. Key achievements over the past one year include: 30 partnership MOUs were signed with private sector companies to offer HIV prevention and health services to their employees and communities; 516 peer educators from 21 private sector partner companies were trained; 6,698 individuals from the general population were reached with HIV prevention messages through the trained peer educators; 43 condom outlets were established which enabled promotion and distribution of 368,880 condoms; 418 Most at Risk Populations (MARPs) were trained as peer educators who in turn reached 2,113 MARPs with HIV/AIDS prevention messages on safer sex and risk reduction behaviors; 11,753 people received VCT services, family planning, malaria and other health services and received their results; 867 males received VMMC services and were safely circumcised, and 17 health facilities were supported to extend HCT, VMMC and VMMC services and were linked to low cost health products and providers such as JMS. Table 1 below summarizes the achievements.

Exporters Association (UFPEA) MD, Mr. Phillip Borel, Jinja Nile Resort Peer Educators after the peer and George Tamale of FUE at the launch of condom education training in Jinja dispensers at Tampa Fisheries Limited.

To build the capacity of the prevention grantees to continue providing prevention services to the private sector, the Program carried out routine data quality assessments for them. The Program supported the grantees to put in place the necessary monitoring and evaluation (M&E) and human resource systems to carry out M&E activities. The grantees were also supported to make changes in their data collection and reporting systems. During Quarter 4, the Program’s two prevention grants with FUE and UMA came to a close. The Program worked with both grantees to compile their annual achievements and started upon the grant close-out process. As required by the new USAID/PEPFAR FY15 COP, there will be no prevention grants going forward. However, private sector companies will contiue to support prevention activities in several ways including prevention education, condoms distribution and HCT.

Table 1: HIV Prevention through the private sector companies Target Achievement Peer Educators trained 240 517 Males circumcised 2,126 2,470 Population reached with Prevention interventions 7,440 7,729 HTC 14,000 24,485 Condoms distributred 300,000 450,460

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 18 USAID/Uganda Private Health Support Program

Graph 8: HIV Prevention

HIV Prevention 25000

20000

15000

10000

Numberindividuals of 5000

0 Qtr1 Qtr2 Qtr3 Qtr4

Population reached with individual or small group HIV prevention interventions (ABC) MARPs reached with individual and/or small group level HIV preventive interventions

Task 1.2. Expand private sector clinical capacity

1.2.1. Promote team-based on site trainings, coaching and mentorship In Quarter 4, the Program conducted on-site practical training of 13 health workers in cervical cancer screening using Visual Inspection with Acetic Acid (VIA) at Mwenge tea estate clinic. This was proceeded with onsite mentorship and coaching of health workers to further strengthen their skills in this area as well as integrating screening into other services like ART clinic, MNCH/EMTCT and outreaches. Consequently, cervical cancer screening was integrated into other static services at the facility including HIV/AIDS care and MNCH. So far, 123 women have been screened for cervical cancer using acetic acid of whom 8.9% (11/123) were found to be VIA positive. Four of these VIA positive women also tested HIV positive. 10 of these VIA positive women were referred and linked to regional referral and Virika hospitals for further assessment and treatment including cryotherapy. 90% (9/10) of these received Cryotherapy. In Quarter 4, the Program conducted mentorship and coaching in HIV/AIDS services (EMTCT, EID, nutrition, logistic management, reporting and HIV prevention including VMMC) at Emesco, St. Ambrose Charity, Muzizi health centres, Charis Medical Centre, Lira Medical centre and Ayira Nursing Home with a total of 32 staff being mentored. Health workers were re-oriented and equipped with knowledge and skills in providing quality HIV services. In previous quarters, the Program had identified challenges in services delivery at these facilitie and so responded with onsite mentorships. These mentorships focussed on: INH preventive therapy, testing of mothers in labour, EMTCT codes, linkage / referral/follow up and retention of clients. The Program will continue to support these facilities until the services delivery gaps are minimized. In Quarter 4, the Program together with USAID/ASSIST conducted 2 HIV continuum of Response learning sessions for 45 health workers . The goal was to improve the knowledge and skills of health workers in applying modern quality improvement methods to improve quality of care. The participants shared updates on performance in the HIV Continuum of Response (HIV COR) work and the dashboard performances. Key discussions included retention of mother baby pairs, identification of HIV positive children and successful changes regarding provision of preventive services to the HIV negatives from model sites. The health workers developed QI action plans with new QI projects to be implemented in regard to the best practices learnt. During Year 2, the Program with support from Ministry of health rolled out the revised HIV/ART/EMTCT/EID guidelines through site based trainings. Through three day sessions at each facility, a total of 1,012 health workers were trained. Trainings were followed with onsite team based mentorship and coaching at ART sites. During, these mentorships, CMEs were conducted to supplement the trainings and further strengthen the skills of health workers. In addition, the mentorship visits were used as opportunity to disseminate the revised data management tools. As a result of these interventions all Program supported PFPs adopted and started implementing the revised guidelines with the exception of viral load monitoring that will be handled in Year 3.

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 19 USAID/Uganda Private Health Support Program

The Program signed a MOU with USAID/ASSIST to support implementation of QI activities at selected sites in HIV, VMMC and OVC. Together, we conducted HIV COR, VMMC and OVC QI monthly coaching sessions during the year. Further more, the Program supported regional HIV COR and VMMC QI learning sessions for PFPs. During these sessions, review and discussion of facility-specific quality improvement efforts (documentation journals and QI data collection), QI was carried out. Through out the year, the Program supported onsite, integrated mentorship, coaching and support supervision to facilities to strengthen skills of health workers to deliver quality and integrated health services. During these visits health workers were supported in skills strengthening for HIV/ ART, TB management; EMTCT, EID, VMMC, Health management information (recording, reporting, data management and use), family planning and NACS. Through these sessions health workers were guided on the revised /recommended guidelines and supported through practicum sessions in areas like insertion of long term family planning methods, use of the data tools, HTC and cervical cancer screening.

Program staff mentoring HW’s in one of the PFP facilities Setting up filing cabinets and patient files at SCOUL MEHTA Hospital

Mentors at Charis medical centre in Lira during onsite mentorship and coaching

1.2.2. Integration of clinical and business skills During the year, the Program worked with two business support grantees, Private Sector Foundation Uganda (PSFU) and College of Health Sciences to support 222 private healthcare businesses. Details of this activity are discussed in detail under section 1.4.4: Business strengthening support.

1.2.3. Online support > During the year, the Program completed the adaptation of the comprehensive ART management course for Clinical Officers and Nurses into an online module. The Program conducted the course with a total of 20 health workers from 18 health facilities6. Training started with face-to-face sessions that were followed with online interactions spanning 5

6 Engari, Paragon Hospital, Touch Namuwongo, Family Health Resource Center, St. Ambrose Charity, Royal Van Zanten, Kyotera, Lira Medical centre, Health Initiative Association, Charis, Living water, Span, Engari, Galilea, Life Link, Bugambe, Mukwaya general Hospital and Kampala Medical Chambers.

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 20 USAID/Uganda Private Health Support Program

weeks. This allowed health workers to continue with work while improving their skills and knowledge in providing comprehensive HIV care. At the end of the 5 weeks, another face to face session (including a panel discussion) was held to address any outstanding challenges and provide further clarification. To conclude the online course, in Quarter 4, a two day practical placement of trainees at selected centers of excellence was done. The health workers will continue to be supported at through the routine onsite mentorship and coaching as well as the online ATIC platform. > Through the ATIC, PFPs have been provided with technical support in the management of difficult cases at their respective facilities. This is mainly through the toll free number that is available to the health workers. Other platforms like Facebook, Twitter, and email to the ATIC office are available to provide real time interaction between health workers and the online support centre.

Task 1.3. Establish linkages and functional referral systems for services

1.3.1. Establish linkages for referrals from low volume to high volume sites Working with the respective health facility management and through the onsite technical support supervision, mentorship and coaching, the Program has guided health facilities to use the MOH Hub transport system for DBS samples to and from CPHL. Other ART low volume sites have been guided to refer and link clients to high volume sites especially for services that cannot be offered at low volume sites. Examples of established referrals include – clinic in Buikwe district which refers HIV+ clients to St. Francis Health Care Services for enrollment into care. Another example is the referral and linkage of HIV+ clients from Dokolo home based HCT program at Adok Health Center II to the ART Clinic at Agwata Health Center IV for enrollment into care, treatment and support.

1.3.2. Establish linkages for referrals from high volume sites to high capacity laboratories and diagnostic centers During the reporting period, the Program supported PFP facilities to establish referral and linkages to high capacity labs and diagnostic centres for CD4 testing. These included; Royal Vanzanten in Mukono, Peoples’ Medical Centre in and Mabale Clinic in Kyenjojo established referral and linkage with St. Francis Health Care Services in Mukono, HCIV in Mubende and Kyenjojo hospital respectively. Working with the DHTs the Program has linked the PFP facilities to the existing MOH Hub transport system for DBS samples for EID and results to and from CPHL respectively. Linkages and referrals for other samples and tests will carried out once the laboratory assessment and mapping of services is concluded.

1.3.3. Assessment of laboratory services In Quarter 4, the Program worked with the MOH CPHL to conduct an assessment of laboratories. The goal of this assessment was to map the available laboratory services at various selected public and private health facilities so as to build and strengthen laboratory network for linkage and referral through the Public Private Partnership for Health (PPPH). The specific objectives of the assessment were to: 1. Map the laboratory services at the various service provision points in public and private health facilities, focusing on test menu, technology, human resource and infrastructure requirements. 2. Establish regional laboratory services gaps at the various service provision points focusing on the twelve quality management system essential elements. Preliminary findings from the assessment indicate that: 1. There is need to strengthen linkages and referrals for samples between public and private facilities. 2. PFPs need a lot of support in terms of laboratory guidelines, SOPs and mentorship in laboratory service delivery. 3. The region has a number of accessible laboratory centers of excellence (2 regional referral hospitals, 1 district hospital and 1 HC IV) that are transport hubs and have capacity to do most of the tests that private providers are not able to do. 4. Several missed opportunities for example, the hub rider from Kassanda HC IV has not been reaching Peoples’ Medical Centre even when the 2 facilities are in the same town council

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 21 USAID/Uganda Private Health Support Program

5. Private sector company owned facilities provide highly subsidized laboratory services to the general population e.g the tea estate health facilities. The findings from the assessment will inform Program appropriate interventions to strengthen laboratory referral and linkages in the private and public sector.

1.3.4. Partner with National Public Health Laboratory (NPHL) for laboratory capacity building In Quarter 4, the Program partnered with CPHL to train 94 health workers in viral testing and monitoring. These were drawn from 29 Program-supported PFP health facilities7. The national public health laboratory also provided all the trained health facilities with 80 viral load testing kits that will be used to collect Viral load DBS samples that will be transported to and tested by the CPHL at no cost to the PHPs as well as the clients. In addition, the PFPs continued to receive DBS testing kits for EID as well testing services at CPHL for DNA-PCR for early infant diagnosis of HIV in exposed babies. The Program conducted training in laboratory techniques and good clinical practice for 30 health workers from 19 health facilities (Busabala, Mehta, Kinyara, Health Initiatives Association, Emesco, Hima, Toro Kahuna, Engari, Family Health Resource Centre, St. Ambrose Charity, Mwenge, Mukwaya General Hospital, Charis, Touch Namuwongo, Hope Again, Lambu, Kiko, Kakira and Bugambe Tea Estate Clinic). These were followed with on site mentorship and coaching. During Year 2, the Program participated in the national laboratory equipment standardization and harmonization workshop to: > review and update of the current list of lab test menu and techniques as per level of health facilities; > review of the priority laboratory equipment in relation to techniques; > review MOH equipment maintenance and disposal strategy; > review and approval of the new equipment evaluation criteria; and > develop and create consensus on supply list of laboratory equipment and other supplies.

1.3.5. Establish systems for test samples transportation The Program supported 29 sites to use the existing hub transport system of MOH. The Program will use findings of the lab assessment report to continue to inform establishement of systems for samples transportation.

1.3.6. Commodity supply and web-based reporting In Quarter 4, the Program conducted onsite training of 5 health workers at Toro Kahuna HC III. The training focussed on logistics management information systems with emphasis on HIV/ART commodities and supplies. This training followed realization that the facility was not submitting orders to JMS due to lack of knowledge, skills and appropriate tools. Subsequently, the facility has been able to make and submit bi-monthly reports and orders to JMS and receive ARV’s and HIV test kits. In Year 2, the Program organized and conducted a logistics training targeting ART sites. A total of 55 health workers attended the two-day training. The training was as a result of the outcomes from the Logistics Assessment that had been carried out and participants came up with action plans to guide commodities management at the respective ART sites. Through out Year 2, the on-site support supervision, mentorship and coaching integrated and emphasized medicines and logistics management, ordering and reporting. To improve private sector reporting, USAID/Uganda Private Health Support Program continued to strengthened data collection and reporting within the private sector and worked to ensure that private sector outputs are reflected in the National DHIS2. The Program provided updated HMIS

7 Hima Cement Clinic, Mwenge Tea Estate Clinic, Kiko Tea Estate Clinic, Buzirasagama Tea Estate Clinic, Tooro Kahuna, Hope Again, St.Ambrose Charity, Medical Centre, Emesco, Kabalega Medical Centre, Family Health Resource Centre, Engari Community Health Centre, Kyotera Medical Centre, Kisiizi Hospital, Lyantonde Islamic Hospital, Ishaka Adventist Hospital, Lambu Medical Centre, Charis Medical Centre, Lira Medical Centre, Ayira Nursing Home, Kuluva Hospita, Nyapea Hospital, Kumi Hospital, Scoul Mehta, Kakiira Hospital, Health Initiative Association, Living Water Community Med Centre, St.Francis Buluba, Iganga Islamic Health Centre, St.Francis Njeru

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 22 USAID/Uganda Private Health Support Program tools, HMIS on-site mentorship, in-class trainings in HMIS and DHIS2, support supervision visits and partner performance review meetings. As a result, private sector reporting through the DHIS2 has improved from 27% at baseline, 62% and end of Year1 to 80% by the end Year 2. However, reporting for TB services continued to be a challenge despite provision of updated TB registers, training and mentorship on integration of and reporting of services. The assessment on TB services in the private sector will provide more insight on root causes for this challenge. Similar to Year 1, the Program continued to support improvement of data management stystems in the private sector. In Year 2, the Program supported 11 PFPs where they were provided with open high volume filing shelves, hanger and suspension files and filing cabinets. ART sites were supported to improve their file numbering systems and have complete data in the client files.

Task 1.4. Expansion of financial outreach through DCA banks

1.4.1. Expanding financial outreach through Centenary Bank By the end of Year 2, utilization of the USAID/SIDA Health DCA at Centenary Bank had reached a cumulative total of Shillings 4,506,500,000 (USD 1,761,254.9). This is 58.9% utilization of total guarantee amount. Utilization was by 64 borrowers (44 rural and 20 urban). The portfolio quality of the DCA is good. Only 2 notices of default have been made so far. However, all recoveries of arrears on both loans have been made and the bank has therefore not had to resort to making a claim against the guarantee to date. 19 loans (Shillings 1.4 Bn) representing 18.3% of the total guarantee amount have since been fully paid off. Figure 1 below gives a graphical representation of the year utilization per borrower category.

Figure 1: Centenary DCA utilization as a % of the cumulative guarantee amount utilized (SHILLINGS 4,506,500) as at 30 September 2015 per borrower category

100% 90.1% 69.5% 70.5%64.1% 56.3% 59.6% 43.7% 45.3% 30.5% 29.5 % 32.2% 17.3% 18.2%18.2% 20.2% 9.9% 8.9%8.9% 0.8% 4% 2.2%

A total of 21 new loans valued at Shillings 779,500,000 (USD 305,686) were booked under the Centenary bank DCA in Year 2 this constituted 10.2% utilization of total guarantee amount of Shillings 7,650,000 (US$ 3M) and 17.3% of the cumulative amount of the guarantee utilized as at end of the year. These 21 borrowers constituted 33% of the total number of borrowers (64) to date under the Centenary DCA. Figure 2 below gives a graphical representation of the Centenary DCA borrowers by profile category and their DCA utilisation rates as a percentage of the cumulative DCA guarantee as at 30th September 2015.

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 23 USAID/Uganda Private Health Support Program

Figure 2: Centenary DCA Utilisation as at 30 September 2015 by number of borrowers ALL Borrowers, Rural, Existing bank clients/ Male owned Business borrowers, Individual/owner n=64 (100%) n=44, (69%) borrowers, n=47, (73%) businesses, n=5, (8%) borrowers, n=57, (89%) n=,59, (92%) Female owned Urban, businesses, n=20 (31%) n=7, (11%)

New and First time Borrowers, n=17, (27%)

Figure 3 below gives a graphical representation of the number and type of healthcare businesses borrowing under the Centenary DCA. It also illustrates their DCA utilization rates as a percentage of the cumulative DCA guarantee as at 30th September 2015.

Figure 3: Centenary DCA cumulative utilization by type of healthcare business as at 30th September 2015

Equipment manufacturers/ Dentists n=2 (3.13%) Medical training vendors, n=1 (1.6% ) institutions n=2 (3.1%)

Pharmacies/ Drug stores n=7 (10.9%)

Clinics, n=52 (81.3%)

Figure 4 below gives a graphical representation of the number and gender of the owners of the healthcare businesses borrowing under the Centenary DCA. It also illustrates their DCA utilization rates as a percentage of the cumulative DCA guarantee as at 30th September 2015.

Figure 4: Centenary DCA cumulative utilization by borrower gender as at 30th September 2015 (loan value/volume) Female owned businesses, n=7 (11%)

Male owned businesses, n=57 (89%)

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 24 USAID/Uganda Private Health Support Program

Figure 5 below gives a graphical representation of the number and type of healthcare businesses borrowing under the Centenary DCA. It also illustrates their DCA utilization rates as a percentage of the cumulative DCA guarantee as at 30th September 2015.

Figure 5: Centenary DCA Rural versus Urban utilization as at 30th September 2015 (loan value/Volume)

Urban, n=20 (31%) Rural,n=44 (69%)

Figure 6 below gives a graphical representation of the number of first time, new and old borrowers under the Centenary DCA. It also illustrates their DCA utilization rates as a percentage of the cumulative DCA guarantee as at 30th September 2015.

Figure 6: Centenary DCA utilization: Existing vs. First time, New borrowers as at 30th September 2015 (loan value/volume)

New and First time Borrowers, n=17 (27%)

Existing bank clients/ borrowers, n=47 (73%)

Figure 7 below gives a graphical representation of the number of borrowers categorized by the purpose to which they put the loan to use. It also illustrates their DCA utilization rates of each loan purpose finacing category as a percentage of the cumulative DCA guarantee as at 30th September 2015.

Figure 7: Centenary DCA utilization categorised by loan purpose (loan value/ volume) as at 30th September 2015

LP- Equipment purchase, LP- Construction, (UGX 2.043 Bn), N= 27 Expansion, (UGX 1.453 LP- Working Capital, Bn) n=21 (UGX910M),n=21

LP- Ambulance, (UGX 100M) n=1

During the year, one borrower cleared his loan balance of Shillings 15.8 million and took out a repeat loan of Shillings 50 million outside the guarantee.

Additionality of the Centenary DCA to date 1. Centenary DCA has made 9 repeat loans worth Shillings 440 M($173K) with larger average loan amounts of Shillings 50M at reduced interest rates (the reductions average between 1% and 2%)

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 25 USAID/Uganda Private Health Support Program

2. Collateral requirements under Centenary have been relaxed down from 150% of loan amounts to 60% 3. Centenary bank is lending against unregistered property (Kibanja holders or lease offers) 4. The Ecobank loans are offered at prime rate minus margin and in 1 case below prime rate at 19% 5. Centenary has made 16 loans to first time, new borrowers worth Shillings 1.325 bn. (US$ 519K) Were it not for the DCA these loans would not have been made. Despite the successes scored under the Centenary Bank DCA, a number of challenges still exist and the Program will continue to address these in Year 3. > Centenary Bank does not track health sector loans specifically. This is due to a limitation in their current core banking platform that does not cater for tracking of health sector loans. However the bank will complete ether migration of other Cash Management Systems (CMS) to a new banking platform by February 2016 that has the capabilities of tracking health sector loans and the nuances under the sector such as loan type and borrower category profile. > Lack of incentive structure for credit teams to book Health DCA loans. No specific targets are set for DCA loans and neither is there any dedicated credit staff to handle DCA loans. This could be that the bank does not see the economic rationale of assigning a full time staff on the DCA given the relatively small portion the $3M is relative to their overall loan book. > Demonstration of additionally of a DCA loan vis-à-vis other bank financial products beyond relaxation of security requirements is a challenge. > Centenary Bank thinks that the non-revolving function embedded in the guarantee discourages them from using more innovative but short term products like structured trade finance, in favor of the longer term loans as the loans amounts made cannot be refinanced. > The use of the guarantee does not have any significant impact on the interest rate charged by the bank. This is both because the reduction in risk resulting from the guarantee is only sufficient to increase the loan amount (or get the loan approved), rather than reduce the rate. This is mainly influenced by the cost of funds. > The Bank does not task it’s credit officers with achievement of specific DCA targets

1.4.2. Expanding financial outreach through Ecobank Utilization of the USAID/SIDA Health DCA at Ecobank has stalled at Shillings 1,290,000,000 (7.2% utilization of TOTAL guarantee amount as at end of June 2015. This is to 2 borrowers (1 rural, 1 urban). The total DCA Total Guarantee limit is Shillings 17,500,000,000. There have been no notice of default made so far in the program, and 1 loan (Shillings 40M) amounting to 0.2% of the total guarantee amount have since been fully paid off. We have undertaken a thorough review and studied the bottlenecks and constraints underlying the slow utilization of the Ecobank DCA with a view to remedying them in a comprehensive fashion in Year 3. Some of these bottlenecks are: a. All loan applications throughout the countrywide Ecobank 14 branch network are handled at head office which affects the turnaround time. Document collection is a haphazardly done and not given sufficient time leading to inordinate delays. A number of potential clients have been frustrated by the delay and opted out of pursuing their loan application. To compound this, there are hardly any follow ups of prospective DCA prospects due to the lack of proximity and the long distances between the potential client and the ‘far away’ head office. b. Ecobank has few rural branches despite the fact that they have a target of 50% utilization to rural borrowers. They only have two branches, that is Jinja and Mbarara. Even then, these two branches are not fully operationalized to handle credit because they do not have credit staff the branches. c. Ecobank does not relax collateral requirements despite having the DCA guarantee. In most cases, they do not sufficiently leverage the DCA for purposes of securitization of the loans and are in fact over secure the lending. d. The maximum loan period for Ecobank is 5 years. This constrains lending for purposes of construction and expansion that required medium to long term financing. In fact the bank does not offer mortgage financing. e. High staff turnover at the branches outside the central region has adversely impacted the DCA uptake. In just one year, both branch managers of Jinja and Mbarara branches quit and there was no one to drive DCA activities. Both these manages had attended our access to finance

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 26 USAID/Uganda Private Health Support Program

(A2F) workshops and had signed up to a follow up action plan for client identification, sign ups and retention. This also complicated our follow up efforts post the A2F workshops since no one had taken ownership of the DCA pipeline matrix at the bank level. f. For any loan amount applied from Ecobank, the client is required to have audited books of accounts. This is a limiting factor for some clients because it also comes with a cost. g. The Ecobank branches outside the central region only lend to clients within a radius of 30km from the branch location. This makes it difficult for clients situated far away to access credit h. Ecobank does not take up any other collateral other than registered property (titled property). This makes it hard for some clients to access financing. For example Kathel Medical Care who wanted to acquire a loan of 19.5 million failed to do so because they had unregistered land as security. To address the above challenges, we have devised and commenced implementing strategies to ramp up the utilisation of the Ecobank DCA. These include: 1. Deliberately targeting bigger size businesses such as medical equipment vendors that already have audited accounts and are seeking relatively larger loan sizes, for the Ecobank DCA. We will also widen the pool of potential Ecobank DCA prospects beyond the A2F workshop participants. We will also draw from the pool of clinics and hospitals that are under the different health insurance schemes. We will also target the UHMG Good Life franchise network of clinics as potential Ecobank DCA potential clients. 2. Embark on a cross selling strategy of DCA borrowers under Centenary Bank who have maxed out the guarantee celling of US 300,000 allowable to any one borrower and channel them into the Ecobank pipeline. 3. We have already held a meeting with the new Ecobank Managing Director to secure high level support for the DCA activities at Ecobank. In this meeting we secured the Bank’s commitment and buy in for the structural changes needed at the upcountry branches and which have come in the way of DCA utilisation. 4. Aggressive follow ups will be made with Ecobank in DCA pipeline development. We will ensure that we do not lose momentum to make sure all pending loan applications are concluded so as not to lose potential clients who have dropped out before because of the long delays in loan application appraisal and approval. 5. Continue giving TA support to Ecobank in order to ramp up the utilization of the Ecobank DCA. This will include providing financial management support (getting their financials ready) to potential prospects that need it as a prerequisite to loan application. We will also work with Ecobank to ensure that the identified DCA prospects complete and submit the loan applications. We will continue to give TA support to the potential borrowers with further additional one-on-one assistance where it is still required. We will work with the Ecobank team to provide additional support/ information necessary to channel viable loan applications to Ecobank’s banks credit committee for consideration. This includes joint client visits with an EcoBank loan officer. The Financial and Business Adviser, who began work in mid – June will solely be dedicated to driving and implementing these strategies. She will also go through the HaaB business training and counselling in order to ensure that the TA offered to Ecobank DCA prospects in streamlining their financials is consistent and tied in with the already ongoing Business Development Service (BDS) support to clinics and hospitals that are receiving such support without intending to borrow under the DCA. Figure 8 below gives a graphical representation of the year utilization per borrower category.

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 27 USAID/Uganda Private Health Support Program

Figure 8: Ecobank DCA utilization as at 30th September 2015 by number of borrowers ALL Borrowers, Rural, Male owned businesses, Existing bank clients/ Business borrowers, n=2 (100%) n=1 (50%) n=2(100%) borrowers, n=1(50%) n=2(100%) Female owned businesses, n=0 New and First time Borrowers, Urban, n=1(50%) n=1 (50%)

Individual/owner borrowers, n=0

Figure 9 below gives a graphical representation of the Centenary DCA borrowers by profile category and their DCA utilization rates as a percentage of the cumulative DCA guarantee as at 30th September 2015.

Figure 9: Ecobank DCA utilization as a % of the cumulative guarantee amount utilized (Shillings 1,290,000) as at 30 September 2015

100% 96.9% 96.9% 100% 100% 96.9% 96.9% 96.9%

3.1% 3.1% 3.1% 0% 0% 3.1% 0% 0% 0% 0% 0% 3.1% 0% 0%

Figure 10 below gives a graphical representation of the number of borrowers categorised by the purpose to which they put the loan to use. It also illustrates their DCA utilization rates of each loan purpose finacing category as a percentage of the cumulative DCA guarantee as at 30th September 2015.

Figure 10: Ecobank DCA utilization categorised by loan purpose (loan value/ volume) as at 30 September 2015 Loan Purpose- Loan Purpose- Construction, Equipment purchase Expansion, (UGX40M), n=1 UGX1.25Bn (n=1)

Loan Purpose- Ambulance, n=0 Loan Purpose- Working Capital, n=0

During the year we held 4 workshops. The 2 in Arua and Mbale had a total of 34 participants for the Centenary DCA. We also held 2 workshops (one in Kampala and the other in Jinja) specifically targeting the creation of a pipeline for the Ecobank DCA for 30 potential borrowers. The Kampala workshop targeted medical equipment manufacturers, major medical equipment vendors; manufactures, distributors, dealers and supplier agents as potential vendor financing agents of Ecobank under the DCA. We also gave TA support to Ecobank Jinja and Mbarara branches in

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 28 USAID/Uganda Private Health Support Program order to ramp up the utilisation of the Ecobank DCA. In the year we visited and assessed the financing needs of 16 potential borrowers (8 in Jinja and 8 in Mbarara). The major lesson learnt in DCA utilization is that A2F workshops followed up by vigorous TA support to DCA prospects is an effective way to build a credit pipeline. Out of the 64 borrowers under the Centenary DCA loan portfolio guarantee, 25 of them are a direct result of our efforts. This is TA to the bank and potential borrowers through A2F workshops and one to one support. Our TA provider role is critical in building the DCA credit pipelines.

Figure 11: Centenary DCA borrowers that have gone through A2F workshops and received TA 80

60

40

20

0

ALL Borrowers Went through A2F Wkshop & got TA

These are some of the opportunities that are available in expanding financial outreach for maximum impact: a. Assisting DCA banks to develop baseline data (establish financial and sales performance baseline metrics for the borrowers). b. Assisting DCA borrowers to report via the HMIS. c. Private Health networks such as Marie Stopes and PACE would like to leverage the PHS Business strengthening and access to finance TA for the benefit of their members. d. The ability to demonstrate the additionally of a DCA loan vis-à-vis other bank financial products through the innovative measures that the DCA banks notably Centenary bank are undertaking. e. Link DCA borrowers to QI initiatives under the Program.

1.4.3. Expansion of financial outreach through non DCA banks The Program commenced the process of engaging with the management and boards of financial institutions to stimulate non DCA private health lending on the basis of the findings in our Private Health Lending: Opportunities for Growth report. This market data on the current status of health lending and the opportunities was disseminated to 12 non DCA commercial banks and a follow up action plan that we are pursuing developed.

1.4.4. Technical Assistance to DCA, non DCA banks and borrowers a. The private health lending assessment was finalized during the year and findings disseminated to key program stakeholders on December 9, 2014. The report identified the constraints and opportunities of financial institutions in Uganda to serve private health sector providers. It reported on the use of financial services (financial inclusion) by PFPs and projected financial needs in the near future. The report gives the USAID/Uganda Private Health Support Program an evidence base in its critical role and ongoing efforts of expanding financial outreach in the private health lending market. Below are key highlights of findings: i. The financial sector has been gradually increasing lending to the health sector for the last three years (2011-2013). Since 2009, there have been 1,682 loans disbursed to 534 health sector businesses. The value of current loans outstanding to health sector businesses (as of March 2015) is 222 billion shillings. While these trends reveal positive growth in health sector lending, the value of overall health lending represents only 1% of Uganda’s commercial bank total loan portfolios. ii. Assessment of health sector loans from 2009 – 2013 indicated that they performed slightly worse than the banking sector’s small and medium-sized enterprises (SME) lending portfolio. In this period, the value of delinquent health loans was around 4%, compared to 2.8% - 4.1% for general SME borrowers.

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 29 USAID/Uganda Private Health Support Program

iii. Health care facilities face many of the same constraints in accessing financing as do other SMEs businesses in Uganda. This includes a general lack of financial acumen and understanding of the formal financial sector; many also complain of the sector’s high interest rates and bank’s lack of pro-active outreach to the health care sector. A 2014 survey of 32 DCA loan recipients noted that their biggest challenge after receiving their health business loan was the high interest rates (54%) charged by Centenary Bank and the inability to obtain long-term fixed asset financing (47%). iv. The key reasons banks do not lend to healthcare facilities include: (1) a lack of business and financial management expertise—which can result in the health business’s poor management of funds, lack of financial records, and lack of understanding of the importance of basic documentation needed to acquire financing; (2) lack of acceptable collateral security; (3) poor infrastructure (physical premise and equipment) and limited staff skills to serve as the basis of expanding operations; and (4) need for fairly small loan sizes—which is less attractive to bank loan officers who often receive bonuses based on the value of their monthly disbursements. Banks also perceive the health sector as having limited demand in terms of volume and loan size. The full report on private health sector lending study was submitted to USAID on April 22, 2015. In addition to the above, the Program provided the following TA to borrowers. 1. The Program provided follow up TA to 13 clinics in Northern Uganda and 10 clinics in Eastern Uganda; 15 clinics in Western Uganda and 12 in Central Uganda that went through the A2F workshops and have submitted loan applications or were preparing to do so. The support included developing financing plans for the clinics, assisting in setting up financial record keeping systems, making cash flow projections for the healthcare businesses, streamlining the financial records and in projecting cash flow needs of the healthcare business, developing a financing plan, identifying potential financing needs, making recommendations to clinic owners and the bank to transfer existing loans to a DCA bank and making proposals to the clinic owner for a financing plan to be discussed on subsequent visits. 2. We offered technical assistance to Ecobank in gender based lending and targeting of female borrowers under the USAID/Health DCA via a training workshop for senior credit staff. We gave TA support to a distressed Ecobank DCA borrower in Lira (King James Comprehensive Nursing School); client monitoring of 1 DCA borrowers and credit pipeline development of 6 Centenary Bank potential borrowers in Mbale, Soroti and Lira.) 3. We participated in gathering data and in writing the the Joint Annual Review of the 2 DCA banks with USAID mission and assisted with writing the DCA client related sections of the report.

1.4.5. Business strengthening support (Provide financial and business training and technical assistance to a network of health clinics) During the year, the Program commenced the implementation of Phase 1 of the business training and mentoring activity for the private healthcare sector (refered to as HaaB- Health as a business) through two business support organizations (grantees); namely, Private Sector Foundation (PSFU) and Makerere University College of Health Sciences (MakCHS). The following activities were undertaken in Quarter 1: a. Working with the grantees, we completed the due diligence assessment/baseline of 222 target private healthcare businesses b. Customized training materials that were used in delivering BDS training c. Designed ToT training materials and a curriculum for the ToT (for the BDS grantee trainers) as part of the capacity building effort that was anticipated under the grant to equip trainers with skills to deliver impactful BDS services to our target PFPs. d. Developed a criteria and used it to select the final list of priority private healthcare businesses to receive business strengthening support taking into account the Year 2 focus for supporting high volume sites ( that offer HIV/AIDS, malaria, MCH, nutrition, OVC and TB services). e. Held a training of trainer’s workshop for the 2 BDS grantee trainers (MakCHS and PSFU) ahead of the start of the Business Development Support. The overall objective of the ToT was to provide guidelines for the Provision of Business Development Services under the HaaB activity. During the training, consensus was reached on the number of days each training workshop was going to take, the maximum number of participants from each health

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 30 USAID/Uganda Private Health Support Program

businesses’ to attend the training as well as the category as well as the maximum number of participants to be at each training workshop. f. Built the skills and effectiveness of 22 business counsellors (both PSFU and MakCHS) that would carry out the counselling bits of the BDS project. g. Held 6 entry workshops (Arua, Gulu, Mbale, Mbarara, Fort Portal and Kampala) for the healthcare business owners selected to participate in the HaaB activity. A total of 202 participants from 156 clinics/ hospitals attended. Specifically, the workshops were held to secure buy in from the business owners in recognition of the fact that they would be responsible for providing the leadership required to ensure that the post training action plans adopted at the training are not only implemented but that they lead to sustainable and meaningful change in the healthcare businesses. After these kick-off activities the project began in earnest and achieved the following results:

Table 2: HaaB Beneficiaries by district Region No. of Districts Covered Particulars of Districts East 16 Amuria, Serere, Soroti, Kumi, Bukedea, Paliisa, Kibuku, Budaka, Sironko, Mbale, Manafwa, Busia, Bugiri, Iganga, Mayuge, Kamuli North 13 Arua, Nebbi, Zombo, Adjumani, Gulu, Amuru, Nwoya, Lamwo, Pader, Oyam, Apac, Lira, Abim Central 7 Buikwe, Kampala, Mpigi, Mukono, Nakasongola, Wakiso, Kayunga West 12 Kabarole, Hoima, , Kyenjojo, Kiryandongo, Kasese, Mubende, Mityana, Kanungu, Kamwenge, Kibaale, Bundibujo South 19 Ibanda, Isingiro, Lyantonde, Masaka, Kabale, Kiruhura, Mbarara, Ntungamo, West Rakai, Sembabule, Hoima, Rukungiri, Kasese, Kabarole, Kamwenge, Kibaale, Kyegegwa, Mityana, Mubende.

TOTAL 67

Table 3: HaaB Training participation rates per workshop Healthcare Businesses Individual participants

Targeted Trained (%) Targeted Trained (%) Workshop I 192 159 (82.8%) 384 285 (74.2%)

Workshop II 192 151 (78.6%) 384 269 (70.1%)

Workshop III 192 144 (75.0%) 384 243 (63.3%)

Under the HaaB activity these have been the focus areas of business counselling. 1. Financial record keeping: filing, using journals and ledgers 2. M&E of customer numbers 3. Preparation and review of routine financial reports: income statement, cash flow statement, balance sheet 4. Cash flow management and cash control 5. Cost management audits and cost control 6. Preparation and review of monthly operating budget projections 7. Preparation and use of marketing plans, customer care 8. Preparation and use of marketing plans 9. Development of business growth strategies 10. Access to finance 11. Inventory management 12. Business leadership: structure, responsibilities, delegation, oversight, etc. 13. Revenue centre analysis 14. Strategic planning

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 31 USAID/Uganda Private Health Support Program

15. Others requested: business profiling, restructuring, etc.

Table 4: The HaaB Business counselling progress to date Central and Western Uganda Eastern and Northern Uganda Total HCBs that have benefitted from Counselling 123 62 185

1.4.6. HaaB business counselling outputs New measures have been introduced in various HCBs. These include: > Record keeping systems- use of accounting > Daily banking policy before spending –as opposed to drawing cash from the daily sales made. > Financial reporting – production of financial statements > Improved credit management > Development of business growth and marketing plans > Employment of new staff for key departments/functions e.g. finance/cash handling/recording etc > Daily tracking of client numbers > Computerized systems in some PFPs > After the HaaB training many clinics started operating their clinics/Hospitals as a business as fact that was not very crucial to them before the training > More delegation from Owners/Managers is being done at various PFPs As part of our oversight and TA support function under HaaB, the Program has carried out the following activities during the year: a. We have carried out post Business Training and Counselling monitoring visits to 112 of the HaaB participating clinics over the course of the year. b. We have carried out quarterly Joint mid-term reviews of the HaaB project with each grantee at the end of each quarter. c. We have provided feedback to both grantees on the post business counselling and training from the visited health care businesses. d. We have received, reviewed and given feedback to both the grantees on the workshop training and counselling reports submitted for each quarter. e. We have provided quality assurance oversight to 1 training workshop 1 for the high end clinics in Kampala and 1 for the low end clinics in Kampala. f. We assisted the grantees in the finalisation of the customisation of Forms 1 and 3 – the Business Counselling request form and the Business Counselling record form. g. We reviewed each of the quarterly technical reports from the sub grantee and provided feedback. h. We finalised the post business training and counselling monitoring tool. i. We carried out a mid-term progress review in July for each of the HaaB activity. For each of the 2 BDS grantees (PSFU and MakCHS), we reviewed progress to date, validated assumptions at project inception, drew lessons learnt and established proposals for improvement. j. Carried out on site support supervision of business counselling sessions at sample clinics to observe that the health businesses were being supported in entering transactions in a cash analysis book. k. Prepared guidelines for the RFA for a grant application for the potential Year 2 HaaB activity l. Worked with Private Sector Foundation Uganda in the preparation of the no cost documents for the HaaB 1 activity. We reviewed and gave feedback and completed the interim report as part of the no-cost documentation. m. Worked with Makerere University College of Health Sciences in following up on the completion of the activities for the HaaB activity that ended on 30th September 2015 n. Set targets for the final HaaB PMP for the HaaB activity.

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 32 USAID/Uganda Private Health Support Program

Challenges in implementation of the HaaB activity a. Widespread habit of accumulating information in source documents for several days before making entries into HMIS, journals, and ledgers b. Unwillingness of a few owners to disclose some financial information (especially cash outflows) to their financial managers c. Remoteness of many rural clinics d. Some of some PFP owners/managers have not yet fully appreciated the benefits of business counselling support.

Lessons learnt under the HaaB activity 1. The state of financial management amongst PFPswas worse than earlier known, and it has consumed significant time to get the HaaB-initiated systems running smoothly 2. Even some seemingly organized PFPs lacked efficient business operational systems 3. Facilitating owners through business analysis is critical for helping them identify and appreciate existing gaps and loopholes within their systems/operations. 4. Where owners and senior managers are involved in counselling sessions, there is a better sense of ownership, commitment to change and accountability.

1.5. Support innovative approaches for orphans and vulnerable children During Year 2, the Program continued to support innovative approaches for orphans and other vulnerable children (OVC) through 10 performance based grants to 10 CBOs. These 10 grantees reached 7,494 OVC with services based on need from the period October 2014 – September 2015. All the grantees were supported to implement OVC activities through the private sector engagement approach of matching Program funds with the private sector funds and resources to deliver services to the OVC. Using the government vulnerability assessment tool, the Program identified the critically and moderately vulnerable children. These children received services based on need in the six service delivery Core Program Areas (CPAs) of economic strengthening, food and nutrition security, education, child protection and legal support, psychosocial support and basic care and health, water, sanitation and housing. Linkages and referrals have been established for the OVC services where they have referred the OVC to key HIV and other health service providers like JCRC, TASO, Nurture Africa for ART and government health facilities for HIV services like HCT, ART, SRH and other opportunistic infections.

OVC at a vulnerability assessment OVC and their caregivers at an HCT outreach centre in Buhimba- Hoima district mobilized by KORD Jinja

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 33 USAID/Uganda Private Health Support Program

Graph 9: Total OVC reached based on need 7000 6000 5000 4000 3000

2000 Total OVC reached 1000 0 Child Food and Health protectio economic nutrition water and Education PSS n and strengthe security sanitation legal ning support Total reached 2189 940 1551 3054 967 3040 Female 1215 495 822 1573 481 1724 Male 974 445 729 1481 486 1316

By end of Year 2, 67% OVC had accessed HCT services positives were refered to the nearest health centers for ART and EMTCT services. The teenage OVC were sensitized and referred for reproductive health (RH) services at the health facilities within their localities. By engaging private companies, the CBOs enhanced the support they provided and further ensured the sustainability of OVC services. Beyond monetary contributions, the companies supported OVCs in the following ways (summary of examples): > Eco-Agric Company Limited and Elgonia Coffee provided seedlings to the apprentices and guided them on setting up nursery beds. As a result, OVC households have become food secure. Many of the OVC households that engaged in agricultural activities such as growing orange fleshed sweet potatoes, maize, beans and vegetables had realized two seasons of harvest by the end of the year. > Traidlinks Hoima worked with Eco-Agric to the market its produce and create more value addition to their crops. > Nexus Uganda Limited (a local construction firm) leads efforts for apprentiships trainings and skilling for OVCs supported by KIFAD. OVC training and skilling focusses on construction, Carpentry and Joinery as well as brick laying. > Kakira Sugar Limited offered internship placement for OVCs for a period of one year to get skills in plumbing, metal fabrication (among others) at the sugar factory. > Barclays bank Masindi facilitated entrepreneurial trainings for the caregivers of the OVCs supported by Family Spirit Children’s Centre. The bank supported the VSLA groups to grow their savings through offering them skills in investment and management of loans. The Program worked with the CBOs to support Caregiver and an OVC at one of her stall that she started after borrowing establishment of VSLA groups. Through these, more than money from a VSLA group in Wakiso 900 OVC households saved and some accessed loans to start up income generating activities in small scale farming, horticulture, and food vending among others. Nexus Uganda Limited working with KIFAD in Wakiso district supported the facilitation and formation of two VSLA groups. The company facilitated the training of these groups and to date they have 30 members each who are saving and borrowing to better their lives and those of the OVC that they support.

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 34 USAID/Uganda Private Health Support Program

Coordination, collaborations and linkages The Program continued to be part of the Ministry of Gender Labor and Social Development (MGLSD) Child Protection Technical Working Group (TWG). We attended bi-monthly coordination meetings. The Program also joined and actively participates in the Capacity Building Committee of this TWG and was represented at all TWG meetings during in Year 2. At local government level, the 10 OVC grantees were part of the district/sub-county OVC coordination committees, district networks such as the Uganda Network of AIDS Service Organizations (UNASO), and the NGO forum coordination meeting. They also continuously reported their implemented activities to the district using the OVC management information system (MIS) reporting tool. Linkages and referrals were also established for the OVC services. All 10 grantees were linked to and were able to refer their HIV+OVC to HIV/AIDS and other health service providers such as JCRC, TASO, Nurture Africa (for ART) and neighboring government health facilities.

1.5.1. Performance based grants to CSOs During Year 2, the Program disbursed a total of US $300,000 in grants to 10 civil society organizations (CSOs) located in seven districts: Masaka, Hoima, Masindi, Wakiso, uikwe, Jinja and Tororo. The CSOs engaged 10 private sector companies and leveraged a private sector contribution of amounting to US $110,800. These private sector funds were matched with the Program’s grant funds to deliver comprehensive services to 7,494 OVC. Graph 10: Private sector financial contribution to OVC support-USD

40,000

35,000

30,000

25,000

20,000

15,000

10,000

5,000

- ABC KORD KIFAD FICHI FXB ECO Caring INUG SOS FSCC AGRIC Hands Planned - Cost share contribution Cost share Realised todate During Quarter 4, the Program reviewed the OVC grantee’s proposals and budgets for renewal, provided them with relevant feedback and guided them to come up with improved versions that had revised targets and activities.

1.5.2. Capacity building for grantees During Year 2, the Program signed a memorandum of understanding (MOU) with the USAID/ASSIST project to guide implementation of quality improvement activities for the OVC partners. Quality improvement support was delivered through onsite mentorship, coaching, and learning sessions. The Program organized two training workshops in which 24 grantee staff were trained in monitoring and evaluation, private sector engagement, VSLA methodology, and reporting. From this training, action plans were compiled by each sub-grantee identifying areas in OVC programming for improvement.

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 35 USAID/Uganda Private Health Support Program

During Quarter 4, the Program conducted a SIMS assessment for the OVC grantees. Areas for improvement were noted and these will guide further capacity building support to the grantees. These included: > Documentation and filing of individual OVC and household data (case management) > Availability and use of Standard Operating Procedures (SOPs) > Training in the new MGLSD OVC MIS (a national online OVC database) > As part of the assessment, assisting CBOs to design performance improvement plans.

Task 1.6. Improve private sector participation in district service delivery coordination

1.6.1. Strengthen district PPPH coordination During Year 2, the Program facilitated a two-part PPPH training workshop over a period of 5 days. The first part of the training was conducted in Kampala targeting MOH, Ministry of Finance, private sector and other development partners in April 2015. The second part was a district health management team (DHMT) workshop focusing on the district health officer (DHO), PPPH focal person, biostatistician, and two private sector representatives from each of the six invited districts. It was also conducted in the same month. The purpose of the workshop was to build the PPP Node within the MOH and local focal persons’ capacity to deliver training on PPPH policy, institutional arrangements to implement PPPHs, roles and responsibilities on PPPH, and basic PPPH concepts. In addition, the workshops built capacity in core skills needed to effectively coordinate the private sector including private sector engagement, participatory planning, and contracting. Specifically, the workshops accomplished the following: The DHOs and PPPH focal persons were trained on (1) the PPPH Node’s terms of references, and staffing and technical services to support others in implementing PPPHs; (2) the roles and responsibilities and linkages between key government agencies (e.g. Office the President, Parliament, Ministry of Finance, PPP-TWG, and MOH), and; (3) the terms of references for the PPPH focal person at the district level. It was also an interactive platform for the Program, the participant districts and the PFPs to share basic PPP concepts, best practices, regional experiences, challenges and lessons learnt from other regions. The Kampala training was attended by 70 participants from MOH, Ministry of Finance, the PPP Node, World Bank-IFC, WHO, the Belgian Technical Cooperation, Uganda Healthcare Federation and its member associations, the medical bureaus and other private sector representatives. The district training hosted in Jinja drew 30 participants from Mukono, Mubende, Jinja, Buikwe and Mbale districts. The Program also organized and facilitated district private health stakeholder meetings in Jinja, Buikwe, Mubende and Mityana. The meetings were attended by over 170 private health sector representatives. The purpose of these meetings was to enhance PPPH coordination between the district and the private health sector. Jinja is one of the districts with a functional PPPH desk office and an effective coordination committee. Presentations on the understanding of PPPH policy, district coordination, costing and pricing, and pooled procurement were made. There were a number of outcomes and action items from the workshop. For example, the Buikwe PFPs asked to be given time to form an association and requested the Program to support a follow- on meeting. Mubende was among several Program partner districts without a functional PPPH desk office and an effective PPPH coordination committee. At the meeting, the DHO agreed to lobby the DHMT to assign an individual for the role. Mityana was found to be among the few Program partner districts with a functional PPPH desk office, though no effective PPPH coordination committee. The Program provided technical assistance to Mityana district on brokering an upcoming PPP project. The district and a private entrepreneur are in the final stages of setting up a nursing and midwifery training institution. Under this PPP, the government has provided land to a private investor under a leasing agreement for the training institution. This PPP will be used as a showcase of the possibilities of PPPs in other districts. The Program worked with the PPPH Node to design a detailed letter to the DHOs to appoint a PPPH focal person in the five focus districts where they were non-existent. These were Mubende, Mityana, Buikwe, Mukono, and Wakiso. The letters were sent to MOH for endorsement. The Program also organized and facilitated the PPPH Technical Working Group annual meeting attended by 12 participants from PPPH Node, MOH, the Belgian Technical Cooperation, and the medical bureaus.

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1.6.2. Greater participation of private sector in district planning In Year 2, the Program held a partners’ meeting for all Program partner facilities in Mpigi, Wakiso and Kampala districts. The meeting was attended by DHMT representatives from the the three districts as well as the PPPH focal persons from Jinja and Mbale. The focal persons shared their experiences in relation to PPPH coordination. The goal of the meeting was to further encourage private sector facilities’ participation in districts programming for health services. Together with other private sector stakeholders, the Program participated in development of the KCCA five year HIV/AIDS strategic plan (2015/16-2020/21). KCCA shared the performance in HIV/AIDS services (public and private contributions) using data from DHIS2. KCCA noted that although there was informal evidence that the private sector was providing HIV/AIDS services, DHIS2 reports from the private sector are not consistent to back this up. During Quarter 4, the Program met with private health stakeholders and DHMTs in Jinja, Kampala, Buikwe, Mubende and Mityana districts. The purpose of these meetings with the DHMTs and private health providers was to follow up on previous trainings and to discuss how best to collaborate activities through the DHMTs to ensure private sector prioritization and participation in the District Operational Plans (DOPs).

1.6.3. PPPH desk offices functioning During Year 2, the Program conducted a PPPH post-training follow-up for Mubende, Mukono, Buikwe, Jinja and Mbale district. During this visit, the Program met with the DHOs, PPPH focal persons and two private sector representatives. There were a number of findings from the review: Mukono had progressed to form a district based private providers’ association in a bid to better coordinate the private sector. Although Jinja already had a functional desk office, following the training, all partnerships between the public and private sector were now being formalized. Mbale had a few innovations in place such as the PPP on waste diposal. Under this PPP, the private facilities in Mbale collect their waste and work with the regional referral hospital to have it disposed at its facility. Buikwe was another success story, the DHMT had involved the private sector in their annual budgeting process and a budget line allocated to support supervison beyond the private-not-for-profit (PNFP) sector. In Mubende, there had been some work towards building a pipeline for PPPs. The district requested further Program support in the formation of a district private sector association.

Challenges: > Overall, macroeconomic issues are affecting the wider Ugandan economy, with the potential of disrupting the quick utilization of the DCA going forward. The DCA banks are operating in a tight macro-economic environment that has seen inflationary pressures on the cost of capital and the interest rates charged on loans. The Central bank recently raised the base lending rate to 16%. As a consequence both DCA banks have raised their lending prime rates by 1percentage point. Ecobank from 23.5% to 24.5% and Centenary from 22 to 23%. These high interest rates coupled with the depreciation of the Uganda shilling against the dollar will decrease the appetite for borrowing, thereby reducing DCA utilization. In addition to the high prime lending rates, the banks use a ‘Prime rate plus’ pricing method with a margin of 6% in the case of Centenary and 9% in the case of Ecobank. These factors all mean that the cost of borrowing has gone up for the targeted healthcare businesses under the DCA. > At the beginning of the Year 2, the Program received communication regarding engagement with GOU staff including MOH staff. As a result, there were delays in implementation of some of the key activities, e.g assessment of TB and laboratory services. > Roll-out of the new ART guidelines for all the ART accredited partner sites in the private sector was a much more intense exercise that anticipated. This led to delays in kick off of some planned activities that included health worker training and integrated outreaches. > Some PFP facilities have not received access rights to DHIS2 due to the buearacratic processes of acquiring password and user names from resource centre at MOH. This has continued to contribute to poor reporting from the private sector. > The CBOs supporting OVC activities are sometimes overwhelmed by the huge demand from vulnerable OVC households.

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Recommendations:  The Program will continue providing TA to the bank and borrowers to ramp up utilization of the DCA. The major lesson learned in DCA utilization is that A2F workshops followed up by vigorous TA support to DCA prospects is an effective way to build a credit pipeline. Out of the 64 borrowers under the Centenary DCA loan portfolio guarantee, 25 of them are a direct result of our efforts. This is TA to the bank and potential borrowers through A2F workshops and one to one support. Our TA provider role is critical in building the DCA credit pipelines.  The Program will continue to seek for USAID approval as and when it requires critical engagement of the government of Uganda staff (including MOH staff).  The Program continues to form productive relationships and work with the district bio- statisticians for access rights to DHIS2 for the private sector.  The Program will encourage OVC grantees to engage with and leverage resources from as many private sector companies as possible.

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Task 2. Increasing Affordability of Private Health Services and Products

2.1. Reducing the prices of health products and services

2.1.1. Recommending prices for essential medicines During Year 2, the Program held six private health stakeholder meetings in Wakiso, Jinja, Kampala, Buikwe, Mubende and Mityana districts to introduce recommended prices to private health stakeholders. During these meetings, the Program found that since the PFPs current business model benefitted from the lack of a recommended price list, they were not keen on adopting a price list. Many of the private providers the Program interacted with were hesitant to adopt recommended prices mainly because current practice is to embed ancillary services costs in the medicines prices. The Program found that to attract more clientele, many PFPs did not charge consultation fees but instead routinely marked up medicine prices to cater for the consultation fees. The Wakiso district PPPH focal person and PFPs also noted that the general public had a perception that cheaper medicines were not effective so they had to charge higher prices for the medicines. To address these concerns, the Program met with the Uganda National Health Consumers Organization (UNHCO--- a consumer advocacy organization that advocates for health consumer rights and responsibilities) to interest it in promoting standardized prices through the organization’s consumer advocacy forums. UNHCO expressed openness to work with consumers to raise awareness on reasonable prices for medicines and subsequently develop a recommended price list. The Program shared with UNHCO the current medicines price list from the 2014 Medicines Transparency Alliance (META)/Coalition for Health Promotion and Social Development (HEPS) survey for distribution. The Program further held meetings with the National Drug Authority (NDA) to acquire and update its outdated price list. NDA informed Program that they are coming up with a formulary that will be ready in the next 1 - 3 years. The NDA advised the Program to use its national drugs registry in the meantime to develop the recommended prices. Following the NDA’s recommendation, the Program met with HEPS Uganda to support dissemination of the 2014 National Drug Authority (NDA) licensed pharmaceutical distributors and retailers list. Providers’ knowledge of the approved pharmacies would enable them purchase quality medicines at prevailing market rates. HEPS has a network of over 15,000 pharmacies and drug shops countrywide that it interfaces with on a quarterly basis through its extensive network of detailers. HEPS agreed to distribute the NDA list of approved pharmacies at no extra cost to the Program. To this effect, the Program developed an MOU with HEPS Uganda. During Quarter 4, The Program supported the printing of the NDA list of approved and licensed pharmacies. We then partnered with HEPS Uganda to distribute 5,239 brochures to 90 pharmaceutical wholesale distributors in 71 districts8.

2.1.2. Developing and disseminating professional fee guidelines During Year 2, the Program held consultative meetings with the Uganda Medical Association (UMA) to enable it forge ahead with the process of developing professional fee guidelines for private healthcare practitioners. The Program found that although UMA had previously set up a TWG to develop professional fees and a consortium of private clinics in Kampala had also attempted to develop standard rates for a range of health services, these initiatives had stalled. The Program resuscitated UMA’s efforts to develop the professional fee guidelines for healthcare professionals by initially supporting research to determine the average fees healthcare professionals charge for a select number of commonly offered procedures or tests. The Program worked with the private health stakeholder’s TWG and UMA to develop a scope of work and subsequently put out an RFP advert in the local dailies. A consulting firm, RG

8 Adjumani, Alebtong, Amolator, Amuria, Apac, Arua, Budaka, Bududa, Bugiri, Buhweju, Bukedea, Bulambuli, Bulisa, Bundibugyo, Bushenyi, Busia, Butaleja, Buyende, Dokolo, Hoima, Ibanda, Iganga, Isingiro, Jinja, Kabale, Kabarole, Kaberamaido, Kaliro, Kamuli, Kamwenge, Kanungu, Kasese, Katakwi, Kibaale, Kibuuku, Kiruhura, Kiryandongo, Kisoro, Koboko, Kole, Kumi, Kyegegwa, Kyenjojo, Lira, Luuka, Manafwa, Maracha, Masindi, Mayuge, Mbale, Mbarara, Mitooma, Moyo, Namayingo, Namutumba, Nebbi, Ngora, , Ntungamo, Otuke, Oyam, Pallisa, Rubirizi, Rukungiri, Serere, Sheema, Sironko, Soroti, Tororo, Yumbe, and Zombo.

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 39 USAID/Uganda Private Health Support Program

Investments, was selected and shortlisted as the finalist. The firm was given an opportunity to present its methodology and approach to UMA, the Program, and the private sector TWG. Following the signing of the contract, the firm submitted an inception report that outlines final activity schedule, understanding of the assignment, and the data collection tools. During Quarter 4, the contracted firm submitted a report on the current local data and regional information on professional fees in Kenya, Tanzania, Zimbabwe and the United Kingdom. The firm started on the data collection exercise and will submit its 1st draft of professional fee guidelines in the first quarter of FY 2015/16. This draft will include data collected from field visits and data analysis in Quarter 1. The Program also presented the UMA annual scientific health conference in August 2015 to solicit for feedback from the medical professionals.

2.1.3. Supporting pooled procurement for private health providers During Year 2, the Program approached four pharmaceutical companies to share their prices with the private health stakeholders in the five districts it visited during the PPPH district meetings. The pharmacies were JMS, Ecopharm Pharmaceuticals, Plus Medic Pharmacy, and Friecca Pharmacy. With the exception of one (Friecca), the rest were open to sharing their price list and to offer volume discounts to the private health stakeholders for health commodities of interest. The Program further approached Abacus Uganda (pharmaceutical provider) and JMS to liaise with the district based private health associations that have so far been formed to extend pooled procurement. However due to the legal status of the private health associations, the pharmaceutical providers were not comfortable in extending credit payment. As a result, the Program started a processing of procuring a lawyer to support district associations to legally register. During Quarter 4, the Program sought the services of a local legal firm to assist the district associations to speed up the process of finalizing their constitutions and registering their respective associations. The firm will support the Program to understand the nature of the organizations to be registered, their membership, organizational objectives, and to advise on the most appropriate organization that could engage in pooled procurement. Starting with Mukono district, the firm will review their constitution and support drafting of the final constitution. Another goal of the legal firm will be to ensure compliance with the law, completeness of the constitution, clear terms on membership, and provide for the governing structures particularly a Board of Trustees. Finally, the firm will register the private providers association, draft Trust rules and incorporate the trust. It is after their registration to become a legal entity that can make bulk procurements that private providers in districts such as Mukono will start making bulk purchases. The Program received written notification from JMS expressing its interest in immediately serving these private providers.

2.1.4. Disseminate national treatment protocols During Year 2, the Program disseminated the new revised VMMC protocols, tools and guidelines, nutrition guides and IEC materials that were received from the MOH to the Program’s 109 partner facilities. These were disseminated through the training programs for health workers while others were disseminated during the monthly and quarterly support supervision visits to Program partner sites.

2.2. Reducing financial barriers to accessing health services

2.2.1. Promote health insurance and link it to micro and community health insurance During Year 2, the Program embarked on the process of promoting community health insurance and health savings for micro finance institutions and its OVC VSLAs and Savings And Credit Co- operatives (SACCOs). The Program sought applications from qualified, legally registered, not for profit organizations for an award to promote and manage health insurance and health savings schemes as well as build the capacity of established financial institutions (both formal and informal) such as community based savings groups such as SACCOs, Microfinance Institutions (MFIs), and VSLAs to engage in health insurance/savings. This process was concluded and the Program will seek approval for the grantee during the first quarter of FY 2015/2016. In addition to the 10 OVC grantees VSLA groups, the Program met with three microfinance institutions (Opportunity Bank, UGAFODE microfinance, and ) to prepare their savings clients as beneficiaries for the grant. All three banks indicated a strong willingness to have their

Year 2 Annual and Q4 report: October 2014 – September 2015 Page 40 USAID/Uganda Private Health Support Program savings members participate in community health insurance and are currently awaiting the grant to start. During Quarter 4, the Program review team concluded the pre-award visits of the three firms that were shortlisted to promote and incentivize savings groups, MFIs and SACCOs to start saving for health and to form/join existing community health insurance groups. Upon selection of the final grantee, this activity will continue throughout FY 2015/2016.

2.2.2. Promote health savings schemes This activity was combined with 2.2.1 above. The Program will work with selected grantees to approach and interest large savings group members to save for health.

2.2.3. Increase access to and expand scope of existing franchises and voucher programs This activity was proposed under a clinical grants mechanism with one of the Program’s partner facilities that was already providing ANC vouchers in Kiruhura district. However, this activity did not go forward as a result of cancellation of the clinical grants.

2.3. Promoting preventative care amongst providers and clients

2.3.1. Incentivize private providers to provide more preventative care During Year 2, the Program worked with the MOH to design and print 3,000 materials of prevention on the topics of nutrition, malaria in pregnancy, and TB prevention. These materials were distributed during the UMA and FUE peer education sessions while others were disseminated during their health outreach activities including the annual UMA Health and Nutrition Fair held in June 2015. The TB preventative care materials were distributed during the TB assessment that was conducted with the Program’s 109 partner sites. During the distribution exercise, the Program sensitized PFPs on the importance of preventative care.

2.3.2. Promote early health seeking behaviors among consumers This activity was combined with 2.3.1. above. The Program used community outreaches organized by the Program’s prevention grantees (FUE and UMA) as a platform to emphasize the benefits of early health seeking behavior. Other materials were disseminated through the training programs for health workers.

Challenges: > Many private providers noted that the public they served had a perception that cheaper medicines were not as effective as their more expensive counterparts which often forces them to charge higher prices for many medicines. The Program planned to work with the NDA to promote standardized prices for medicines as stated in the roles of the NDA in the Uganda National Drug Policy (2002). However NDA informed the Program this was no longer in its mandate. > The private health stakeholders lacked knowledge on the processes involved in forming district level stakeholder associations. They are particularly concerned about the liabilities involved if they start implementing health financing activities such as pooled procurement.

Recommendations: > The Program will partner with consumer advocacy organizations such as UNHCO and HEPS Uganda first to educate consumers and secondly to advocate for adherence to recommended prices since they have an inherent interest in the end users experiencing lower medicine prices. The Program will also work with the NDA and Pharmaceutical Society of Uganda (PSU) to update their mandates to include recommended prices and price monitoring mechanisms for medicines. > There is need for further research and stakeholder engagement on this matter to advice future strategies to address the cost of drugs. > The Program is working with a legal consultant to support the district based private health stakeholders in forming district level associations that have the capacity to transact and can be held liable by private pharmaceutical providers when making bulk purchases.

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Task 3. Improved Quality of Private Health Sector Facilities and Services

3.1. Develop a self-assessment voluntary quality improvement system (VQIS) to enable PHP providers to deliver quality services

3.1.1. Benchmark the tool against international practice During Year 2, the Program continued to work with Quality Health International (QHIC), the firm contracted to develop the VQIS tool. QHIC conducted a benchmarking exercise in Nairobi Kenya. In addition to the QHIC team, the UHF vice Chairman Ms. Grace Ssali and Angellah Nakyanzi – Private Sector Program Coordinator also took part in the benchmarking process. The benchmarking process advised a name change from ‘voluntary’ quality improvement system (VQIS) to ‘self-regulatory’ quality improvement system (SQIS) to enable adoption of the tool by more private health providers. So, we make reference to SQIS from this point onwards. The Kenyan standards and process draws heavily from the PharmAccess “SafeCare” model. The process has been highly inclusive of all private sector stakeholders delivering health; as a result, the Kenyan MOH received an international award for public-private dialogue. The visit to Kenya gave the QHIC team and the Program further assurance that they were on the right track. It also brought to the surface the notion that the Uganda team needs to target the medium and small clinics who provide a sizable share of health services to the population but that do not yet fully embrace quality of care practices for one reason or another. Specifically, the trip showed that the Ugandan and Kenyan experiences were similar in the following ways: 1. Both are facilitating a consultative process engaging the private sector to develop standards, tools and processes. 2. Both are developing quality assessment tools that are targeting the full range of facilities including small and medium size clinics in resource-constrained settings. 3. Both are exploring the most-effective and “acceptable” strategy to implement the tool in the private sector. In fact, Kenya MOH is conducting a consultative process with the regulatory boards and piloting a feasibility study examining whether the MOH, a private agency and/or quasi-state agency should implement the quality process with private providers. However, the Ugandan and Kenyan experiences differ in degree because Kenya is further along the process. It was also clear that the score system needs to be revised and a weight attached to each standards. A few standards were also modified and new ones recommended for inclusion.

3.1.2. Pilot standards in districts outside of Kampala district During Year 2, the Program conducted a two-visit pilot in 64 facilities in 8 districts and all the changes and recommendations were incorporated into the draft standards. During the first visit QHIC visited and disseminated guidelines to health facilities and briefed them on how to use the tools. The tools were left at the facilities for facility self-administration throughout January 2015. QHIC also held meetings with DHOs/DHMTs in all the 16 districts visited. During the year, QHIC presented a report of this first visit. In February 2015, the Program together with QHIC carried out the second field visit of the pilot. This was done in form of validation workshops/feedback sessions. During the first visit, QHIC shared the self-regulatory standards tool kit with private health facilities. However, for the second visit (feedback workshops), the facilities were invited to the DHOs’ offices for focus group discussions with at least two representatives from the four facilities selected per district to allow the DHOs to take part in the feedback meetings. The Program although unable to participate in all, participated in the sessions for Soroti, Kumi, Mbale, Tororo, Busia, Masaka, Mbarara, Lyantonde and Bushenyi districts. All recommendations made were incorporated to improve the tool. The subcontractor submitted a detailed reports on both the first and second visits.

3.1.3. Develop VQIS and roll-out plan During Year 2, the Program together with QHIC finalized the standards and developed the roll out plan. The process started with the development of a concept note on the roll out plan that was approved.

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During Quarter 4, the rollout plan was finalized. The underlying principal of the roll out plan is that the tool must not sit on the shelves but must be understood, owned and applied to bring change in quality of private health care services. The plan to roll out the SQIS use will take five steps namely; 1) ensuring availability, update and custodianship of the tool, 2) dissemination and distribution of the tool to ensure correct use, 3) monitoring its use, 4) monitoring outcomes/impact of the tool’s use by measuring and documenting quality standards for selected PHPs at the start of SQIS implementation and then after SQIS implementation to measure impact and 5) improving the tool and implementation process.

3.1.4. Digitize and produce final standards and assessment tools During Year 2, the Program digitized the final standards and assessment tools. By the time, the standards were launched in August 2015, the digitization was not yet complete but a prototype of the system was developed. During Quarter 4, the contracted firm developed a demo version of the SQIS system. The process is almost in its final stages as the firm submitted their inception report, the prototype and the web- based tool to the Program team for review and testing. The demo system can now be accessed following this link: http://sqis.med.ug/home/#1443512959144-5470b597-8fdc. This activity will be finalized in Quarter 1 of next FY 2015/2016.

3.1.5. Launch the VQIS at a high-level workshop During Year 2, the Program in partnership with MOH and UHF launched SQIS in a high level meeting on August 26, 2015 attended by over 80 participants from MOH (both National and districts), PFPs who took part in the first and second visits and other stakeholders including the media. The state Minister for Health Dr. Chris Baryomunsi was represented by the Commissioner Quality Assurance and Ag. Director for Planning Dr. Henry Mwebesa. It was during this meeting that the name was changed from VQIS to SQIS following recommendations during the field visits and benchmark.

3.2. Strengthen District Health Management Teams’ (DHMTs’) capacity to engage and partner with the private sector to improve quality

3.2.1. Disseminate widely VQIS system, guidelines and tools to Program districts Dissemination of the tool started during the launch of standards in Quarter 4. During the launch, a recommendation was made for tools to be printed and availed to the three professional councils and KCCA so that every PHP renewing their annual registration can get a copy. The councils also pledged to upload the tool on their websites and to start using it to as a licencing tool. The Program in conjunction with UHF will further disseminate over 200 copies through professional associations.

3.2.2. Disseminate widely treatment guidelines to Private sector facilities This was accomplished under activity 2.1.4 above.

3.2.3. Orient district level staff responsible for private sector quality on VQIS During Year 2, the district staff were oriented on the standards during both the first and second VQIS pilot visits that took place in 16 districts and 64 facilities. During the first visit when the tool was introduced for the pilot implementation, the consultants had meetings with the district staff and oriented them on the standards. During the second visit where the consultants and Program team went back to get feedback on the tool, the district staff were again part of the feedback meetings where the entire tool was again reviewed. However, the orientation on the digitized standards did not take place in Quarter 4 as planned because by the end of the quarter, the standards were not yet fully digitized. Therefore, this will be continue and will be completed in Quarter 1 of the next FY 2015/2016.

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3.3. Develop tools to unify and streamline systems supervising private sector quality

3.3.1. Update the Council Acts During Year 2, the Program initiated the process of engaging a third party capacity building organization through a competitive grants solicitation process. As a result, the African Center for Global Health and Social Transformation (ACHEST) was selected to be awarded the grant. This grant will build capacity of the medical councils through: conducting an organizational assessment of each of the Councils, designing and implementing a streamlined, web-based licensing process, converging the Council database to improve record keeping and tracking of private facilities, creating tools and using technology to assess quality such as facility-level checklists, updating and linking the current Continuous Professional Development (CPD) system to quality standards, and strengthening supportive supervisions that take into account feedback from the VQIS, client satisfaction surveys, Site Improvement Monitoring Systems (SIMS) and other facility reviews. Illustrative activities the grantee will undertake to unify the regulatory activities of the councils include: reviewing existing Acts to update and harmonize them; creating a streamlined, standardized process across all councils to obtain and renew professional and facility licenses; creating a common, web-based platform, that is user-friendly and technology appropriate, to apply and/or renew professional and/or facility licenses, and; establishing a universal platform to track and monitor professional and facility licenses. During Quarter 4, the Program submitted a request for grant approval to USAID and is still waiting for feedback before ACHEST can be formally awarded the grant. This activity will continue in Year 3.

3.3.2. Advance the National Health Professions Act During Year 2, this activity was integrated into the Council grant (see activity 3.3.1 above). The National Health Professionals’ Authority draft bill was presented to the MOH senior management team for approval and buy-in. No communication on the next steps has come in from MOH regarding the Minister’s presentation to Cabinet, despite the number of meetings between IFC, MOH and the Program. The Program in partnership with IFC also awaits approval from the Parliamentary Committee chairs of Finance and Health for a consultative meeting with these committees for their buy-in by the time the bill gets to Parliament. This activity will commence when the Council grant receives approval. The Program took advantage of the benchmarking exercise in Nairobi to attend a meeting with the Registrars’ forum and International Financial Corporation (IFC). The purpose of this meeting was to reflect on the process and what needs to be done to push these efforts further and also inform the work of the Council grant when it is up and running. One of the key next steps was a meeting with the State Minister of Health, Hon. Dr. Chris Baryomunsi who will give an update on cabinet’s views on the bill.

3.3.3. Assist Kampala City Directorate of Health Services to harmonize and field test a uniform application for facility licensure This activity and activity 3.3.5 were also integrated into activity 3.3.1 to avoid duplication of activities and will be implemented through the ACHEST grant in Year 3.

3.3.4. Assist Kampala City Directorate of Health Services and Environment to conduct a private provider census This activity was put on hold until FY 2015/2016.

3.3.5. Assist Kampala City Directorate of Health services and UHF to apply VQIS This activity and activity 3.3.3 above were integrated into activity 3.3.1 to avoid duplication of activities and will be implemented through the ACHEST grant in Year 3.

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3.4. Strengthen UHF’s capacity to build a cohesive and capable private sector to promote standards of care to PFP providers

3.4.1. Strengthen UHF leadership and governance During Year 2, the Program supported UHF in a number areas regarding strengthening their leadership and governance. The key areas of support were; > Collaboration with the UHF Board to design a Capacity Development Plan whose main objective was to address UHF’s capacity gaps. The result will be strengthened capacity to become a more cohesive and capable organization that will represent the private sector in Uganda. > Facilitation to UHF to develop a five year strategic plan that would; 1) help make management of UHF as an organization easier by providing a framework and a clearly defined direction for decision-making, 2) establish a uniform vision and purpose that is shared among all members of UHF and help them pull in the same direction, 3) create an increased level of commitment to UHF and its objectives and 4) help UHF with setting priorities and matching resources to opportunities. > During the year, the Program team conducted in-depth interviews for the UHF board members and secretariat. The purpose of these interviews was to establish: 1) the progress made by the board in its governance role since last retreat and training in September 2014, 2) challenges experienced by the board in its governance role, 3) establish any capacity development needs of UHF board as a whole. The board interviews provided input in the designing of the capacity development plan and further discussion with the board on the strategic direction of UHF in addition to board members discussing innovative ideas they had adopted such as holding monthly health talks and regional forums (though the latter was already in the UHF work plan). The Program also provided insight on strategies for member recruitment such as providing of member services that would in turn encourage non-members to join. The Program is currently lobbying the PPPH Node in MOH regarding UHF membership on the PPPH TWG and Health Policy Advisory Committee. The Program also worked with IFC to support UHF to transparently recruit the Executive Director (ED) and Finance Officer (after the resignation first the ED and later the Finance Officer). During Quarter 4, the Program supported UHF to develop a Board Charter. It defines the Board’s roles and responsibilities to assist Board members in effectively carrying out their strategic oversight function consistent with the standards of independent judgment, ethics, and integrity they are expected to observe. It also provides guidelines on decision making processes and ethical practices. The Charter is complementary to the requirements regarding the Board of Trustees and its members as contained in Uganda Health Federation Limited (UHF) Memorandum and Articles of Association and other applicable laws and regulations.

3.4.2. Build UHF’s capacity to deliver services valued by its members During Year 2, the Program supported UHF in implementing its performance based grant. The Program supported UHF to carry out member services that raised UHF’s visibility and demonstrated its value to a growing number of members. These activities included: producing an e-Newsletter, carrying out regional forums to sensitize potential members about UHF and what it can offer them, conducting networking events through the launch of Health Matters, provision of secretarial services to members, mediation and conflict resolution between members. The Program further supported UHF to implement activities aimed at recruitment of new members, particularly targeting potential members outside Kampala through the development of the member recruitment strategies, content and agendas for the forums. During those regional forums and networking events, UHF identified and signed up members. As a result, UHF has registered 40 members during Year 1 of the grant compared to 26 from the previous two years.

3.4.3. Strengthen UHF’s financial sustainability During Year 2, the Program supported UHF to strengthen its financial sustainability through a number of activities: > Supported UHF to develop a five year business plan. The business plan maps out the precise future of UHF business in detail. It is a strategy that takes into account the resources and goals UHF has and explains what needs to be done to get the organization to a position of greater

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financial strength and heightened competence as the future unfolds. The plan will help UHF to find funding, support UHF manage growth, deliver marketing approach and also manage organizational and employee requirements. > Supported UHF to develop a sustainability plan which will positively impact UHF’s reputation and brand image by demonstrating that the organization is taking responsibility for its actions and embracing change for the greater good. An essential part of UHF’s success is the engagement and development of strong relationships with government of Uganda and other internal and external stakeholders based on trust, respect, and cooperation. > Supported UHF to document all revenue collected since 2013 as a way of promoting financial accountability and reporting. Over the last 3 years, UHF collected SHILLINGS 73,836,540/= from membership dues, exhibitions, newsletter sponsorship and in-kind contributions excluding funding from grant proposals. Over 60 percent of this collection has come in during the past year.

3.4.4. Strengthen UHF’s capacity to implement VQIS During Quarter 4, the Program trained UHF in SQIS, in addition to inviting UHF to all Program SQIS related meetings and activities, as a way of building its capacity to implement SQIS. One of the key activities UHF participated in was the SQIS benchmarking exercise in Nairobi attended by UHF Board vice Chair Ms. Grace Ssali (now UHF ED). As a result, UHF took the lead in organizing the launch of the standards that was conducted in August 2015 in a high level workshop in Kampala. UHF has also printed a number of copies of the tool to be disseminated to their member associations.

3.5. Assist the DHMTs to implement PPPHs that strengthen PFPs’ capacity to deliver quality services

3.5.1. Raise awareness on the PPPH Policy During Year 2, the Program organized and facilitated a two-part training workshop for the central level MOH staff, district level PPPH focal persons, Ministry of Finance, private sector representatives and other related individuals/organizations in Kampala. These efforts have been discussed in detail in 1.6.1: Strengthen district PPPH coordination above. The Program organized and hosted the yearly PPPH-TWG meeting attended by MOH PPPH Node officials, BTC, and the medical bureaus. The outcomes of the meeting were (1) soliciting PPPH inputs into the next Health Sector Development Plan (2) Getting updates on strengthening the PPPH Node and (3) Receiving progress on the commencement of the World Bank supported voucher scheme.

3.5.2. Support private sector associations like UHF to advocate and promote PPPHs During Year 2, the Program involved UHF in PPPH related activities as a way of supporting it to advocate and promote PPPH. UHF was invited for a two day PPPH training for stakeholders in Kampala where the acting ED, Board Chair and Vice Board Chair represented UHF. The goal was to build their capacity to advocate for PPPHs. Following the recruitment of the UHF new ED, the Program started lobbying to have UHF represented on the TWG PPPH and the Health Policy Advisory Committee (HPAC). The HPAC serves as an excellent forum for the interaction of policy-makers and researchers.

3.5.3. Assist six of the most promising districts to identify and design one PPPH that will strengthen private sector quality During Year 2, the Program conducted a one and a half day PPPH district training held in Jinja, where five districts were taken through a series of presentations on how to scope for health PPPs. Each of the five districts identified a priority area where a potential PPPH could be done. Priority areas included provision of MCH services (Mukono) and collaboration with the traditional and complementary medicine providers (TCMPs) (Mubende). These efforts have been discussed in detail in 1.6.1: Strengthen district PPPH coordination above. The Program went ahead to conduct a PPPH post-training follow-up visit for Mubende, Mukono, Buikwe, Jinja and Mbale. These efforts have been discussed in detail in 1.6.3: PPPH desk offices functioning above.

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Challenges: > The Program experienced some delays in finalizing the Councils’and PPPH grant applications. since the applicants needed to greatly strengthen and clarify their proposals while the Grants team was missing Grants Manager for one quarter. > The UHF Executive Director resigned without proper handover of her office, a situation that interrupted implementation progress for about three months before the new ED started.

Recommendations: > The Program will work around the delay during Year 3 by starting on some of the other activities that are not in the grant such as engaging PPPH coordination. > The Program worked with IFC to support UHF to hire a new Executive Director. Going forward, the Program will orien the new ED in proper handover procedures to ensure continuity of services in case they were to leave.

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Annex 1: Success Story—Using Mobile Money Technology to Improve Efficiencies at Program Management Level Mobile money enables funds to be deposited, transferred, and withdrawn electronically through mobile phone accounts. However, its use in the health sector in Uganda is still an emerging practice. In July 2014, the USAID/ Uganda Private Health Support Program transitioned from using cash payments to using mobile money for Program transactions that include staff and trainee per-diems, vendor payments. The goal was to improve efficiency, accountability, security and transparency in Program financial transactions. In 2014, the Program engaged Yo! Uganda Limited (a local mobile money provider) as a mobile money aggregator and started with a pilot for transfers of monthly airtime to Program staff. With lessons from the pilot, the Program gradually started making more mobile money payments. By March 2015 all staff travel advances, training participants per diems, integrated health outreach expenses and other Program vendors were being paid via mobile money. At the beginning, there were several challenges that included doubts from the payees on the credibility of mobile money systems, as many were used to cash payments. With assurance from the Program as well as providing examples on the benefits of the system, the payees slowly begun to appreciate mobile money payments. Sometimes, the Program had to disqualify the unwilling vendors as a way to ensure elimination of cash payments. Another challenge that arose was that sometimes payees provided inaccurate cell phone numbers for mobile money payments. The Program had to bear liability for not attaining 100% accuracy of cell phone numbers entered in the system (Yo! Uganda does not accept liability for this). The Program also had to ensure that payees only provided telephone numbers that were registered for mobile money by cross checking thoroughly before uploading numbers. Between July and December 2014, the Program Finance Management Specialist dedicated time at the weekly staff meetings to provide updates on progress and challenges of the mobile money transactions system as well as collect feedback from staff. A lot of progress has been made and between Juneand September 2015: There have been no funds returned due to inaccuracy or non-registered numbers. The Process:

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Program benefits include: > Previously, staff received travel advances (for per diem and lodging) through their respective bank accounts. This caused unnecessary delays for especially staff that did not have accounts with Standard Chartered Bank or whose banks did not have a network of upcountry branches. > The system has lowered administrative burdens. For example during the training outreaches and training activities, Program staff will only concentrate on obtaining the cell phone numbers and signatures of participants as opposed to travelling to and from the banks to withdraw cash (per diems and lodging for the participants). > Program staff do not have to carry large sums of cash to the field thus avoiding the risks associated with handling cash. > There is a huge a reduction in petty cash payments since all small vendors (less than USD 100) are paid through mobile money. > This method has provided the Program with permanent real-time records for bulk payments (per diems for trainees, workshop participants) enabling financial transactions to be independently verified and tracked > By September 30, 2015 over 1,000 individual payments had been made using mobile money

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Annex 2: Success Story—Quality Improvement Strategies to Strengthen Service Delivery at Mehta Hospital & Kinyara HC III Starting in Program Year 1, the Program has used a CQI approach to improve quality of VMMC service at Mehta Hospital and Kinyara HC III. The two facilities provide comprehensive HIV care, treatment and support among other services. At the beginning of the year, the two PFPs were assessed for quality of VMMC services. The assessment looked at; management systems; supplies, equipment &environment; registration, group education and IEC; individual HIV counselling and testing; SMC surgical procedure; M&E and infection prevention in VMMC. The baseline showed very poor performance of both facilities scoring 0-53% in most areas except supplies, equipment, environment and infection prevention.

Baseline

Supplies, Registration Male circumcision Health Management Individual Infection equipment & group education surgical M&E Unit systems HCT prevention environment and IEC procedure Kinyara 30 50 0 33 HCII Mehta 40 83 0 14 84.6 Hospital The Program signed an MOU with USAID/ASSIST to support the facilities in continuous quality improvement. The health workers received regular support through; training in SMC/QI strategies, attending SMC QI learning sessions and site based QI coaching and mentorship sessions. Health workers at both PFPs formed site based QI teams, identified and implemented QI projects. The projects were evaluated quarterly to assess performance, identify the good practices, identify areas for improvement and develop new projects. A follow up assessment in February 2015 showed improvement with scores ≥ 78% in all the areas except registration, group education, HTC and surgical procedure (these areas were not assessed as there were clients at the facility at the time of the visit). By September 2015, the facilities showed consistent quality improvement in care across the SMC cascade. These interventions will be institutionalized in the facilities to form part of staff and performance review meetings. However, the key challenge remains high staff attrition affecting continuity of QI activities requiring new staff re-training and mentorship.

September 2015

Supplies, Registration Individual Male circumcision Health Management Monitoring & Infection equipment & group education counselling surgical Unit systems evaluation prevention environment and IEC & HIV testing procedure Kinyara 60 83 70 87 80 57 100 HCII Mehta 80 100 100 100 88 86 100 Hospital Strengthening continuous quality improvement strategies in the private health sector is feasible through learning sessions, mentorship and coaching. Quality improvement learning sessions provide appropriate fora for health workers to share experience, knowledge, good practices and challenges.

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